Patterns of adaptation to children's food allergies.

BACKGROUND: Families with food allergy (FA) are at risk of reduced quality of life and elevated anxiety. A moderate level of anxiety may be beneficial to sustain vigilance for food avoidance; however, excessive anxiety may increase risk for burden and maladjustment. The current study presents a framework for understanding the patterns of adaptation to FA across families and to identify typologies of families that would benefit from intervention. METHODS: Participants included 57 children, 6-12 years old with documented FA, and their mothers. Families were assessed using the Food Allergy Management and Adaptation Scale. Families also completed measures of quality of life, anxiety, FA management, and psychosocial impairment. RESULTS: A hierarchical cluster analysis revealed that 56 of the 57 families of food-allergic children were categorized into four groups that differed on their adequacy of family FA management, levels of anxiety, and balanced psychosocial functioning: balanced responders (n = 23; 41%), high responders (n = 25; 45%), and low responders (n = 3; 5%). The fourth group, anxious high responders (n = 5; 9%), was characterized by extremely high maternal FA anxiety scores and low scores for balanced integration of FA management and psychosocial functioning. Families in clusters differed across illness and psychosocial outcome variables. CONCLUSION: Families with FA were characterized by patterns of FA management, anxiety, and ability to integrate FA demands into daily life. Identified adaptation patterns correspond with clinical impressions and provide a framework for identifying families in need of intervention.

Onset and persistence of childhood asthma: predictors from infancy.

OBJECTIVE: In a prospective study of children with a family history of asthma, asthma onset by 3 years of age was found previously to be positively associated with variables from the first year of life, including elevated total immunoglobulin E (IgE), frequent respiratory infections, and parenting difficulties. We followed this cohort of genetically at-risk children to investigate the relationship between factors assessed in infancy and asthma, allergy, and psychological status at school age. METHODS: A cohort of 150 children who were at risk for developing asthma were identified prenatally on the basis of the mothers' having asthma. For 28 children, the father had asthma as well, putting them at bilateral genetic risk. Families primarily were middle and upper middle class Caucasians. Parents came to the clinic during the third trimester of pregnancy for assessments of medical and psychosocial functioning. A home visit took place when the infant was 3 weeks old, when parenting risk was assessed before the onset of any asthma symptoms. Parenting difficulties included problems with infant caregiving as well as components of maternal functioning, such as postpartum depression and inadequate marital support. Blood was drawn for serum IgE at 6 months of age. Parents and offspring subsequently came to the clinic multiple times, with the last clinic visit during the child's sixth year. Follow-up at age 6 involved a clinic visit for allergy and psychosocial evaluations, consisting of interviews and a behavior questionnaire. Seventy-seven children received the allergy and psychosocial evaluation, 26 received the psychosocial evaluation in the clinic, and 30 families received telephone interviews and mailed in questionnaires. Additional monitoring of families by telephone and mail was maintained over the next 2 years, until the children were 8, to ensure accurate characterization of the course of illness. Comprehensive medical records were obtained and reviewed for all health care contacts. Children were designated as having asthma when there was documentation in medical records of physician-diagnosed asthma, observed wheezing, and/or prescription of asthma medications during the time period when the child was between 6 and 8 years of age. Parental reports of the occurrence of asthma corroborated the medical record data. RESULTS: Data regarding asthma status were available for 145 children through 8 years of age. Forty (28%) of the children manifested asthma between 6 and 8 years of age. Among variables previously reported to predict asthma onset by age 3, 3 proved to have significant univariate relationships with asthma between ages 6 and 8: elevated IgE levels measured when the children were 6 months of age, global ratings of parenting difficulties measured when infants were 3 weeks old, and higher numbers of respiratory infections in the first year of life. Among these offspring of mothers with asthma, paternal asthma showed a significant association with asthma between ages 6 and 8. Eczema in the first year was not significantly related to later asthma. Multiple logistic regression showed that the model that best predicted asthma at ages 6 to 8 from infancy variables included 2 main effects. The adjusted odds ratio for 6-month IgE was 2.15 (1.51, 3.05) and for parenting difficulties was 2.07 (1.15, 3.71). Although socioeconomic status (SES) was not associated with asthma at ages 6 to 8, families of lower SES were more likely to be rated as having parenting difficulties early in the child's life. The mothers of lower SES breastfed for a shorter period of time and were more likely to smoke during their infant's first year. There were more respiratory infections during the first year of life among infants whose mother was rated as having more parenting difficulties. Mothers who reported smoking breastfed their infants for a shorter length of time. Male gender was significantly associated with higher IgE levels when infants were 6 months of age. Laboratory testing was completed for 77 children at age 6. Total serum IgE levels were significantly higher for the children with asthma between ages 6 and 8. Skin-prick testing showed that the children with asthma had significantly more positive skin test reactions than did the children without asthma. Psychosocial interview data at 6 years of age were available for 103 families, and behavioral questionnaires were available for 133 families. On the basis of 6-year interviews, children with asthma were rated as being at greater psychological risk than were the children without asthma. Mothers' Child Behavior Checklist (CBCL) ratings of their children's behavior indicated higher internalizing scores for the children with asthma as compared with the children without asthma. Like the 6-month IgE, 6-year IgE was higher for boys. IgE levels measured at 6 months of age were significantly correlated with 6-year IgE levels. Parenting difficulties measured at 3 weeks were significantly correlated with 6-year measures of maternal depression, CBCL Internalizing score, and Child Psychological Risk (CPR) score. There also were significant correlations among the psychosocial variables assessed when the children were 6 years of age; maternal depression was significantly associated with child CBCL Internalizing score and CPR score, and the last 2 also were significantly correlated. Multiple logistic regression showed that 2 concurrently measured variables entered the model showing the strongest associations with asthma at ages 6 to 8. The adjusted odds ratio for CPR score was 3.21 (1.29-7.96) and for 6-year IgE was 1.71 (1.04-2.80). CONCLUSIONS: This study of the natural history of childhood asthma focused on the development of asthma into the school-age years in a genetically at-risk group of children. The relationships between biological and psychosocial variables in the first year and school-age asthma support the formulation of asthma as beginning early in life, with the developing immune system interacting with environmental influences. The data provide support for the possible contribution of psychosocial factors to asthma onset and persistence into childhood.

Metropolitan home living conditions associated with indoor endotoxin levels.

BACKGROUND: Household endotoxin exposure in allergy and asthma has been gaining attention for its dual potential to exacerbate these conditions in individuals with established disease and to abrogate atopy before disease onset. OBJECTIVE: We sought to better understand the home environmental and lifestyle factors influencing house dust endotoxin levels. METHODS: From the homes of 86 infants with wheeze in metropolitan Denver, Colorado, house dust endotoxin (detected with a standardized Limulus Amebocyte Lysate assay) and common indoor allergen (Fel d 1, Can f 1, Der p 1, Der f 1, and Bla g 1) contents were quantified. Comprehensive home environment and lifestyle questionnaires were completed during home visits by trained study staff and parents. RESULTS: House dust endotoxin levels were associated with only 2 home environmental features: animals in the home and the presence of central air conditioning. The strongest positive associations were found with animals in the home. Interestingly, the homes without cats or other animals revealed a negative correlation between house dust Fel d 1 and endotoxin (P =.03). Central air conditioning, especially during months of typical use, was associated with lower house dust endotoxin levels. No significant associations between house dust endotoxin levels and home dampness, number of household inhabitants or young children, cleaning frequency, or presence of tobacco smokers in the home were found. CONCLUSIONS: Indoor endotoxin exposure can be increased by the presence of animals in the home and decreased with central air conditioning. In some homes without animals, where allergen exposure adequate for sensitization still occurs, there are lower levels of house dust endotoxin. Therefore in homes without animals, factors that influence allergen and endotoxin levels in house dust probably differ. Households with detectable allergen levels but low endotoxin levels may provide a predisposing environment for animal allergen sensitization.

Impact of a multidisciplinary day program on disease and healthcare costs in children and adolescents with severe asthma: a two-year follow-up study.

For patients whose asthma remains in poor control necessitating high utilization of medical services, a referral to a specialized "center of excellence" is often considered. A decade ago, we evaluated our pediatric asthma program of long-term hospitalization (median stay of 75 days) and found significant decreases in subjects' medical utilization following this intervention. In an effort to contain treatment costs, the former program was markedly altered to one of abbreviated stay with emphasis on family management of asthma. The purpose of the present study was to determine the outcome of children treated in the revised program with regard to disease severity, quality of life, and subsequent utilization of medical resources. Children with severe asthma who were admitted to the program and fulfilled study criteria were consecutively enrolled. Data was obtained concerning disease characteristics, treatment, and quality of life at admission, and at 1 and 2 years following discharge. Medical records for the year prior to program admission and for the 2 years following discharge were coded for medical care encounters. Ninety-eight children, aged 9 months to 18 years (mean age, 10.9 years), were enrolled. They participated in the program for a mean of 15.6 ( +/- 8 SD), median of 15.0, and range of 2-51 treatment days. The group showed significant improvement (P < 0.0001) from admission to 1- and 2-year follow-up in median corticosteroid use, asthma functional severity, perceived competence in asthma management, and quality of life for both caregiver and child. Medical record data showed significant improvement (P < 0.0001) at both 1- and 2-year follow-up in median number of corticosteroid bursts, emergency department visits, hospital days, and overall utilization of medical care encounters. A median total medical encounter cost/patient of $16,250 ($6,972-$25,714 interquartile range (IQR)) for the year prior to program participation was reduced to $1,902 ($505-$6,524 IQR) at 1-year and $690 ($185-$3,550 IQR) at 2- year follow-up (P < 0.0001). We conclude that multidisciplinary care in a short-term, outpatient, day treatment program can significantly contribute to improvement in asthma severity, quality of life, and reduction in healthcare costs.

The five minute speech sample in children with asthma: deconstructing the construct of expressed emotion.

OBJECTIVE: To use the Five Minute Speech Sample (FMSS) to assess Expressed Emotion (EE) in various samples of children with asthma in order to clarify (1) developmental and validity issues for the EE construct and (2) the use of the FMSS technique, specifically, in children with chronic medical illness. METHOD: Data were collected on a sample of 84 adolescents with severe, chronic asthma who had failed outpatient management. In addition, a sample of 30 children with asthma, ages 6-9. were recruited from an outpatient pediatric clinic. A comparison sample of 15 children without any chronic illness, ages 6 9, were recruited by notices posted in the community. The primary caregiver of each child was assessed using the FMSS. RESULTS: FMSS interviews were reliability coded in all samples. Rates of high Criticism (FMSS CRIT), Emotional Overinvolvement (FMSS EOI), and EE were comparable to rates previously reported in child and adolescent samples. Although the validity for ratings of FMSS CRIT was well supported, the validity of FMSS EOI ratings and the overall EE construct were more problematic. CONCLUSIONS: The FMSS is a useful and largely valid measure in children with asthma. Ratings of FMSS CRIT were found to have strong validity. There was little problem shifting the context of FMSS administration from chronic mental to chronic medical illness, but a variety of developmental considerations arose, especially regarding FMSS EOI ratings. Although we raise concerns about viewing EE as a valid construct, it may remain a useful predictive index.

Relation between house-dust endotoxin exposure, type 1 T-cell development, and allergen sensitisation in infants at high risk of asthma.

BACKGROUND: Bacterial endotoxin is known to induce interferon gamma and interleukin 12 production, and therefore has the potential to decrease allergen sensitisation. To find out the role of early chronic endotoxin exposure in the development of allergen sensitisation and asthma, we compared concentrations of endotoxin in house dust with allergen sensitisation in infants at high risk for developing asthma. METHODS: 61 infants 9-24 months old with at least three physician-documented episodes of wheezing were studied. Concentrations of house-dust endotoxin and allergens were measured in the infants' homes. Allergen sensitisation was measured by skin-prick testing with a panel of common inhalant and food allergens. In a subset of these infants, proportions of T lymphocytes producing interferon gamma, and interleukins 4, 5, and 13 were calculated by cell-surface and intracellular cytokine staining, with flow cytometry. FINDINGS: House-dust endotoxin concentrations ranged from 104 to 10,000 endotoxin units (EU) per mL (geometric mean 912 EU/mL). Concentrations did not vary significantly over a 6-month interval. Ten infants (16%) were sensitised to at least one allergen. The homes of allergen-sensitised infants contained significantly lower concentrations of house-dust endotoxin than those of non-sensitised infants (mean 468 vs 1035 EU/mL, respectively; p=0.01). Increased house-dust endotoxin concentrations correlated with increased proportions of interferon-gamma-producing CD4 T cells (p=0.01). Such concentrations did not correlate with proportions of cells that produced interleukins 4, 5, or 13. INTERPRETATION: This study may provide the first direct in-vivo evidence that indoor endotoxin exposure early in life may protect against allergen sensitisation by enhancing type 1 immunity.

A multimethod assessment of behavioral and emotional adjustment in children with asthma.

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.

Clinical outcomes of steroid-insensitive asthma.

BACKGROUND: Steroid insensitivity increasingly is being recognized in patients with severe, chronic asthma. Virtually no data exist regarding the clinical outcomes of steroid insensitive (SI) asthma despite clear expectations of poorer longitudinal course for this condition. METHODS: We obtained 2-year follow-up data from 34 pediatric patients who had been evaluated for steroid insensitivity at a national asthma referral center. Outcomes evaluated included current oral glucocorticoid (GC) dose; number of GC bursts, emergency room visits, and hospitalizations for asthma in the prior 12 months; Asthma Functional Severity; Pediatric Asthma Quality of Life; and Pediatric Asthma Caregiver's Quality of Life. RESULTS: At follow-up, patients with SI asthma and their caregiving parent both reported poorer quality of life (QOL) compared with those with steroid sensitive (SS) asthma (adolescent: 4.6 +/- 0.4 versus 5.6 +/- 0.3; P < .05; caregiver: 5.1 +/- 0.4 versus 6.2 +/- 0.2; P < .05). Steroid-insensitive patients showed no significant difference in GC dose, number of GC bursts, emergency room visits or hospitalizations, or Asthma Functional Severity compared with SS patients. CONCLUSIONS: Steroid insensitivity was associated with significantly poorer QOL at 2-year follow-up. Steroid insensitive patients did not show poorer clinical outcomes compared with SS patients as assessed by current steroid requirements and health care utilization. Overall, the observed pattern of results suggests that SI asthma may be a worse form of asthma because a more fixed pattern of lung obstruction has developed. Further longitudinal study of the clinical and cellular outcomes of SI asthma is needed to more fully characterize the types and magnitude of risks associated with SI status.

An investigation of the medical care utilization of children with severe asthma according to their type of insurance.

A comparison of the medical care utilization of children with severe asthma according to insurance type was performed. Subjects were grouped by which type of insurance they had: capitated, fee for service, or Medicaid insurance. Medical records were coded into utilization categories, by presenting complaint, sick- or well-child visit, and if a generalist or specialist provided care during the visit. The Medicaid group had less specialist, sick-child care than the groups with capitated or fee for service insurance. The Medicaid group also had more emergency room visits than the other two groups. The three groups had a similar amount of total physician/clinic visits. Even though similar care was shown to be available for those with Medicaid insurance, this low resource group often uses expensive emergency room care.

Developmental models of infant and childhood temperament.

The developmental courses of specific temperamental constructs were explored by using structural equation model fitting. Maternal ratings were obtained from either 2 or 3 different temperament questionnaires for 180 children at 3, 6, 12, 18, 24, 36, and 48 months of age. Several formal structural models were fit in infancy (3-18 months), in the toddler-preschooler period (24-48 months), and across all measurement occasions. In infancy, the autoregressive simplex model fit well for all 4 composites considered: Positive Emotionality, Distress-Anger, Fear, and Activity Level. In contrast to the considerable change in temperament during infancy, temperament appears to be very stable from 24 to 48 months of age, and a common factor model fits well with these data. Across all measurement occasions, models that allowed for stability in temperament to be at least partially mediated through intermediate forms of the trait fit best.

Assessing the family asthma management system.

The importance of "self-management" has been increasingly recognized in the treatment of asthma. In the case of childhood asthma, such management must be accomplished by the family system, including the caregivers, the asthmatic child, and the alternate caregivers in collaboration with the health care providers. This paper presents an assessment tool, the Family Asthma Management System Scale (FAMSS), for evaluating the effectiveness of the family asthma management system. The scale is internally consistent and has excellent interrater reliability. The FAMSS score, together with an asthma severity measure, jointly accounted for a significant portion of the variance when predicting the functional severity of asthma experienced by this group of children.

The organizing effects of early relationships.

The Developmental Psychobiology Research Group (DPRG), based at the University of Colorado Health Sciences Center, brings together researchers from a variety of disciplines and institutions with the goals of sharing information and stimulating further investigations into all aspects of development. Every other year a retreat is held over the course of several days, with a focus on a particular theme that is addressed by guest speakers and members alike. The following collection of papers comprises the presentations of two of the speakers at the 1990 DPRG retreat and three other papers, relevant to the theme, that were presented at the retreat.

Early asthma onset: the interaction between family stressors and adaptive parenting.

It has been repeatedly noted by clinicians that psychological stressors appear to be associated with the expression of asthma in individuals who have a genetic vulnerability for developing the disease. While retrospective evidence has supported this clinical observation (Levitan 1985; Teiramaa 1986), the association between emotional stressors and illness onset can only be convincingly demonstrated using a longitudinal design (Mrazek 1988; Steinhausen et al. 1983). In 1985 the W. T. Grant Asthma Risk Study was designed to identify which physiological and psychological risk factors for asthma were most highly associated with eventual expression of the disease. Young infants who were genetically at risk for asthma were evaluated and their development was prospectively monitored. The primary objective of the longitudinal study was to identify risk factors for illness expression. If this were possible, these risk factors could then be targeted for intervention efforts designed to delay the initial onset of asthmatic symptoms. The ultimate objective of an effective intervention would be that for some children, the illness could be prevented completely.

Quality of marital relationship: a clinical rating scale.

Clinical research requires the measurement of complex variables in a manner that is as simple as possible while still being precise. This paper presents a clinical rating scale that was developed as a global measure of the quality of couples' relationships. These couples participated in a study that investigated asthma onset in children at genetic risk for developing this illness. The ratings of marital quality at the prenatal point were significantly related to the number of behavior problems the children were reported to have at 2 years of age. The use of the scale is outlined, together with descriptive data for this group. Reliability data and evidence for predictive and construct validity are presented.

Marriages with children at medical risk: the transition to parenthood.

Prior studies suggest that the birth of a new baby causes a modest but reliable drop in marital satisfaction. The present study replicates and extends this finding in couples with children at medical risk and probes the mechanisms behind this effect. Longitudinal data on marital satisfaction, family structure, infant illness and temperament, and family life events were collected at prenatal, 6, 12, and 18 month periods. Family structural burdens and family stress burdens had a significant negative effect on marital satisfaction. Child-related burdens were less reliably related. Results are discussed in the context of stress and coping as well as developmental psychopathology.

Early asthma onset: consideration of parenting issues.

This report examines the relationship between early parental behavior and the later onset of asthma in a cohort of 150 children who were genetically at risk for developing asthma. Judgments of both parenting problems and maternal coping were made during a home visit when the infant was 3 weeks old. A clinical interview with the mother was developed and reliably coded. The sample was divided into two groups based on the presence or absence of concerns about coping and parenting. During the following 2 years, the respiratory status of the children was monitored. Four categories of respiratory status were defined: (1) asthma; (2) recurrent infectious wheezing; (3) a single isolated wheezing episode; or (4) no wheezing. Early problems in coping and parenting were associated with the later onset of asthma (p less than 0.001). Furthermore, parents of children who developed asthma were more likely to have been having difficulties at the 3-week visit than those whose children developed infectious wheezing (p less than 0.005).

Recognition of emotion from vocal cues.

In two studies investigating the recognition of emotion from vocal cues, each of four emotions (joy, sadness, anger, and fear) was posed by an actress speaking the same, semantically neutral sentence. Judgments of emotion expressed in these segments were compared with similar judgments of voice-synthesized (Moog synthesizer) samples (study 1) or with three different alterations of the full-speech mode (study 2). Correct identification of the posed emotion was high in the full-speech samples. Voice-synthesized samples seemed to capture some cues promoting emotion recognition, but correct identification did not approach that of other segments. Recognition of emotion decreased, but not as dramatically as expected in each of the three alterations of the original samples.

Outcome evaluation of behavioral parent training and client-centered parent counseling for children with conduct problems.

The central question addressed was, how effective is parent training in reducing conduct problems in children in comparison to client-centered parent counseling? A secondary question was the relative effectiveness of the two treatment groups in comparison to a wait control group that when untreated during the 8-week period of treatment provided the other groups. Families of 36, 5- to 12-year-old conduct problem children were screened and assigned at random to treatment groups, but wait control group assignment depended upon therapist availability. Supervised graduate student therapists conducted 10 treatment sessions for each family. Parent reports and paper and pencil tests of child deviance and parent satisfaction showed a superior outcome for behavioral over the client-centered and wait control groups, and no differences between the latter two groups. At follow-up there was no maintenance of this superiority. Home observation data showed no advantage of behavioral over client-centered treatment, and these two groups did not improve significantly more than the wait control group. These results were discussed in the light of possible interactions between treatment and measurement, and methodological and sampling differences between this and other studies.