Parental anxiety and other psychosocial factors associated with childhood asthma

J Chron Dis Vol. 34. pp. 627 lo 636. 1981 PrInted 111Great Britain. All nghts reserved

Copyneht

0021.9681.81;120627-lOSO2.000 0 1981 Pergemon Press Ltd

PARENTAL ANXIETY AND OTHER PSYCHOSOCIAL FACTORS ASSOCIATED WITH CHILDHOOD ASTHMA* HERMAN STAUDENMAYER National Jewish Hospital and Research Center/National Asthma Center. 3800 East Colfax Avenue, Denver, Colorado 80206, U.S.A. and The Department of Psychiatry, University of Colorado Health Sciences Center, 5777 East Evans Avenue, Denver, CO 80222. U.S.A (Received 17 October 1980) Abstract-The effects of childhood asthma on the parents was assessed by five psychosocial factors which were empirically derived from a questionnaire administered to 159 mothers and 70 fathers. The scales were independently derived for mothers and fathers and showed good reliability. The cluster solutions for mothers and fathers were similar, and the same labels were used for the scales: Emotionnl Distress, Interference, Manipulation, Ocerprotecrioeness and Family C’ommunication. Parental anxiety, as indexed by Emotional Distress and Interference, was related to the amount of debilitation experienced by the children, as were the fathers’ perceptions of Manipulution and the mothers’ self-perceptions of Ouerprotectioeness. It was suggested that there was a relationship between the mothers’ failure to acknowledge their children’s manipulations and their own overprotectiveness. Good Family Communication was unrelated to debilitation, but the results were interpreted with reservations. Overall, the study indicates that parental anxiety, like the children’s anxiety, analyzed in another study, was related to the medical manageability of the disease. The diagnostic instruments developed to assess this anxiety are short and easy to administer and can be readily used by physicians to aid their decisions in medical management.

INTRODUCTlON

of chronic childhood illness often include members of the family who are not the patient. Parents have been implicated in psychosocial studies of childhood chronic illness, and specifically asthma [l-5]. For example, one factor which has been of primary concern is the parents’ reaction to their child’s illness. Pinkerton and Weaver [6] have called this concept acceptance of the illness. In their formulation, the overaccepting parent subtly reinforces the illness by overprotecting the child, catering to his/her fears and providing nurturance in conjunction with the illness rather than encouraging effective self-initiated action by the child. Parental over-protectiveness has further been linked to dependency and other child psychopathology [7-91. At the other extreme, the underaccepting parent is described as one who underplays the significance of the illness, minimizes the early signs of exacerbations, and perhaps fails to follow through on medical care. Acceptance of the illness and other parental coping styles are certainly important aspects of childhood asthma that should be considered in a wholistic approach to the management of the disease. But there is another aspect of childhood illness that has been neglected, namely the parents may themselves be under unusual stress. One group of researchers have focused on the burden of parenting an asthmatic child [lo, 113. Many parents are very worried about their child’s illness and this often results in a great deal of anxiety and distress for them. Furthermore, parents who feel thwarted in their own lives and who are unable to pursue their own interests and activities often experience frustration and anxiety over this kind of interference. There are further implications to the other THE VICTIMS

*This work was supported in part by a grant from the National Institutes of Health (AI-15392) 627

628

HERMANSTAUDENMAYER

children in the family. If a parent feels that the needs of these other children are being ignored, it may add to his/her stress. There are many ways that a child with chronic illness can affect the family. For example, if a child uses asthma to manipulate the parents, they are often impeded in their attempts to foster independence or to discipline the child effectively. This can frustrate the parents and leave them feeling helpless. Parental attitudes about medical care and their knowledge about the nature and care of asthma may also be linked to successful management of the illness. For example, some parents of poorly controlled asthmatic children tend to be overly dependent on professional services [12]. Parents who neither understand the illness nor are capable of taking appropriate actions to deal with exacerbations may not only experience more anxiety but may also fail to support constructive self-care attitudes and habits in their child. This study has two objectives, (1) to develop an instrument which assesses parental psychosocial factors associated with childhood asthma, and (2) to evaluate the relationship between parental anxiety associated with the disease and the level of medical intervention required to manage the disease. EXPERIMENT

1:

DEVELOPMENT

PSYCHOSOCIAL

OF

THE

MEASURES

The aim of this experiment is to develop a pencil and paper diagnostic test which can be filled out by the parents without the assistance of a physician who may wish to employ it in private practice. The psychosocial factors which it assesses are empirically derived from a sample of parents whose children span the range of medical manageability from those who can be controlled with occasional as-needed (p.r.n.) medications in private practice to those who are considered intractable and require hospitalization. METHODS

Subjects

Parents of asthmatic children from three subsamples which reflect utilization of institutional services were asked to volunteer. A total of 159 mothers and 70 fathers participated in this study. There were 47 mothers and 27 fathers whose children were treated in the inpatient service at the National Jewish Hospital and Research Center/National Asthma Center (NJH), 64 mothers and 8 fathers whose children were seen in the NJH outpatient clinic and 48 mothers and 35 fathers whose children were treated in private practice. Demographic data for the children are reported elsewhere [13]. The discrepancy in the number of mothers and fathers reflects the fact that the mother usually accompanied the child. In the inpatient service at NJH both parents are requested to be present when the child is admitted to the hospital. However, these children are referred from across the country, and it is not uncommon for only the mother to accompany the child. In the outpatient clinic, the children reside in the greater Denver area and are usually accompanied by their mother when coming in for treatment. In the private practice subsample, the fathers were more readily accessible, largely because these children were involved in an education-exercise program conducted at NJH which encouraged both parents to participate. Procedure

Each of the parents filled out a questionnaire at the time they volunteered for the study. The items on the questionnaire were composed in consultation with experienced clinical professionals in the Behavioral Sciences Pediatric Department of NJH. An initial screening of all the items was conducted by four professionals who independently sorted the items into the following preset conceptual categories: Emotional distress, acceptance of the illness, interference in normal activities, overprotectiveness, perceived manipulation, family communication and medical attitudes. Items that were not consistently

Parental Anxiety Associated with Childhood Asthma

629

sorted into the same category by the judges were discarded because their meaning was ambiguous. The resulting questionnaire was comprised of 97 items. Each item was evaluated in response to the question, ‘How often have I felt this way?’ A five point scale was used (1 = almost always, 2 = a lot, 3 = half and half, 4 = a little, 5 = almost never). A subset of 36 parents were administered the questionnaire a second time within 1 month for the purpose of computing test-retest reliability. Twelve items which did not correlate significantly (a = 0.05) from the first to the second test were discarded. The remaining 85 items were input into a cluster analysis program [14]. RESULTS

Separate empirical key cluster analyses were conducted for the mothers and the fathers. While the resulting clusters were similar, there were enough differences in the specific items in the clusters to warrant separate presentation of the results for the mothers and the fathers. Mothers Five meaningful clusters emerged which included 37 items. These were interpreted conceptually and labeled Manipulation (Ml), Emotional Distress (M2), Filmily Communication (M3), Overprotectiveness (M4) and Znterference (M5). The items which were included in the preset cluster analysis for each of the clusters are presented in Table 1 along with their oblique cluster coefficients. The amount of the initial correlation matrix accounted for by each cluster when entered as a first factor was 24%, 58%, lo%, 40% and 489;, for cluster Ml-M5, respectively. These percentages indicate that M2, M4 and M5 each have substantial generality when considered alone and therefore have potential as diagnostic scales. Table 2 presents the correlation matrix for the clusters with the internal consistency reliabilities included on the diagonal of the matrix. M2, M4 and M5 were intercorrelated. Ml showed moderate relationships to M2 and M5, while M3 was independent of all other clusters. The internal consistency reliabilities were very high for Ml, M2, M4 and M5 and acceptable for M3. Futhers

Five clusters, which included 38 ‘items, emerged from the empirical cluster analysis. The clusters were conceptually similar to those abstracted for the mothers and were given the same labels: Interference (Fl), Manipulation (F2), Overprotectiveness (F3), Fumily Communication (F4) and Emotional Distress (F5). The items and the oblique factor coefficients from the results of the preset cluster analysis are presented in Table 3. The amount of the initial correlation matrix accounted for by each cluster when entered as a first factor was 50x, 23x, 23X, 14% and 45% for clusters Fl-F5, respectively, indicating that Fl and F5 have potential as diagnostic scales. Table 4 presents the correlation matrix for the clusters with the internal consistency reliabilities included on the diagonal of the matrix. Fl correlated substantially with F5 and F3, while F2 was moderately correlated with F5. The internal consistency reliabilites were very high for all of the clusters. DISCUSSION

The cluster solutions for the mothers and fathers were similar enough to warrant labeling the measures with the same names. There were, however, items under some of the clusters which were different for the mothers and the fathers. Consequently. the interpretation of some of the clusters is subtly different. Two of the clusters reflected the effect of the child’s illness on the parents. These were Emotionul Distress (M2 and F5) and Interference (M5 and Fl). Emotional Distress for the mother included items which indicate that she feels physically exhausted from having to care for her child, she gets upset when the child wheezes, and she feels the family is oriented around the child’s attacks. Other items indicate that the mother feels con-

HERMAN STAUDENMAYER

630

TABLE1. PRESENTCLUSTERANALYSES ON 159 MOTHERS OF ASTHMATIC CHILDREN

Cluster items M 1: Manipulation 1. My child uses the asthma to get what he (she) wants from me. 2. My child uses the asthma to manipulate me. 3. When my child wants my attention, he (she) will wheeze to get it. 4. I think my child brings on an asthma attack to get out of school. 5. I feel that if I ignored the asthma my child would soon outgrow it. M2: Emotional distress 1. I am an emotional wreck from worrying about my child’s asthma. 2. No one really understands what I am going through. 3. No one really understands the frustrations of raising a sick child. 4. The whole household revolves around my child’s asthma attacks. 5. Raising a child with asthma is exhausting. 6. I get very upset when my child starts to wheeze. 7. My life would be better if my child’s asthma was better. 8. Our family can’t do anything or go anywhere because our asthmatic child may have an attack. 9. I feel tied down by my child’s asthma. 10. Whether I do or I don’t, I’m damned. 11. No matter how I handle it, my child’s asthma cannot be well controlled. 12. I feel the tension rising inside me as my child begins to wheeze. 13. I have racked my brain trying to figure out why my child gets sick. 14. I cannot show the feelings that I am having.

Ml

M5

0.90 0.84

0.36 0.43

-0.14 - 0.05

0.18 0.26

0.39 0.52

0.82

0.20

- 0.05

0.08

0.25

0.59

0.25

-0.13

0.07

0.29

0.46

0.14

-0.04

0.00

0.07

0.37 0.08

0.78 0.72

- 0.25 -0.15

0.58 0.43

0.63 0.43

0.15

0.70

-0.12

0.48

0.54

0.28 0.34 0.26 0.24

0.69 0.65 0.64 0.64

-0.01 -0.17 - 0.24 - 0.08

0.50 0.45 0.51 0.32

0.66 0.62 0.48 0.49

0.21 0.20 0.37

0.61 0.61 0.59

-0.01 - 0.03 -0.10

0.54 0.48 0.35

0.61 0.66 0.58

0.26 0.23

0.58 0.57

0.03 -0.10

0.41 0.53

0.42 0.45

0.15 0.23

0.56 0.54

0.05 -0.23

0.42 0.33

0.44 0.48

-0.02 -0.08 0.07

0.81 0.53 0.39

0.04 0.04 0.19

0.01 -0.01 0.11

-0.30

0.36 -0.22

M3 : Family communication -0.12 1. I find out all that I can about asthma. -0.10 2. My child and I discuss his (her) illness. 0.06 3. I am aware of how well my child is breathing. 4. When there is a family problem, we a11sit down and talk about -0.08 it. M4: Overprotectiveness 0.14 1. Whenever my child goes somewhere without me, I am worried. 0.11 2. I am afraid to let my child out of my sight. 0.18 3. I worry that my child may get sick while I’m away. 4. My child’s illness makes me feel that he (she) needs me more 0.24 now than before he (she) got sick. -0.01 5. I prefer to have my child with me all the time. 0.05 6.1 am concerned that my child will die. 0.07 7. At the first sign of a problem I want to call the doctor. 0.03 8. I feel closer to my child when he (she) is sick. M5: Interference 1.1 have become socially isolated because of my child’s asthma. 2. I have had to give up a lot of my own satisfaction in order to take proper care of my child. 3. I feel that I am ignoring the rest of my family in order to take care of my sick child. 4. My other children resent the amount of time I spend with my sick child. 5. I secretly resent the responsibility of caring for a sick child. 6. I still enjoy my life even though my child has asthma.

Correlations of items with oblique cluster domains M2 M3 M4

-0.21

0.62 0.52 0.56

0.01 0.01 -0.07

0.80 0.78 0.72

0.44 0.51 0.43

0.51 0.30 0.45 0.29 0.27

-0.05 0.10 0.18 -0.16 0.09

0.61 0.55 0.54 0.49 0.45

0.40 0.26 0.36 0.21 0.21

0.19

0.59

0.09

0.43

0.84

0.23

0.65

0.13

0.41

0.80

0.35

0.63

0.43

0.74

0.37 0.30 0.22

0.56 0.45 -0.43

-0.08 0.40 -0.02 0.25 0.23 -0.31

0.59 0.50 -0.45

-0.06

strained and isolated, and that she feels that no one really understands what she is going through. Emotional Distress for the father included the same or similar items. The father also feels exhausted, he feels his life would be better if the child did not have asthma, he feels he cannot express his true feelings, and he feels that others do not understand what he is going through. In addition, the father expresses concern about controlling the child’s asthma and ignoring the rest of the family. The difference between the parents is

631

Parental Anxiety Associated with Childhood Asthma TABLE

2.

CLUSTER

SCORE

CORRELATIONS AND SOLUTION

Ml : Manipulation M2: Emotional Distress M3: Family Communication M4: Overprotectiveness M5 : Interference

RELIABILITIESFOR

MOTHERS'

PRESET

Ml

M2

M3

M4

M5

0.86

0.34 0.91

- 0.08 -0.12 0.62

0.14 0.62 0.01 0.84

0.36 0.74 - 0.03 0.48 0.83

N.B. The reliabilities are on the diagonal.

the fathers are predominantly concerned and worried about the child’s illness. The mothers express a much deeper and more profound level of disturbance, not so much focused on the illness of the child but rather focused on themselves. Interference (M5 and Fl) was highly correlated with Emotional Distress for both the mother and the father. The mothers’ cluster included items which reflect interference in social activities and loss of time with other family members. The mothers expressed feelings of unfulfillment and resentment over having to give up so much time to the care of the asthmatic child. Interference for the father also included items which reflect that he feels that he has to give up some of his satisfaction to take care of the child and that the family’s activities are restricted. Other items indicate that the father worries about the child’s asthma and is concerned when the child is away from him. Overprotectiveness for the mothers (M4) indicated concern about being away from the child and fear that the child may die. One item indicates a tendency to call the doctor immediately at the first sign of wheezing. Another item indicates that the parent feels closest to the child when the child is sick and may reflect the psychopathology associated with overprotectiveness. The cluster for the fathers (F3) is similar to that of the mothers with the exception that there is not so much concern about being with the child constantly. Manipulation by the child (Ml and F2) consisted of the same items for the mother and the father. The items reflect the parents’ perception of the child’s manipulations and how the child uses the asthma to gain advantage over the parents. The last cluster, Family Communicution (M3 and F4) measures the quality and extent of communication between the child and the parents about asthma, and the knowledge the parents have about asthma. For the father, the measure additionally reflects how well he can perceive the symptoms of breathing difficulty in the child.

that

EXPERIMENT

2: PARENTAL

DEBILITATION

SCALE

IN THE

SCORES

AND

CHILD

Another study [13] showed that children who suffer relatively more debilitation, as measured by the number of asthma attacks, emergency room visits, hospitalization, school absenteeism and interference in daily activities, are more likely to require institutional treatment and also have a greater incidence of high levels of anxiety. Following this line of thought, it is hypothesized that parental anxiety, like their children’s anxiety or because of it, will be directly related to the amount of debilitation. It is further hypothesized that Overprorectiveness will also be related to debilitation because an overprotective parent may interfere with appropriate self care habits and the attitude of self responsibility deemed necessary for proper management [15]. What the role of Family Communication plays in debilitation is not clear from the results of the study with the children. However, if we assume that appropriate self-care is related to good family communication and there are no other factors such as poor medical management which undermine that communication, then it is expected that more of the parents of the private practice patients who experienced the least debilitation will perceive themselves as having good communication with their children.

632

HERMANSTAUDENMAYER TABLE3. PRESETCLUSTER ANALYSES FOR70 FATHERS OF ASTHMATIC CHILDREN

Cluster items

Fl

Correlations of items with oblique cluster domains F2 F3 F4

F5

Fl : Interference

1. I have had to give up a lot of my own satisfaction in order to take proper care of my child. 2. I feel tied down by my child’s asthma. 3. I am an emotional wreck from worrying about my child’s asthma. 4. Our family can’t do anything or go anywhere because our asthmatic child may have an attack. 5. Whenever my child goes somewhere without me, I am worried. 6. The whole household revolves around my child’s asthma attacks. 7. I am afraid to let my child out of my sight. 8. I have become socially isolated because of my child’s asthma. 9. My first reaction to an asthma attack is confusion and fear. 10. 1 feel like I know more about my child’s asthma than most doctors. 11. I get very upset when my child starts to wheeze. 12. I do not know how to explain to my child why he (she) is sick while other children are healthy.

0.87 0.17

0.41 0.20

0.47 0.18

0.10 - 0.04

0.64 0.64

0.17

0.28

0.44

0.09

0.70

0.73 0.72

0.31 0.34

0.27 0.39

- 0.06 0.09

0.67 0.45

0.70 0.69 0.62 0.57

0.21 0.24 0.13 0.23

0.35 0.35 0.34 0.26

0.15 0.18 0.01 -0.12

0.55 0.49 0.49 0.38

0.52 0.44

0.12 0.14

0.24 0.30

0.26 -0.13

0.45 0.30

0.37

0.08

0.22

-0.16

0.34

0.95 0.82

0.02 0.13

- 0.09 -0.13

0.34 0.29

0.71

- 0.06

0.03

0.34

0.68 -0.39

- 0.07 0.14

-0.18 0.12

0.41 -0.20

0.24 0.14

- 0.25 -0.12

0.78 0.68

0.44 0.3 1

0.23 0.07

0.52 0.38 0.24 0.13 0.22

0.28 -0.15 -0.11 0.16 0.05

0.68 0.49 0.43 0.39 0.38

0.19 -0.01 0.14 0.10 0.10

0.53 0.15 0.15 0.09 0.17

0.10 - 0.08 0.11

-0.14 0.14 0.25

- 0.69 0.61 0.52

0.15 0.01 0.25

0.26 - 0.02

- 0.08 0.15

-0.50 0.44

0.13 0.03

0.13 0.31

0.40 0.40

-0.20 0.10

F2: Manipulation 1. My child uses the asthma to manipulate me. 0.32 2. My child uses the asthma to get what he (she) wants from me. 0.25 3. I think my child brings on an asthma attack to get out of school. 0.09 4. When my child wants my attention, he (she) will wheeze to get 0.42 it. 5. I can live with my child’s asthma. -0.15 F3: Overprotectivensss 1. The illness has brought us closer together. 2. Our child’s illness has brought our family closer. 3. My child’s illness makes me feel that he (she) needs me more now than before he (she) got sick. 4. I prefer to have my child with me all the time. 5. It is up to the doctors to control the asthma. 6. I feel I am more of a parent when caring for my asthmatic child. 7. I feel closer to my child when he (she) is sick.

F4: Family communication 1. I’m not sure what to do when I see my child develop breathing 0.06 problems. 2. My child and I discuss his (her) illness. 0.19 0.15 3. I am aware of how well my child is breathing. 4. I am the last person to call upon to handle a medical emer0.27 gency. 5. I find out all that I can about asthma. 0.16 6. When there is a family problem, we all sit down and talk about -0.11 it. 0.11 7. My child can do the right thing in an emergency. F5: Emotional distress 1. Raising a child with asthma is exhausting. 2. My life would be better if my child’s asthma was better. 3. My hopes for controlling my chitd’s asthma have been constantly frustrated. 4. I feel that I am ignoring the rest of my family in order to take care of my sick child. 5. My friends feel sorry for me because of my child’s illness. 6. I cannot show the feelings that I am having. 7. No one really understands what I am going through.

-0.13 -0.01

0.62 0.55

0.3 1 0.50

0.43 0.24

0.05 -0.01

0.84 0.74

0.66

0.43

0.27

0.03

0.71

0.66 0.39 0.37 0.38

0.14 0.19 0.24 0.24

0.26 0.19 0.26 0.01

- 0.05 -0.01 -0.16 0.05

0.70 0.68 0.52 0.45

METHODS

Procedure

The scale scores for each individual were computed by adding the responses for the individual items comprising each cluster. The scale scores were then normalized using T

633

Parental Anxiety Associated with Childhood Asthma TABLE

4.

CLUSTER

SCORE

Fl : Interference F2: Manipulation F3 : Overprotectiveness F4: Family Communication F5: Emotional Distress

CORRELATIONS AND SOLUTION

RELIABILITIESFOR

Fl

F2

0.91

0.31 0.86

F3 0.41 - 0.03 0.76

FATHERS' PRESET

F4 0.04 -0.11 0.25 0.73

FS 0.69 0.38 0.29 - 0.02 0.86

N.B. The reliabilities are on the diagonal

score transformations with a mean of 50 and SD of 10. The transformed scores for each scale were then used to divide the subjects into three approximately equally sized groups (much, middle, little) defined by cutoff points one-half of 1 SD above and below the mean. The cut points in the raw scale scores are shown in Table 5 for the mothers and in Table 6 for the fathers, along with the possible range of the scale scores and the mean and SD. The scales are oriented such that the lower scores indicate much of what the scale measures and the higher scores indicate little. For example, a low score on Manipulation indicates relatively much perceived manipulation, while a high score means virtually none. The prevalance of the number of mothers and fathers in each of these three groups is reported for the three subsamples representing the level of institutional treatment given the children, i.e. inpatient, outpatient or private practice. RESULTS

According to the hypothesis, the number of parents with scale scores in the much category on all but Family Communication should be largest when their children were inpatients, smallest when their children were treated in private practice, and intermediate when their children were outpatients. To test this hypothesis, chi-square tests of independence were carried out between the three subsamples and the three scale categories for each of the five scales. The results for the mothers are summarized in Table 7. The prevalence of perceived Manipulation was comparable in the three subsamples as was the level of Family Communication. However, relative to the expected values, more of the mothers of inpatients experienced much Emotional Distress, Overprotectiveness and Interference while more of the mothers of private practice patients experienced little. The prevalence rates for the mothers of the outpatients were between that of the rates for the inpatients and the private practice patients. The results for the prevalence rates for the fathers are presented in Table 8. The rates for Overprotectiveness were comparable in the three subsamples. Relative to the expected values, more of the fathers of inpatients experienced high levels of Interference, Munipulution and Emotional Distress, while more of the fathers of private practice patients experienced low levels on these measures. The rates for Family Communication approached statistical significance (P = 0.067) and indicated that there was more communication in the families of inpatients than in the families of private practice patients. No conclusions about the rates for fathers of outpatients could be made from the limited data available. DISCUSSION

The results of the prevalence rates of the psychosocial factors in the three subsamples for the mothers and fathers indicated that the degree of parental anxiety was related to the level of institutionalized treatment required and, consequently, the amount of debilitation experienced by the children [13]. Most of the parents of the children treated in private practice expressed very little Emotional Distress or Interference in their lives, whereas the majority of parents of the children treated as inpatients at NJH expressed much Emotional Distress and Interference. The amount of debilitation experienced by the children was not related to the mothers’ perceptions of Manipulation. However, the

: Manipulation

4.15

26.34

6-30

M5: Interference

210 234 229

7-9

25-28

260

21-33

=25

22-24 49-59

Little

14.0

13.3

21.5

13.4

54.2

24.3 24.8

4.1-4.7

2 = a lot, 3 = halfand

22.5

1.6-2.4

24.3

3.54.2

3.44.2

=5.0

4.3-4.9

Average scale score classification* Middle Little Much

The scale values are: 1 = almosf always,

524

126

~6

548

121

Much

Cluster score classification Middle

8.41 2.71 5.48 3.1-l 6.10

51.54 23.26 23.87 18.73 26.49

12-60

5-25

7-35

7-35

7-35

Fl : Interference

F2: Manipulation

F3: Overprotectiveness

F4: Family

*Average scale score = cluster score/number half 4 = a little, 5 = almost never.

distress

communication

F5: Emotional of items in the cluster.

SD

Cluster Mean

scores

Possible range

Cluster Little P 56 =25 221 221 230

48-55 22-24 22-26 1l-20 2429

23.3

4 2.3

13.0

5 4.2

53.9

3.44.2

2 = a lor, 3 = half and

> 3.0 2 4.3

2.4-2.9

= 5.0 2 3.9

4.3-4.9 3.1-3.8

2 4.6

4.0-4.5

Average scale score classification* Much Middle Little

The scale values are: 1 = almost always,

223

I I6

121

121

147

Much

Cluster score classification Middle

TABLE 6. SUMMARY DATA AND GUIDELINES FOR CLASSIFICATIONOF FATHERSINTO LOW, MODERATEAND HIGH SC‘OREGROUPS

of items in the cluster.

6.84

*Average scale score = cluster score/number ha/J 4 = a little, 5 = almost never.

3.13

8.26 30.16

8-40

54.00

4-20

3.08 11.40

23.15

5-25

14-70

SD

M4: Overprotectiveness

communi-

distress

scores

Mean

Cluster

M3: Family cation

M2: Emotional

Ml

Cluster

Possible range

TABLE 5. SUMMARY DATA AND GUIDELINES FOR CLASSIFICATIONOF MOTHERSINTO LOW, MODERATEAND HIGH SNOREGROUPS

Parental

TABLE

7. PERCENTAGE

OF MOTHERS

Anxiety

IN THE SCALE

EXPECTED

CELL

Associated

CATEGORIES

PERCENTAGE

with Childhood

FOR EACH PSYCHOLOGIC IN EACH

CATEGORY

635

Asthma

FACTOR

WITHIN

EACH

SUBSAMPLE

WITH

IN PARENTHESES

Subsample

Psychologic factor

Expected value

Scale category

Private patients (N = 48)

Outpatients (N = 64)

Inpatients (N = 47)

Chi-square test

Much Middle Little

(18) (31) (51)

21 32 47

20 36 44

10 25 65

~‘(4) = 5.6. P = 0.23

Emotional distress

Much Middle Little

(29) (31) (40)

55 30 15

23 33 44

10 31 58

~‘(4) = 29.5, P < 0.001

Family communication

Much Middle Little

(33) (36) (31)

32 43 26

30 39 31

38 25 38

z*(4) = 4.0. P = 0.41

Overprotectiveness

Much Middle Little

(22) (41) (37)

40 32 28

16 41 37

I2 42 46

x2(4) = 14.0, P = 0.007

Interference

Much Middle Little

(24) (34) (42)

43 45 13

19 30 52

13 29 58

x’(4) = 26.4. P < 0.001

Manipulation

TABLE

8. PERCENTAGE

OF FATHERS

IN THE SCALE

EXPECTED

CELL

CATEGORIES

PERCENTAGE

FOR

EACH

IN EACH

PSYCHOLOGIC

CATEGORY

FACTOR

WITHIN

EACH

SUBSAMPLE

IN PARENTHESES

Subsample

Psychologic factor

Scale category

Expected value

Inpatients (N = 27)

Outpatients (N = 8)

Private patients (N = 35)

Chi-square test

Interference

Much Middle Little

(20) (39) (41)

44 30 26

13 63 25

3 40 57

x2(4) = 19.4 P < 0.001 1

Manipulation

Much Middle Little

(20) (27) (53)

37 26 37

0 38 62

11 26 63

x’(4) = 9.2. P = 0.055

Overprotectiveness

Much Middle Little

(30) (33) (37)

41 26 33

25 50 25

23 34 43

x’(4) = 3.6. P = 0.47

Family communication

Much Middle Little

(24) (49) (27)

41 41 19

25 63 13

11 51 37

&4) = 8.8, P = 0.067

Emotional distress

Much Middle Little

(27) (36) (37)

63 22 15

0 50 50

6 43 51

r’(4) = 29.1. P < 0.001

inpatients who also experienced the most debilitation were more often perceived as being manipulative by their fathers. This discrepancy in parental perceptions might be explained if we consider the results of Overprotectiveness. More of the mothers of inpatients perceived themselves to be overprotective while there were no differences among the fathers. If the fathers’ perceptions of Manipulation are accurate, then it can be speculated the mothers do not acknowledge the manipulation because it leads to actions which are compatible with their own overprotectiveness. The results of Family Communication for the fathers were contrary to the predictions of the hypothesis. Fathers of inpatients more often had good communication with their children than the fathers of private practice patients. This finding substantiates the interpretation of Family Communication from the children’s point of view which indicated that lack of communication was not a significant factor in amount of debilitation. Again it must be pointed out that the hypothesis presupposes that valuable information is being communicated before it can have an effect on debilitation.

WITH

636

HERMAN STAUDENMAYER

CONCLUSION

Another study [13] has shown that much of the anxiety and emotional distress that asthmatic children experience is a consequence of a history of poor medical managebility rather than intractable asthma. The present study has shown that parental anxiety is also a consequent of the same poor medical manageability. Instruments to assess some psychosocial factors in asthmatic children and their parents that may be meaningfully related to the medical manageability of childhood asthma have been established in this and another study [13]. These instruments are easy to administer and can at least serve as an initial screening device to alert the physician to the stress and anxiety in the family. This anxiety can often be alleviated by discussing the disease with the family. If it cannot be alleviated, referral to a stress management clinic may be appropriate. Future research can be directed toward identifying individual types of children and parents based on patterns of scores across several of these psychosocial scales. Also, scale scores from the children can be combined with scale scores from the parents to construct family patterns. These patterns could then be related to measures of the medical manageability of the illness during long-term follow-up periods. This line of research could ultimately lead to the identification of individuals and families who would benefit from educational and therapeutic programs designed to alleviate the anxiety in the family which can accompany chronic, childhood illness [15, 161. Acknowledgements-I would like to express my appreciation to the families who cooperated in this research; to Irwin Matus, Ph.D., a clinical child psychologist for his assistance in selection of the questionnaire items and for his helpful criticisms throughout the course of the project; to John C. Selner, M.D. for making patients in his private practice available for the study and for comments which enhanced the message of the manuscript; to Peggy S. Harris for managing the follow-up program and typing the manuscript; to Irwin Matus, Peggy Harris, Ann Johnson and Winnie Barrett for their assistance in administering the questionnaires; to the nursing staff of the NJH inpatient and outpatient departments for their cooperation; and to Matthew Wiener and Martin Lefkowitz who gave me an appreciation of how comprehensive medical care could be realized. REFERENCES 1. Matus I, Bush D: Asthma attack frequency in a pediatric population. Psychosom Med 41: 629-636, 1979 2. Liebman R, Minuchin S, Baker L et al.: Chronic asthma: A new approach to treatment. In: Child Psychiatry: Treatment and Research. McMillan MF and Henao S (Eds). New York: Brunner-Mazel, 1977, pp. 153-171 3. Weiner HM : Psychobiology and Human Diseases. New York : Elsevier North-Holland, 1977 4. Knapp PH, Matht AA, Vachon L: Psychosomatic aspects of bronchial asthma. In: Bronchial Asthma: Mechanisms and Therapeutics. Weiss EB and Segal MS (Eds). Boston: Little, Brown, 1976, pp. 1055-1080 5. Purcell K, Weiss J, Hahn W: Certain psychosomatic disorders. In: Manual of Child Psychopathology. Wolman BE (Ed). New York: McGraw-Hill, 1972 6. Pinkerton P, Weaver CM: Childhood asthma. In: Modern Trends in Psychosomatic Medicine-2. Hill OW (Ed). New York: Appleton-Century-Crofts, 1970 7. Anthony J, Benedek T: Maternal rejection, overprotection and perplexity. In: Parenthood. Boston: Little, Brown, 1970 8. Rees L: The significance of parental attitudes in childhood asthma. J Psychosom Res 7: 181-190, 1963 9. Rees L: The importance of psychological, allergic and infective factors in childhood asthma. J Psychosom Res 7: 253-262,

1964

10. McLean JA, Ching AYT: Follow-up study of relationships between family situation and bronchial asthma in children. J Am Acad Child Psychiat 12: 142-161, 1973 11. Dubo S, McLean JR, Ching AYT et al.: A study of relations between family situation, bronchial asthma and personal adjustment in children. J Pediatr 59: 402-414, 1961 12. Liebman R, Minuchin S, Baker L: The use of structural family therapy in the treatment of intractable asthma. Am J Psychiat 131: 535-599, 1974 13. Staudenmayer H: Medical manageability and psychosocial factors in childhood asthma. J Chron Dis (in press).

14. Tryon RC, Bailey DE: Cluster Analysis. New York: McGraw-Hill, 1970 1.5. Selner JC, Staudenmayer H: Parents’ subjective evaluation of a self-help education-exercise program for asthmatic children and their parents. J Asthma Res 17: 13-22, 1979 16. Minuchin S: Families and Family Therapy. Cambridge, Mass.: Harvard University Press, 1977