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Parental Mental Health, Childhood Psychiatric Disorders, and Asthma Attacks in Island Puerto Rican Youth
Parental Mental Health, Childhood Psychiatric Disorders, and Asthma Attacks in Island Puerto Rican Youth Alexander N. Ortega, PhD; Renee D. Goodwin, PhD; Elizabeth L. McQuaid, PhD; Glorisa Canino, PhD Objective.—Previous research documents an association of poor parental mental health with asthma in children. This study aims to determine whether the associations between parental mental health problems and childhood asthma attacks persist after controlling for childhood anxiety and depression and other confounding factors. Design/Methods.—A community household sample of youth ages 4 to 17 years and their primary caregivers from the US Commonwealth of Puerto Rico was studied to determine the associations between parental mental health and childhood asthma attacks. Regression models that predicted asthma attacks in youth controlled for parental mental health problems, childhood anxiety and depression, zone of residence, and parents’ age, education, and perception of poverty. Results.—After adjusting for children’s depressive and anxiety disorders as well as other important confounders, associations between parental depression, suicide attempts, ataque de nervios, and history of mental health treatment and asthma attacks in offspring, by parental report, persisted. Additionally, the frequency of parental mental health problems was associated with children’s asthma attacks. Conclusion.—Parents with mental health problems were more likely to report histories of asthma attacks in their children compared with parents without mental health problems in Puerto Rico. These associations were not attributable to internalizing disorders in youth but persisted independent of childhood psychopathology and other confounding factors. Clinicians and researchers should recognize the relations between poor parental mental health and childhood asthma and explore the potential role of family psychosocial and behavioral factors related to the manifestation of the disease. KEY WORDS:
childhood asthma; Hispanic Americans; mental health
Ambulatory Pediatrics 2004;4:308 315
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ediatric asthma is a serious public health problem, affecting approximately 4.4 million children and adolescents in the United States, making it the most prevalent childhood chronic disease.1–3 Minority children, especially mainland and island Puerto Rican children, have an unusually high prevalence of parent-reported asthma.4,5 A recent community-based probability study indicated an asthma prevalence, based on parental reports, in island Puerto Rican children of approximately 30%, compared with 10% for mainland whites, 13% for mainland blacks, and 12% for mainland Hispanics.6 In a recent report, Findley et al7 reported that, compared with other groups of children in New York, Puerto Rican children had the highest morbidity, mortality, and hospitalization for asthma; 35% of the Puerto Rican children in their study had asthma. The reasons for the high prevalence of asthma in Puerto Rican children remain unclear.
Epidemiological studies have identified several risk factors for childhood asthma prevalence and severity in minority children, including family history,8 environmental factors (eg, pet ownership, allergens),9 family health beliefs,10 and disparities in health care use.11 Studies have also found associations between psychological and psychiatric problems and asthma among youth. For example, studies have reported that anxiety and, to a lesser extent, depression are more prevalent in children with asthma.4,6,12 A US study of children from four sites (New York, New Haven, Atlanta, and San Juan) found that pediatric asthma was specifically associated with anxiety, whereas anxiety was not associated with other chronic illnesses. In contrast, depression was not associated with asthma, but was associated with other chronic illnesses.6 Clinical studies in France show similar results.12 Other studies have reported associations between maternal mental health and asthma in offspring. Early studies of maternal mental health and pediatric asthma focused on parental coping behaviors. In particular, one study found that, in a sample of children at risk for developing asthma, poor parenting skills and parent coping were predictive of asthma onset.13 More recent studies have demonstrated associations between maternal anxiety and depressive symptoms and asthma.14–18 Gustafsson et al19 observed that family dysfunction was related to wheezing in infancy. Bender et al20 reported a relationship of family psychological adaptation with parental perception of asthma control. Despite this mounting evidence, the reasons for the ob-
From the Division of Health Behavior and Health Promotion, The Ohio State University School of Public Health (Dr Ortega), Columbus, Ohio; Department of Epidemiology (Dr Goodwin), Mailman School of Public Health, Columbia University, New York, NY; Department of Psychiatry and Human Behavior (Dr McQuaid), Rhode Island Hospital, Brown Medical School, Providence, RI; and the Behavioral Sciences Research Institute (Dr Canino), Medical Sciences Campus, University of Puerto Rico, San Juan, Puerto Rico. Address correspondence to Alexander N. Ortega, PhD, The Ohio State University School of Public Health, Division of Health Behavior and Health Promotion, 320 W Tenth Ave, Columbus, OH 43210 (e-mail: [email protected]). Received for publication October 14, 2003; accepted April 4, 2004. AMBULATORY PEDIATRICS Copyright q 2004 by Ambulatory Pediatric Association
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Associations among parental psychopathology, childhood internalizing disorder, and asthma outcomes.
served association between parental mental health and childhood asthma are not well established. One possibility is that less functional families may have difficulty following through with treatment guidelines, which in turn, may increase children’s risk of having severe asthma. Shalowitz and colleagues14 reported an association of maternal life stressors and symptoms of depression with high levels of childhood asthma morbidity in a sample of children from subspecialty practices. Alternatively, parents with mental health problems may have distorted perceptions of their children’s asthma symptoms (ie, they might overreport certain symptoms). For example, Wamboldt et al21 suggested that parents with mental health concerns might have significant stressors that influence reporting higher levels of internalizing symptoms for their children. This may also apply to higher reporting of physical symptoms as well. While evidence consistently suggests an association between parental mental health and asthma in youth, limitations of previous studies leave a number of unanswered questions regarding the relationship. First, with the exception of one study, studies have relied on rather small clinical samples of children instead of large population-based study designs.6 Thus, it is unclear whether these findings are generalizable to the community. Second, most studies have used psychiatric symptom scales but have not examined psychiatric disorders.22 Third, as previous studies have relied on clinical samples, only children with mild to moderate asthma23 or very severe asthma20 have been studied, so previous findings may not be extended to children across a broad range of illness severity. Finally, previous studies, to our knowledge, have been limited by the inability to control for the potential confounding of childhood psychiatric disorders when examining the relations between parental mental health and asthma in offspring. Addressing the issue of confounding by childhood psychiatric problems is important both conceptually and physiologically, given the associations between parental mental health and psychiatric outcomes in youth24 and of asthma with mental illness in both parents 15,25 and youth4,6,12 (see the Figure). Moreover, the delineation of which psychiatric and psychological problems, in both child and parent, are most proximal to asthma outcomes is critical for planning asthma interventions. For instance, researchers have suggested the importance of child psychiatric consultation for children with severe symptoms of asthma,26,27 while others have focused on the importance of parental and family intervention, such as reducing pa-
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rental and family stress and improving parenting skills.13,19,28–30 If indeed parental mental health problems are found to be significant predictors of asthma after the consideration of childhood internalizing disorder, it might be more effective to focus interventions on the parent instead of the child. Parental psychopathology may also be associated with increased likelihood of reporting asthma or other physical and mental health problems in children rather than increased illness per se. This finding could reflect overreporting or misinterpretation of minor physical symptoms or a cognitive bias resulting from depression or altered mental health status. This study examined the effects of parental mental health problems and the frequency of those problems on asthma attacks in a representative household sample of youth ages 4 to 17 years on the island of Puerto Rico. In an effort to extend available information building on previous studies that have observed an association between parental mental health problems and pediatric asthma, this study sought to determine whether the associations between parental psychopathology and parent reports of childhood asthma attacks persist after controlling for childhood anxiety and depression and other confounders, with a community-based sample. METHODS The ‘‘Service Use and Need in Puerto Rican Children’’ study examined mental health service use and psychiatric disorders for children ages 4 to 17 years in 1998 living in the US Commonwealth of Puerto Rico. The purpose of the original study was to provide data that would guide the integration of epidemiological and mental health service utilization data and to provide an organizational perspective for the study of Puerto Rican children’s mental health. The study used two samples. The current study reports on a community-based sample of 1891 children and adolescents and their primary caregivers. Research on the association between childhood psychiatric disorders and asthma in this sample has been reported previously.4,31 The present study focuses specifically on the association between parental mental health problems and parent reports of childhood asthma attacks. Community Sample The methods used in the community sample have been fully described in separate reports.4,32 In brief, the sample is an island-wide household probability sample of children ages 4 to 17 years (in 1999–2000) living in the US Commonwealth of Puerto Rico. After enumerating 6857 households, 2102 were found eligible and of these, 1891 children and caregivers were interviewed, for a 90.4% response rate. Measures Survey information was collected through direct interview with children and adolescents and their primary caregivers (89.4% of the caregivers were mothers). Descriptor variables included parental education (less than high school, high school, at least some university), per-
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ception of poverty (live very well, live comfortably, live from check to check, almost poor, poor; scored 1 to 5) and age as a continuous variable in years, and zone of residence (urban, rural; because Puerto Rico is a relatively small island, suburban was not categorized). Perception of poverty was used instead of other usual indicators of poverty, such as household income or parental education, because prior analyses of the current data showed no relationship between psychiatric disorders and income or parental education.32 The items used to assess perception of poverty were adapted from a measure developed by Gore et al,33 and the measure has been used in a number of other studies.34–36 The Diagnostic Interview Schedule for Children-IV (DISC) was administered to both the children and their primary caregivers to obtain composite measures of childhood psychiatric disorders. The DISC, a reliable, respondent-based instrument that is widely used in epidemiological surveys and clinical settings, provides diagnostic data on both psychiatric disorders and symptoms.37,38 The DISC is the only diagnostic instrument based on the standard psychiatric nosology that has been translated into Spanish by an international team of Hispanic bilingual investigators.39 The Spanish version of the DISC-IV used in the current study has been shown to have good testretest reliability for most disorders.37 Although concordance for child’s and parent’s reports has not been analyzed for the DISC-IV, concordance between parental and child reports was low for all diagnostic categories in a prior version of the instrument (DISC 2.3).40 These results were consistent with a number of other studies that have found that, whenever parents and children are independently assessed to determine the presence of child symptoms and or diagnosis, they report different information.41–44 In spite of this lack of concordance, both parent’s and child’s reports were combined to arrive at one diagnostic category because both may provide unique and meaningful information. Two global diagnostic categories, one for anxiety and another for depression, were developed. These categories were constructed by collapsing all specific diagnoses with common clinical characteristics, for example, major depressive episode and dysthymia, into the category of ‘‘any depressive disorder’’ and specific anxiety disorders, for example, separation anxiety, panic, social phobia, posttraumatic stress disorder, and generalized anxiety, into the category of ‘‘any anxiety disorder.’’ A case was considered positive if it met full DSM-IV diagnostic criteria in either the parent or child DISC-IV. Parental Mental Health The Family Psychiatric History Screen for Epidemiologic Studies (FH) was administered to the parent respondents to measure lifetime history of parental mental health problems.45 The instrument measures lifetime symptoms of depression and anxiety (6 items), conduct, or substance-abuse disorders (4 items), and whether or not the parent has ever been treated for or incapacitated by a psychological, emotional, or drug/alcohol problem. The sen-
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sitivity and specificity of self-report for the measures were reported in the Methods for the Epidemiology of Child and Adolescent Mental Disorders study (which included a site in Puerto Rico). The measure was found to have moderate to fair sensitivity and specificity for depression (64.4, 75.0) and panic (92.5, 89.2), and low sensitivity but high specificity for substance use (33.3, 93.6).45 The parental mental health questions from the FH module used in the current study assessed parental depression (2 or more weeks of feeling sad, blue, or depressed or lost all interest or pleasure in things), suicide (ever tried to commit suicide), alcohol and drug problems (ever had or been thought to have a drinking or drug problem), ataque de nervios (ever had an ataque de nervios), mental illness (ever had a serious emotional problem), history of school expulsion (ever been expelled from school), employment problems (ever been fired or laid off from a job because of behavior, attitude, or work performance), justice problems (ever been put in jail, arrested, or convicted of a crime other than drunk driving), ever seen a mental health provider (ever seen a psychiatrist, psychologist, social worker, doctor, or other health professional for a psychological or emotional problem), inattentive (ever during childhood have more problems paying attention or concentrating than other children your age), and hyperactive (ever during childhood have more problems because of being more active and impulsive, ie, hyperactive, than other children your age). In addition to the abovementioned instrument, we measured parental lifetime history of nerve attacks or ‘‘ataque de nervios’’ (in Spanish). Ataque de nervios is a welldocumented, culturally bound syndrome that is prevalent among Caribbean Latinos, particularly Puerto Ricans.46–50 This syndrome has been defined as an idiom of distress, which is commonly reported with symptoms of screaming uncontrollably, attacks of crying, trembling, and feelings of being out of control.51 We included an item on ataque de nervios in our protocol because prior epidemiological studies of the adult population on the island of Puerto Rico documented that around 16% of the population suffered from these attacks and because high rates of comorbidity between the attacks and anxiety and depressive disorders have been documented in this population.48 We also created a summary measure of the frequency of parental mental health problems by adding the number of affirmative reports of the 7 parental mental health problems from the FH instrument that are used in the final, current analyses (see Logistic Models). A preliminary univariate analysis was performed on the summary measure to determine cutoffs for a categorical measure of the intensity of mental health problems, and the categories were as follows: 0, 1, 2, or 3 or more. Finally, childhood asthma attacks were lifetime reports provided by the parents and coded as binary responses (yes, no). Three measures of asthma were included in the original study and all were based on parental reports (history of asthma diagnosis, history of asthma attacks, and history of asthma hospitalization). In the current study, we chose to include only history of asthma attacks be-
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Table 1. Characteristics of Sample by Lifetime History of Childhood Asthma Attack† n (%) No History of Asthma Attack (n 5 1466)
History of Asthma Attack (n 5 416)
Parental education Less than high school (n 5 538) High school or equivalent (n 5 756) At least some college (n 5 557)
433 (32) 587 (40) 416 (27)
104 (27) 170 (41) 139 (32)
Parental perception of poverty I live very well (n 5 1003) I live from check to check (n 5 614) I live poorly (n 5 265)
789 (51) 467 (33) 210 (15)
214 (51) 147 (34) 55 (15)
Parental age Less than 30 years 30 to 39 years 40 to 49 years 50 or older
278 609 414 165
78 180 126 32
P* NS
NS
NS (16) (48) (26) (10)
(15) (53) (25) (8) ,.05
Zone of residence Rural (n 5 460) Urban (n 5 1424)
388 (27) 1078 (73)
72 (19) 344 (81)
Any childhood anxiety disorder Yes (n 5 124) No (n 5 1750)
81 (96) 1381 (94)
43 (11) 369 (89)
Any childhood depressive disorder Yes (n 5 48) No (n 5 1832)
31 (2) 1434 (98)
17 (7) 398 (93)
,.01
,.02
*Chi-square. †The difference in n values are due to missing values.
cause our previous analyses found that history of asthma attacks were more robustly associated with psychiatric disorder than either asthma diagnosis or asthma hospitalization.4,31 Furthermore, researchers have postulated that the risk of asthma episodes depends on a complex relationship between psychological factors and experiencing an asthma attack,52 and asthma attacks are important mediators between asthma and psychological status.53 Analysis The sample was weighted to represent the general population of children in Puerto Rico in the year 2000. The weights correct for differences in the probability of selection due to the sampling design and adjust for nonresponse. To account for the complex sampling design, standard errors were estimated with SUDAAN software (release 8.0).54 First, bivariate analyses of association were performed by chi-square to compare subjects on selected characteristics (maternal education, perception of poverty, age, zone of residence, any childhood anxiety disorder, and any childhood depressive disorder) by history of asthma attack (yes, no). Then we compared the 11 parental mental health variables from the family history module (all coded yes, no) and the summary measure of the problems with the children’s histories of asthma attacks. Finally, logistic regression analyses were performed to assess the effects of 7 independent variables measuring parental mental health (depression, suicidal, alcohol/drug
problems, ataque de nervios, mental illness, ever seen a mental health provider, and inattentive) on childhood asthma attacks. The 7 independent parental mental health variables were chosen based on the significant results at P 5 .10 of the chi-square analyses (see Results). We computed the adjusted odds ratios after accounting for anxiety and depressive disorders in youth; zone of residence; and parental education, age, and perception of poverty. In preliminary analyses, we found that the parental mental health measures were marginally to highly intercorrelated and moderately collinear when predicting asthma attacks. Thus, we chose not to include the independent parental mental health measures in one model to avoid potential multicollinearity. Instead, we computed an intensity measure of parental mental health problems (see Measures). We computed unadjusted and adjusted dummy variable logistic regression models with four categories of the frequency of reported parental mental health problems (0, 1, 2, or 3 or more) as independent variables predicting asthma attacks in youth. Zero parental mental health problems was used as the reference. For the logistic regression models, odds ratios and their 95% confidence intervals are reported. RESULTS Table 1 shows the results of the differences in subject characteristics by history of childhood asthma attack. Only one marginal significant difference was observed for the characteristics. Children living in urban areas were
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Table 2. Associations of Parental Mental Health Variables and Childhood Asthma Attacks n (%) No History of Asthma Attacks (n 5 1466)
History of Asthma Attacks (n 5 416)
Depression No (n 5 1350) Yes (n 5 532)
1098 (76) 368 (24)
252 (62) 164 (38)
Suicidal No (n 5 1754) Yes (n 5 128)
1380 (94) 86 (6)
374 (89) 42 (11)
Alcohol/drug problems No (n 5 1753) Yes (n 5 129)
1376 (94) 90 (6)
377 (90) 39 (10)
Ataques de nervios No (n 5 1585) Yes (n 5 297)
1264 (86) 202 (14)
321 (75) 95 (25)
Mental illness No (n 5 1768) Yes (n 5 114)
1389 (95) 77 (5)
379 (91) 37 (9)
School expulsion No (n 5 1834) Yes (n 5 48)
1432 (97) 34 (3)
402 (97) 14 (3)
Employment problems No (n 5 1853) Yes (n 5 29)
1445 (99) 21 (1)
408 (98) 8 (2)
Justice problems No (n 5 1836) Yes (n 5 46)
1437 (97) 29 (3)
399 (96) 17 (4)
Ever seen a mental health provider No (n 5 1475) Yes (n 5 407)
1178 (80) 288 (20)
297 (73) 119 (27)
Inattentive No (n 5 1720) Yes (n 5 162)
1355 (92) 111 (8)
365 (89) 51 (11)
Hyperactive No (n 5 1748) Yes (n 5 124)
1371 (93) 95 (7)
377 (91) 39 (9)
Frequency of parental mental health problems 0 (n 5 1065) 1 (n 5 354) 2 (n 5 205) 3 or more (n 5 264)
P* .0001
(.07)
(.10)
.0001
(.06)
NS
NS
NS
,.02
,.04
NS
,.0001 889 254 144 179
(63) (15) (9) (13)
172 98 61 85
(44) (22) (14) (21)
*Chi-square.
more likely to have had an asthma attack than those living in rural areas. For the psychiatric disorders, both children with any anxiety disorder and any depressive disorder were more likely to have a history of asthma attack than those with no anxiety or depressive disorder. Table 2 shows the results for the parental mental health variables and history of childhood asthma attack. Four significant associations were found at P 5 .05. Children with a history of asthma attack were more likely to have parents with depression, ataque de nervios, ever seen a mental health provider, and inattentive symptoms than children with no history of asthma attack. At P 5 .10, we also found that suicidal, alcohol/drug problems, and men-
tal illness were significant. Further, frequency of parental mental health problems was associated with asthma attacks. Children with histories of asthma attacks were more likely to have parents with one or more mental health problems than children who had no histories of attacks. Table 3 shows the logistic regression results measuring the associations between 7 independent variables of mental health and asthma attack (chosen based on the significant bivariate results at P 5 .10). Overall, the estimated odds ratios changed little once they were adjusted, suggesting there was minimal confounding by children’s internalizing disorder, zone of residence, or parents’ education, age, or perception of poverty. In brief, children
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Parental Mental Health and Asthma Attacks
Table 3. Unadjusted and Adjusted Effects of Parental Mental Health Problems on Childhood Asthma Attacks, Logistic Regression Results*
Independent Variables Depression Suicidal Alcohol/drug problems Ataque de nervios Mental illness Ever seen a mental health provider Inattentive
Unadjusted OR (95% CI) 1.9 1.8 1.6 2.0 1.8 1.5 1.6
(1.4, (1.0, (1.0, (1.4, (1.1, (1.1, (1.1,
2.5) 3.1) 2.6) 2.7) 2.9) 2.1) 2.3)
Adjusted† OR (95% CI) 1.7 1.7 1.5 1.8 1.5 1.3 1.3
(1.2, (1.0, (0.9, (1.3, (0.9, (1.0, (0.9,
2.2) 2.9) 2.5) 2.4) 2.5) 1.8) 2.0)
*Models predict the presence of a history of asthma attack versus no history of an attack. OR indicates odds ratio; CI, confidence interval. †Adjusted for any depressive and any anxiety disorder in youth, zone of residence, and parental education, age, and perception of poverty.
with a history of asthma attack were more likely to have parents who were depressed, had been suicidal, had ataque de nervios, and had seen a mental health provider sometime in their lives. The adjusted results for alcohol/drug problems, parental mental illness and inattentiveness were not significant at the 95% confidence level; however, the lower bounds of the confidence limits were marginal at 0.9. Table 4 shows the unadjusted and adjusted regression results measuring the associations between the frequency of parental mental health problems (1, 2, or 3 or more vs 0 problems) and asthma attacks. Parents with 1, 2, or 3 or more problems were two times more likely to report asthma attacks in their children; however, the analyses do not suggest a linear trend in the frequency of reports. DISCUSSION This study has two main findings. First, parental mental health problems and the frequency of problems are associated with increased likelihood of parent-reported asthma attacks in island Puerto Rican youth. Second, a relationship between parental mental health problems and asthma attacks in Puerto Rican youth persists after adjusting for anxiety and depression in youth and other potentially confounding factors. To our knowledge, this is the first study to examine the associations between parental mental health problems and odds of asthma attacks in youth in the island Puerto Rican community, controlling for pediatric anxiety and depression as potential confounders of this relationship. Previous studies have examined the direct relations between parental mental health and asthma, severity of asthma, and use of treatment for asthma in youth, but they have not examined the issue of potential confounding of childhood mental disorder. For example, among mothers of children with asthma, perceived stress was greater and the quality of the mother-child relationship more problematic than among mothers of children without asthma.55 This study also observed greater behavioral difficulty in children with asthma than children without asthma.55 Klinnert et al56
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Table 4. Unadjusted and Adjusted Effects of the Frequency of Parental Mental Health Problems on Childhood Asthma Attacks, Logistic Regression Results* Frequency of Problems
Unadjusted OR (95% CI)
Adjusted† OR (95% CI)
0 1 2 3 or more
Referent 2.1 (1.5, 2.9) 2.1 (1.4, 3.3) 2.3 (1.6, 3.3)
Referent 2.0 (1.4, 2.8) 2.0 (1.2, 3.0) 2.0 (1.4, 2.9)
*Models predict the presence of a history of asthma attack versus no history of an attack. OR indicates odds ratio; CI, confidence interval. †Adjusted for any depressive and any anxiety disorder in youth, zone of residence, and parental education, age, and perception of poverty.
also found higher levels of parental difficulties in children with asthma than children without asthma, in addition to reporting an association between psychosocial problems in infancy and increased risk of asthma among schoolaged children. Our current results extend previous findings, including those of our own, of the associations between poor mental health in parents and asthma in Latino youth by showing that they extend to youth in the general Puerto Rican community and not only to those children selected from mainland clinical samples. Further, our data identify specific parental mental health problems that appear most strongly associated with asthma attacks in youth, in particular depression, suicide attempts, and ataque de nervios. Finally, our results show that the relationships between parental mental health problems and the frequency of those problems and parent-reported asthma attacks in Puerto Rican youth persisted independent of internalizing disorder in youth. It was interesting that children with a history of asthma attacks were 80% more likely to have parents with ataque de nervios than children without a history of asthma attacks. While the current data do not permit further analyses of this association, it is interesting to note their similarities. A common symptom of an ataque de nervios is feeling out of control. A number of explanations could contribute to this observed association. For example, parents with children with asthma may feel overwhelmed by the management of the disease or the anticipation of an attack in their children, which may result in an ‘‘ataque’’ in the parents. Some researchers have also postulated that parents with children with a chronic illness such as asthma may have significant stressors that influence reporting higher levels of internalizing symptoms for their children.21 Future studies on asthma in Latino, particularly Puerto Rican, children should continue to explore the relations among internalizing symptoms and disorders in parents and children and asthma outcomes. Further, pediatricians and other providers should keep in mind that these associations exist and that some children with asthma, especially those with severe symptoms of asthma, may need psychosocial intervention that aims to reduce stress in the home environment.30 Our results also suggest that mental disorders in youth
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may make some contribution to the association between parental mental health and asthma attacks in youth, but they do not completely account for it. It is conceivable that there are environmental factors that influence the association between parental psychopathology, psychopathology in children, and asthma in children as well. For instance, if a child who has asthma has a parent with an anxiety disorder, it is conceivable that high levels of anxiety in the parent over the child’s illness could result in increased anxiety in the child him or herself, increasing the risk of onset of an anxiety disorder in the child. It may also be that other environmental factors play a role in these potential pathways. These include lower socioeconomic status, urban-rural environment, and other familyemotional environmental factors. What are some potential mechanisms of the relationship between parental mental illness and health outcomes in youth? The reason for the association between parents’ mental health and asthma attacks in their children cannot be determined from these data, but there are several suppositions. The fear or worry of asthma attacks in offspring alone may lead to mental distress in parents, yet it seems more likely that this may be only one of several contributing factors to a highly stressful environment. It is possible that parents of children with asthma may develop heightened anxiety over threats to the child’s health, such as severe asthma attacks, associated physical morbidity, and even risk of mortality. Alternatively, parents of children with asthma may feel more overwhelmed with everyday stressors and demands associated with childrearing, which may progress to anxiety and depression. These results extend previously documented associations in clinical samples that suggest these possible mechanisms, and they demonstrate that the associations may be applicable in the general community of island Puerto Rican children and not necessarily be due to treatment-seeking bias or be found in only those with severe asthma. Study Limitations Use of parental report as our index of asthma attacks is a limitation of the present study. In this study, there were no formal physician diagnoses or assessment of asthma in the youth, nor were pulmonary function tests carried out to confirm parental report of diagnosis. Therefore, it should be noted that replication of these findings is needed with more objective measures of asthma status, as parental reports of asthma attacks are likely subject to bias. Further, as is the case with any cross-sectional, descriptive data, there may be other residual factors, such as stress, that explain the relations. We are also unable to make claims regarding directionality or causation. For instance, we do not know whether the parents’ mental health problems occurred long before the asthma attacks in their progeny, shortly before, or even after asthma onset, which is a major limitation of our data. Unfortunately, in the present study, we are only able to demonstrate associations. There could also be potential co-occurrence of childhood internalizing disorders and asthma attacks. Future research implementing longitudinal
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designs is necessary to assess the temporal relationships and potential causal links among these variables. Conclusions This study suggests that parental mental health problems and the frequency of those problems are associated with asthma attacks in offspring in the community in Puerto Rico, and these associations persist even after adjusting for the effects of childhood anxiety and depression. Clinicians and researchers should be mindful of the potential role of parental mental health in pediatric asthma patients. Such awareness may help facilitate better clinical decision-making, including recommending intervention on family stressors for some children with asthma. ACKNOWLEDGMENTS This work was supported by US Public Health Service, National Institute of Mental Health grants R01-MH54827 and P01-MH59876, and by the National Center on Minority Health and Health Disparities grant P20-MD000. The authors thank Mr Pedro Garcia and Dr John Rizzo for help in the analysis of data.
REFERENCES 1. Mannino DM, Homa DM, Akinbami LJ, et al. Surveillance for asthma—United States, 1980–1999. MMWR. 2002;51:1–13. 2. Adams PF, Hendershot GE, Marano MA. Current estimates from the National Health Interview Survey, 1996. National Center for Health Statistics. Vital Health Stat. 1999;10:200. 3. Eggleston PA. Asthma. In: McMillan JA, DeAngelis CD, Feigin RD, Warshaw JB, eds. Oski’s Pediatrics: Principles and Practice. 3rd ed. Philadelphia, Pa: Lippincott Williams and Wilkins; 1999:2041–2049. 4. Ortega AN, McQuaid EL, Canino G, et al. Association of psychiatric disorders and different indicators of asthma in island Puerto Rican children. Soc Psychiatry Psychiatr Epidemiol. 2003;38:220–226. 5. Beckett WS, Belanger K, Gent JF, et al. Asthma among Puerto Rican Hispanics: a multi-ethnic comparison study of risk factors. Am J Resp Crit Care Med. 1996;154:894–899. 6. Ortega AN, Huertas SE, Canino G, et al. Childhood asthma, chronic illness, and psychiatric disorders. J Nerv Ment Dis. 2002;190:275–281. 7. Findley S, Lawler K, Bindra M, et al. Elevated asthma and indoor environmental exposures among Puerto Rican children of East Harlem. J Asthma. 2003;40:557–569. 8. Burke W, Fesinmeyer M, Reed K, et al. Family history as a predictor of asthma risk. Am J Prev Med. 2003;24:160–169. 9. Kitch BT, Chew G, Burge HA, et al. Socioeconomic predictors of high allergen levels in homes in the greater Boston area. Environ Health Perspect. 2000;108:301–307. 10. Mansour ME, Lanphear BP, DeWitt TG. Barriers to asthma care in urban children: parent perspectives. Pediatrics. 2000;106: 512–519. 11. Ortega AN, Gergen PJ, Paltiel AD, et al. Impact of site of care, race, and Hispanic ethnicity on medication use for childhood asthma. Pediatrics. 2002;109:e1. 12. Vila G, Nollet-Clemencon C, de Blic J, et al. Prevalence of DSM IV anxiety and affective disorders in a pediatric population of asthmatic children and adolescents. J Affect Disord. 2000;58:223–231. 13. Mrazek DA, Klinnert MD, Mrazek P, Macey T. Early asthma onset: consideration and parenting issues. J Am Acad Child Adolesc Psychiatry. 1991;30:277–228. 14. Shalowitz MU, Berry CA, Quinn KA, Wolf RL. The relationship of life stressors and maternal depression to pediatric asthma morbidity in a subspecialty practice. Ambul Pediatr. 2000;1: 185–193.
AMBULATORY PEDIATRICS 15. Weil CM, Wade SL, Bauman LJ, et al. The relationship between psychosocial factors and asthma morbidity in inner-city children with asthma. Pediatrics. 1999;104:1274–1280. 16. Bosley CM, Corden ZM, Cochrane GM. Psychological factors and asthma. Respir Med. 1996;90:453–457. 17. Carr RE, Lehrer PM, Hochron SM, Jackson A. Effect of psychological stress on airway impedance in individuals with asthma and panic disorder. J Abnorm Psychol. 1996;105:137–141. 18. Frankel K, Wamboldt MZ. Chronic childhood illness and maternal mental health—why should we care? J Asthma. 1998;35: 621–630. 19. Gustafsson PA, Bjorksten B, Kjellman NIM. Family dysfunction in asthma: a prospective study of illness development. J Pediatr. 1994;125:493–498. 20. Bender BG, Annett RD, Ikle D, et al. Relationship between disease and psychological adaptation in children in the Childhood Asthma Management Program and Their Families. Camp Research Group. Arch Pediatr Adolesc Med. 2000;154:706– 713. 21. Wamboldt MZ, Fritz G, Mansell A, et al. Relationship of asthma severity and psychological problems in children. J Am Acad Child Adolesc Psychiatry. 1998;37:943–950. 22. McQuaid EL, Kopel SJ, Nassau JH. Behavioral adjustment in children with asthma: a meta analysis. J Dev Behav Pediatr. 2001;22:430–490. 23. Wamboldt MZ, Weintraub P, Krafchick D, et al. Psychiatric family history in adolescents with severe asthma. J Am Acad Child Adolesc Psychiatry. 1996;35:1042–1049. 24. Oyserman D, Bybee D, Mowbray C. Influences of maternal mental illness on psychological outcomes for adolescent children. J Adolesc. 2002;25:587–602. 25. Bartlett SJ, Kolodner K, Butz AM, et al. Maternal depressive symptoms and emergency department use among inner-city children with asthma. Arch Pediatr Adolesc Med. 2001;155: 347–353. 26. Fritz GK, Steiner H, Hillyard J, Lewiston N. Pediatric and psychiatric collaboration in the management of childhood asthma. Clin Pediatr. 1981;20:772–776. 27. Rietveld S, Creer TL. Psychiatric factors in asthma: implications for diagnosis and therapy. Am J Respir Med. 2003;2:1–10. 28. Calam R, Gregg L, Simpson B, et al. Childhood asthma, behavior problems, and family functioning. J Allergy Clin Immunol. 2003;112:499–504. 29. Klinnert MD, Mrazek PJ, Mrazek DA. Early asthma onset: the interaction between family stressors and adaptive parenting. Psychiatry. 1994;57:51–61. 30. Wright RJ, Cohen S, Carey V, et al. Parental stress as a predictor of wheezing in infancy: prospective birth-cohort study. Am J Respir Crit Care Med. 2002;165:358–365. 31. Ortega AN, McQuaid EL, Canino G, et al. Comorbidity of asthma and anxiety and depression in Puerto Rican children. Psychosomatics. 2004;45:93–99. 32. Canino G, Shrout PE, Rubio-Stipec M, et al. The DSM-IV rates of child and adolescent disorders in Puerto Rico: prevalence, correlates, service use, and the effects of impairment. Arch Gen Psychiatry. 2004;61:85–93. 33. Gore S, Aseltine RH Jr, Colton ME. Social structure, life stress and depressive symptoms in a high school-aged population. J Health Soc Behav. 1992;33:97–113. 34. Roberts RE, Roberts CR, Chen IG. Ethnocultural differences in sleep complaints among adolescents. J Nerv Ment Dis. 2000; 188:222–229. 35. Roberts RE, Chen YR, Roberts CR. Ethnocultural differences in prevalence of adolescent suicidal behaviors. Suicide Life Threat Behav. 1997;27:208–217. 36. Roberts RE, Roberts CR, Chen IG. Functioning of adolescents with symptoms of disturbed sleep. J Youth Adolesc. 2001;30: 1–18. 37. Bravo M, Ribera J, Rubio-Stipec M, et al. Test-retest reliability
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38.
39.
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of the Spanish version of the Diagnostic Interview Schedule for Children (DISC-IV). J Abnorm Child Psychol. 2001;29:433– 444. Shaffer D, Fisher P, Dulcan MK, et al. The NIMH Diagnostic Interview Schedule for Children Version 2.3 (DISC-2.3): description, acceptability, prevalence rates, and performance in the MECA study. Methods for the Epidemiology of Child and Adolescent Mental Disorders Study. J Am Acad Child Adolesc Psychiatry. 1996;35:865–877. Bravo M, Woodbury-Farina M, Canino GJ, et al. The Spanish translation and cultural adaptation of the Diagnostic Interview Schedule for Children (DISC) in Puerto Rico. Cult Med Psychiatry. 1993;17:329–344. Jensen P, Rubio-Stipec M, Canino G, et al. Parent and child contributions to child psychiatric diagnosis: are both informants always necessary? J Am Acad Child Adolesc Psychiatry. 38: 1569–1579. Achenbach TM, McConaughy SH, Howell CT. Child/adolescent behavioral and emotional problems: implications of cross-informant correlations for situational specificity. Psychol Bull. 1987; 101:213–232. Rubio-Stipec M, Canino G, Shrout P, et al. Psychometric properties of parents and children as informants in child psychiatry epidemiology with the Spanish Diagnostic Interview Schedule for Children (DISC.2). J Abnorm Child Psychol. 1994;22:703– 720. Cantwell DP, Lewinsohn PM, Rohde P, Seeley JR. Correspondence between adolescent report and parent report of psychiatric diagnostic data. J Am Acad Child Adolesc Psychiatry. 1997;36: 610–619. Offord DR, Boyle MH, Racine Y, et al. Integrating assessment data from multiple informants. J Am Acad Child Adolesc Psychiatry. 1996;35:1078–1085. Lish JD, Weissman MM, Adams PB, et al. Family psychiatric screening instruments for epidemiologic studies: pilot testing and validation. Psychiatry Res. 1995;57:169–180. Lewis-Fernandez R, Guarnaccia PJ, Martinez IE, et al. Comparative phenomenology of ataques de nervios, panic attacks, and panic disorder. Cult Med Psychiatry. 2002;26:199–223. Guarnaccia PJ, Canino G, Rubio-Stipec M, et al. The prevalence of ataques de nervios in the Puerto Rico disaster study. The role of culture in psychiatric epidemiology. J Nerv Ment Dis. 1993; 181:157–165. Guarnaccia PJ, Guevara LM, Gonzalez G, et al. Cross cultural aspects of psychotic symptoms in Puerto Rico. Res Community Mental Health. 1992;7:99–110. Guarnaccia PJ, Rivera M, Franco F, et al. The experiences of ataques de nervios: towards an anthropology of emotions in Puerto Rico. Cult Med Psychiatry. 1996;20:343–367. Guarnaccia PJ, Rubio-Stipec M, Canino G. Ataques de nervios in the Puerto Rican Diagnostic Interview Schedule: the impact of cultural categories on psychiatric epidemiology. Cult Med Psychiatry. 1989;13:275–295. American Psychiatric Association (APA). Diagnostic and Statistical Manual of Mental Disorders. 4th ed (DSM-IV). Washington, DC: American Psychiatric Association; 1994. Osman LM. Psychological factors in asthma control and attack risk. Thorax. 2002;57:190–191. Greaves CJ, Eiser C, Seamark D, Halpin DMG. Attack context: an important mediator of the relationship between psychological status and asthma outcomes. Thorax. 2002;57:217–221. Research Triangle Park. SUDAAN software for the statistical analysis of correlated data. Available at: http://www.rti.org/sudaan. Accessed May 2, 2003. Carson DK, Schauer RW. Mothers of children with asthma: perceptions of parenting stress and the mother-child relationship. Psychol Rep. 1992;71(3 Pt 2):1139–1148. Klinnert MD, Nelson HS, Price MR, et al. Onset and persistence of childhood asthma: predictors from infancy. Pediatrics. 2001; 108:e69.
childhood asthma; Hispanic Americans; mental health
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P
ediatric asthma is a serious public health problem, affecting approximately 4.4 million children and adolescents in the United States, making it the most prevalent childhood chronic disease.1–3 Minority children, especially mainland and island Puerto Rican children, have an unusually high prevalence of parent-reported asthma.4,5 A recent community-based probability study indicated an asthma prevalence, based on parental reports, in island Puerto Rican children of approximately 30%, compared with 10% for mainland whites, 13% for mainland blacks, and 12% for mainland Hispanics.6 In a recent report, Findley et al7 reported that, compared with other groups of children in New York, Puerto Rican children had the highest morbidity, mortality, and hospitalization for asthma; 35% of the Puerto Rican children in their study had asthma. The reasons for the high prevalence of asthma in Puerto Rican children remain unclear.
Epidemiological studies have identified several risk factors for childhood asthma prevalence and severity in minority children, including family history,8 environmental factors (eg, pet ownership, allergens),9 family health beliefs,10 and disparities in health care use.11 Studies have also found associations between psychological and psychiatric problems and asthma among youth. For example, studies have reported that anxiety and, to a lesser extent, depression are more prevalent in children with asthma.4,6,12 A US study of children from four sites (New York, New Haven, Atlanta, and San Juan) found that pediatric asthma was specifically associated with anxiety, whereas anxiety was not associated with other chronic illnesses. In contrast, depression was not associated with asthma, but was associated with other chronic illnesses.6 Clinical studies in France show similar results.12 Other studies have reported associations between maternal mental health and asthma in offspring. Early studies of maternal mental health and pediatric asthma focused on parental coping behaviors. In particular, one study found that, in a sample of children at risk for developing asthma, poor parenting skills and parent coping were predictive of asthma onset.13 More recent studies have demonstrated associations between maternal anxiety and depressive symptoms and asthma.14–18 Gustafsson et al19 observed that family dysfunction was related to wheezing in infancy. Bender et al20 reported a relationship of family psychological adaptation with parental perception of asthma control. Despite this mounting evidence, the reasons for the ob-
From the Division of Health Behavior and Health Promotion, The Ohio State University School of Public Health (Dr Ortega), Columbus, Ohio; Department of Epidemiology (Dr Goodwin), Mailman School of Public Health, Columbia University, New York, NY; Department of Psychiatry and Human Behavior (Dr McQuaid), Rhode Island Hospital, Brown Medical School, Providence, RI; and the Behavioral Sciences Research Institute (Dr Canino), Medical Sciences Campus, University of Puerto Rico, San Juan, Puerto Rico. Address correspondence to Alexander N. Ortega, PhD, The Ohio State University School of Public Health, Division of Health Behavior and Health Promotion, 320 W Tenth Ave, Columbus, OH 43210 (e-mail: [email protected]). Received for publication October 14, 2003; accepted April 4, 2004. AMBULATORY PEDIATRICS Copyright q 2004 by Ambulatory Pediatric Association
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Associations among parental psychopathology, childhood internalizing disorder, and asthma outcomes.
served association between parental mental health and childhood asthma are not well established. One possibility is that less functional families may have difficulty following through with treatment guidelines, which in turn, may increase children’s risk of having severe asthma. Shalowitz and colleagues14 reported an association of maternal life stressors and symptoms of depression with high levels of childhood asthma morbidity in a sample of children from subspecialty practices. Alternatively, parents with mental health problems may have distorted perceptions of their children’s asthma symptoms (ie, they might overreport certain symptoms). For example, Wamboldt et al21 suggested that parents with mental health concerns might have significant stressors that influence reporting higher levels of internalizing symptoms for their children. This may also apply to higher reporting of physical symptoms as well. While evidence consistently suggests an association between parental mental health and asthma in youth, limitations of previous studies leave a number of unanswered questions regarding the relationship. First, with the exception of one study, studies have relied on rather small clinical samples of children instead of large population-based study designs.6 Thus, it is unclear whether these findings are generalizable to the community. Second, most studies have used psychiatric symptom scales but have not examined psychiatric disorders.22 Third, as previous studies have relied on clinical samples, only children with mild to moderate asthma23 or very severe asthma20 have been studied, so previous findings may not be extended to children across a broad range of illness severity. Finally, previous studies, to our knowledge, have been limited by the inability to control for the potential confounding of childhood psychiatric disorders when examining the relations between parental mental health and asthma in offspring. Addressing the issue of confounding by childhood psychiatric problems is important both conceptually and physiologically, given the associations between parental mental health and psychiatric outcomes in youth24 and of asthma with mental illness in both parents 15,25 and youth4,6,12 (see the Figure). Moreover, the delineation of which psychiatric and psychological problems, in both child and parent, are most proximal to asthma outcomes is critical for planning asthma interventions. For instance, researchers have suggested the importance of child psychiatric consultation for children with severe symptoms of asthma,26,27 while others have focused on the importance of parental and family intervention, such as reducing pa-
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rental and family stress and improving parenting skills.13,19,28–30 If indeed parental mental health problems are found to be significant predictors of asthma after the consideration of childhood internalizing disorder, it might be more effective to focus interventions on the parent instead of the child. Parental psychopathology may also be associated with increased likelihood of reporting asthma or other physical and mental health problems in children rather than increased illness per se. This finding could reflect overreporting or misinterpretation of minor physical symptoms or a cognitive bias resulting from depression or altered mental health status. This study examined the effects of parental mental health problems and the frequency of those problems on asthma attacks in a representative household sample of youth ages 4 to 17 years on the island of Puerto Rico. In an effort to extend available information building on previous studies that have observed an association between parental mental health problems and pediatric asthma, this study sought to determine whether the associations between parental psychopathology and parent reports of childhood asthma attacks persist after controlling for childhood anxiety and depression and other confounders, with a community-based sample. METHODS The ‘‘Service Use and Need in Puerto Rican Children’’ study examined mental health service use and psychiatric disorders for children ages 4 to 17 years in 1998 living in the US Commonwealth of Puerto Rico. The purpose of the original study was to provide data that would guide the integration of epidemiological and mental health service utilization data and to provide an organizational perspective for the study of Puerto Rican children’s mental health. The study used two samples. The current study reports on a community-based sample of 1891 children and adolescents and their primary caregivers. Research on the association between childhood psychiatric disorders and asthma in this sample has been reported previously.4,31 The present study focuses specifically on the association between parental mental health problems and parent reports of childhood asthma attacks. Community Sample The methods used in the community sample have been fully described in separate reports.4,32 In brief, the sample is an island-wide household probability sample of children ages 4 to 17 years (in 1999–2000) living in the US Commonwealth of Puerto Rico. After enumerating 6857 households, 2102 were found eligible and of these, 1891 children and caregivers were interviewed, for a 90.4% response rate. Measures Survey information was collected through direct interview with children and adolescents and their primary caregivers (89.4% of the caregivers were mothers). Descriptor variables included parental education (less than high school, high school, at least some university), per-
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ception of poverty (live very well, live comfortably, live from check to check, almost poor, poor; scored 1 to 5) and age as a continuous variable in years, and zone of residence (urban, rural; because Puerto Rico is a relatively small island, suburban was not categorized). Perception of poverty was used instead of other usual indicators of poverty, such as household income or parental education, because prior analyses of the current data showed no relationship between psychiatric disorders and income or parental education.32 The items used to assess perception of poverty were adapted from a measure developed by Gore et al,33 and the measure has been used in a number of other studies.34–36 The Diagnostic Interview Schedule for Children-IV (DISC) was administered to both the children and their primary caregivers to obtain composite measures of childhood psychiatric disorders. The DISC, a reliable, respondent-based instrument that is widely used in epidemiological surveys and clinical settings, provides diagnostic data on both psychiatric disorders and symptoms.37,38 The DISC is the only diagnostic instrument based on the standard psychiatric nosology that has been translated into Spanish by an international team of Hispanic bilingual investigators.39 The Spanish version of the DISC-IV used in the current study has been shown to have good testretest reliability for most disorders.37 Although concordance for child’s and parent’s reports has not been analyzed for the DISC-IV, concordance between parental and child reports was low for all diagnostic categories in a prior version of the instrument (DISC 2.3).40 These results were consistent with a number of other studies that have found that, whenever parents and children are independently assessed to determine the presence of child symptoms and or diagnosis, they report different information.41–44 In spite of this lack of concordance, both parent’s and child’s reports were combined to arrive at one diagnostic category because both may provide unique and meaningful information. Two global diagnostic categories, one for anxiety and another for depression, were developed. These categories were constructed by collapsing all specific diagnoses with common clinical characteristics, for example, major depressive episode and dysthymia, into the category of ‘‘any depressive disorder’’ and specific anxiety disorders, for example, separation anxiety, panic, social phobia, posttraumatic stress disorder, and generalized anxiety, into the category of ‘‘any anxiety disorder.’’ A case was considered positive if it met full DSM-IV diagnostic criteria in either the parent or child DISC-IV. Parental Mental Health The Family Psychiatric History Screen for Epidemiologic Studies (FH) was administered to the parent respondents to measure lifetime history of parental mental health problems.45 The instrument measures lifetime symptoms of depression and anxiety (6 items), conduct, or substance-abuse disorders (4 items), and whether or not the parent has ever been treated for or incapacitated by a psychological, emotional, or drug/alcohol problem. The sen-
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sitivity and specificity of self-report for the measures were reported in the Methods for the Epidemiology of Child and Adolescent Mental Disorders study (which included a site in Puerto Rico). The measure was found to have moderate to fair sensitivity and specificity for depression (64.4, 75.0) and panic (92.5, 89.2), and low sensitivity but high specificity for substance use (33.3, 93.6).45 The parental mental health questions from the FH module used in the current study assessed parental depression (2 or more weeks of feeling sad, blue, or depressed or lost all interest or pleasure in things), suicide (ever tried to commit suicide), alcohol and drug problems (ever had or been thought to have a drinking or drug problem), ataque de nervios (ever had an ataque de nervios), mental illness (ever had a serious emotional problem), history of school expulsion (ever been expelled from school), employment problems (ever been fired or laid off from a job because of behavior, attitude, or work performance), justice problems (ever been put in jail, arrested, or convicted of a crime other than drunk driving), ever seen a mental health provider (ever seen a psychiatrist, psychologist, social worker, doctor, or other health professional for a psychological or emotional problem), inattentive (ever during childhood have more problems paying attention or concentrating than other children your age), and hyperactive (ever during childhood have more problems because of being more active and impulsive, ie, hyperactive, than other children your age). In addition to the abovementioned instrument, we measured parental lifetime history of nerve attacks or ‘‘ataque de nervios’’ (in Spanish). Ataque de nervios is a welldocumented, culturally bound syndrome that is prevalent among Caribbean Latinos, particularly Puerto Ricans.46–50 This syndrome has been defined as an idiom of distress, which is commonly reported with symptoms of screaming uncontrollably, attacks of crying, trembling, and feelings of being out of control.51 We included an item on ataque de nervios in our protocol because prior epidemiological studies of the adult population on the island of Puerto Rico documented that around 16% of the population suffered from these attacks and because high rates of comorbidity between the attacks and anxiety and depressive disorders have been documented in this population.48 We also created a summary measure of the frequency of parental mental health problems by adding the number of affirmative reports of the 7 parental mental health problems from the FH instrument that are used in the final, current analyses (see Logistic Models). A preliminary univariate analysis was performed on the summary measure to determine cutoffs for a categorical measure of the intensity of mental health problems, and the categories were as follows: 0, 1, 2, or 3 or more. Finally, childhood asthma attacks were lifetime reports provided by the parents and coded as binary responses (yes, no). Three measures of asthma were included in the original study and all were based on parental reports (history of asthma diagnosis, history of asthma attacks, and history of asthma hospitalization). In the current study, we chose to include only history of asthma attacks be-
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Table 1. Characteristics of Sample by Lifetime History of Childhood Asthma Attack† n (%) No History of Asthma Attack (n 5 1466)
History of Asthma Attack (n 5 416)
Parental education Less than high school (n 5 538) High school or equivalent (n 5 756) At least some college (n 5 557)
433 (32) 587 (40) 416 (27)
104 (27) 170 (41) 139 (32)
Parental perception of poverty I live very well (n 5 1003) I live from check to check (n 5 614) I live poorly (n 5 265)
789 (51) 467 (33) 210 (15)
214 (51) 147 (34) 55 (15)
Parental age Less than 30 years 30 to 39 years 40 to 49 years 50 or older
278 609 414 165
78 180 126 32
P* NS
NS
NS (16) (48) (26) (10)
(15) (53) (25) (8) ,.05
Zone of residence Rural (n 5 460) Urban (n 5 1424)
388 (27) 1078 (73)
72 (19) 344 (81)
Any childhood anxiety disorder Yes (n 5 124) No (n 5 1750)
81 (96) 1381 (94)
43 (11) 369 (89)
Any childhood depressive disorder Yes (n 5 48) No (n 5 1832)
31 (2) 1434 (98)
17 (7) 398 (93)
,.01
,.02
*Chi-square. †The difference in n values are due to missing values.
cause our previous analyses found that history of asthma attacks were more robustly associated with psychiatric disorder than either asthma diagnosis or asthma hospitalization.4,31 Furthermore, researchers have postulated that the risk of asthma episodes depends on a complex relationship between psychological factors and experiencing an asthma attack,52 and asthma attacks are important mediators between asthma and psychological status.53 Analysis The sample was weighted to represent the general population of children in Puerto Rico in the year 2000. The weights correct for differences in the probability of selection due to the sampling design and adjust for nonresponse. To account for the complex sampling design, standard errors were estimated with SUDAAN software (release 8.0).54 First, bivariate analyses of association were performed by chi-square to compare subjects on selected characteristics (maternal education, perception of poverty, age, zone of residence, any childhood anxiety disorder, and any childhood depressive disorder) by history of asthma attack (yes, no). Then we compared the 11 parental mental health variables from the family history module (all coded yes, no) and the summary measure of the problems with the children’s histories of asthma attacks. Finally, logistic regression analyses were performed to assess the effects of 7 independent variables measuring parental mental health (depression, suicidal, alcohol/drug
problems, ataque de nervios, mental illness, ever seen a mental health provider, and inattentive) on childhood asthma attacks. The 7 independent parental mental health variables were chosen based on the significant results at P 5 .10 of the chi-square analyses (see Results). We computed the adjusted odds ratios after accounting for anxiety and depressive disorders in youth; zone of residence; and parental education, age, and perception of poverty. In preliminary analyses, we found that the parental mental health measures were marginally to highly intercorrelated and moderately collinear when predicting asthma attacks. Thus, we chose not to include the independent parental mental health measures in one model to avoid potential multicollinearity. Instead, we computed an intensity measure of parental mental health problems (see Measures). We computed unadjusted and adjusted dummy variable logistic regression models with four categories of the frequency of reported parental mental health problems (0, 1, 2, or 3 or more) as independent variables predicting asthma attacks in youth. Zero parental mental health problems was used as the reference. For the logistic regression models, odds ratios and their 95% confidence intervals are reported. RESULTS Table 1 shows the results of the differences in subject characteristics by history of childhood asthma attack. Only one marginal significant difference was observed for the characteristics. Children living in urban areas were
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Table 2. Associations of Parental Mental Health Variables and Childhood Asthma Attacks n (%) No History of Asthma Attacks (n 5 1466)
History of Asthma Attacks (n 5 416)
Depression No (n 5 1350) Yes (n 5 532)
1098 (76) 368 (24)
252 (62) 164 (38)
Suicidal No (n 5 1754) Yes (n 5 128)
1380 (94) 86 (6)
374 (89) 42 (11)
Alcohol/drug problems No (n 5 1753) Yes (n 5 129)
1376 (94) 90 (6)
377 (90) 39 (10)
Ataques de nervios No (n 5 1585) Yes (n 5 297)
1264 (86) 202 (14)
321 (75) 95 (25)
Mental illness No (n 5 1768) Yes (n 5 114)
1389 (95) 77 (5)
379 (91) 37 (9)
School expulsion No (n 5 1834) Yes (n 5 48)
1432 (97) 34 (3)
402 (97) 14 (3)
Employment problems No (n 5 1853) Yes (n 5 29)
1445 (99) 21 (1)
408 (98) 8 (2)
Justice problems No (n 5 1836) Yes (n 5 46)
1437 (97) 29 (3)
399 (96) 17 (4)
Ever seen a mental health provider No (n 5 1475) Yes (n 5 407)
1178 (80) 288 (20)
297 (73) 119 (27)
Inattentive No (n 5 1720) Yes (n 5 162)
1355 (92) 111 (8)
365 (89) 51 (11)
Hyperactive No (n 5 1748) Yes (n 5 124)
1371 (93) 95 (7)
377 (91) 39 (9)
Frequency of parental mental health problems 0 (n 5 1065) 1 (n 5 354) 2 (n 5 205) 3 or more (n 5 264)
P* .0001
(.07)
(.10)
.0001
(.06)
NS
NS
NS
,.02
,.04
NS
,.0001 889 254 144 179
(63) (15) (9) (13)
172 98 61 85
(44) (22) (14) (21)
*Chi-square.
more likely to have had an asthma attack than those living in rural areas. For the psychiatric disorders, both children with any anxiety disorder and any depressive disorder were more likely to have a history of asthma attack than those with no anxiety or depressive disorder. Table 2 shows the results for the parental mental health variables and history of childhood asthma attack. Four significant associations were found at P 5 .05. Children with a history of asthma attack were more likely to have parents with depression, ataque de nervios, ever seen a mental health provider, and inattentive symptoms than children with no history of asthma attack. At P 5 .10, we also found that suicidal, alcohol/drug problems, and men-
tal illness were significant. Further, frequency of parental mental health problems was associated with asthma attacks. Children with histories of asthma attacks were more likely to have parents with one or more mental health problems than children who had no histories of attacks. Table 3 shows the logistic regression results measuring the associations between 7 independent variables of mental health and asthma attack (chosen based on the significant bivariate results at P 5 .10). Overall, the estimated odds ratios changed little once they were adjusted, suggesting there was minimal confounding by children’s internalizing disorder, zone of residence, or parents’ education, age, or perception of poverty. In brief, children
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Parental Mental Health and Asthma Attacks
Table 3. Unadjusted and Adjusted Effects of Parental Mental Health Problems on Childhood Asthma Attacks, Logistic Regression Results*
Independent Variables Depression Suicidal Alcohol/drug problems Ataque de nervios Mental illness Ever seen a mental health provider Inattentive
Unadjusted OR (95% CI) 1.9 1.8 1.6 2.0 1.8 1.5 1.6
(1.4, (1.0, (1.0, (1.4, (1.1, (1.1, (1.1,
2.5) 3.1) 2.6) 2.7) 2.9) 2.1) 2.3)
Adjusted† OR (95% CI) 1.7 1.7 1.5 1.8 1.5 1.3 1.3
(1.2, (1.0, (0.9, (1.3, (0.9, (1.0, (0.9,
2.2) 2.9) 2.5) 2.4) 2.5) 1.8) 2.0)
*Models predict the presence of a history of asthma attack versus no history of an attack. OR indicates odds ratio; CI, confidence interval. †Adjusted for any depressive and any anxiety disorder in youth, zone of residence, and parental education, age, and perception of poverty.
with a history of asthma attack were more likely to have parents who were depressed, had been suicidal, had ataque de nervios, and had seen a mental health provider sometime in their lives. The adjusted results for alcohol/drug problems, parental mental illness and inattentiveness were not significant at the 95% confidence level; however, the lower bounds of the confidence limits were marginal at 0.9. Table 4 shows the unadjusted and adjusted regression results measuring the associations between the frequency of parental mental health problems (1, 2, or 3 or more vs 0 problems) and asthma attacks. Parents with 1, 2, or 3 or more problems were two times more likely to report asthma attacks in their children; however, the analyses do not suggest a linear trend in the frequency of reports. DISCUSSION This study has two main findings. First, parental mental health problems and the frequency of problems are associated with increased likelihood of parent-reported asthma attacks in island Puerto Rican youth. Second, a relationship between parental mental health problems and asthma attacks in Puerto Rican youth persists after adjusting for anxiety and depression in youth and other potentially confounding factors. To our knowledge, this is the first study to examine the associations between parental mental health problems and odds of asthma attacks in youth in the island Puerto Rican community, controlling for pediatric anxiety and depression as potential confounders of this relationship. Previous studies have examined the direct relations between parental mental health and asthma, severity of asthma, and use of treatment for asthma in youth, but they have not examined the issue of potential confounding of childhood mental disorder. For example, among mothers of children with asthma, perceived stress was greater and the quality of the mother-child relationship more problematic than among mothers of children without asthma.55 This study also observed greater behavioral difficulty in children with asthma than children without asthma.55 Klinnert et al56
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Table 4. Unadjusted and Adjusted Effects of the Frequency of Parental Mental Health Problems on Childhood Asthma Attacks, Logistic Regression Results* Frequency of Problems
Unadjusted OR (95% CI)
Adjusted† OR (95% CI)
0 1 2 3 or more
Referent 2.1 (1.5, 2.9) 2.1 (1.4, 3.3) 2.3 (1.6, 3.3)
Referent 2.0 (1.4, 2.8) 2.0 (1.2, 3.0) 2.0 (1.4, 2.9)
*Models predict the presence of a history of asthma attack versus no history of an attack. OR indicates odds ratio; CI, confidence interval. †Adjusted for any depressive and any anxiety disorder in youth, zone of residence, and parental education, age, and perception of poverty.
also found higher levels of parental difficulties in children with asthma than children without asthma, in addition to reporting an association between psychosocial problems in infancy and increased risk of asthma among schoolaged children. Our current results extend previous findings, including those of our own, of the associations between poor mental health in parents and asthma in Latino youth by showing that they extend to youth in the general Puerto Rican community and not only to those children selected from mainland clinical samples. Further, our data identify specific parental mental health problems that appear most strongly associated with asthma attacks in youth, in particular depression, suicide attempts, and ataque de nervios. Finally, our results show that the relationships between parental mental health problems and the frequency of those problems and parent-reported asthma attacks in Puerto Rican youth persisted independent of internalizing disorder in youth. It was interesting that children with a history of asthma attacks were 80% more likely to have parents with ataque de nervios than children without a history of asthma attacks. While the current data do not permit further analyses of this association, it is interesting to note their similarities. A common symptom of an ataque de nervios is feeling out of control. A number of explanations could contribute to this observed association. For example, parents with children with asthma may feel overwhelmed by the management of the disease or the anticipation of an attack in their children, which may result in an ‘‘ataque’’ in the parents. Some researchers have also postulated that parents with children with a chronic illness such as asthma may have significant stressors that influence reporting higher levels of internalizing symptoms for their children.21 Future studies on asthma in Latino, particularly Puerto Rican, children should continue to explore the relations among internalizing symptoms and disorders in parents and children and asthma outcomes. Further, pediatricians and other providers should keep in mind that these associations exist and that some children with asthma, especially those with severe symptoms of asthma, may need psychosocial intervention that aims to reduce stress in the home environment.30 Our results also suggest that mental disorders in youth
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may make some contribution to the association between parental mental health and asthma attacks in youth, but they do not completely account for it. It is conceivable that there are environmental factors that influence the association between parental psychopathology, psychopathology in children, and asthma in children as well. For instance, if a child who has asthma has a parent with an anxiety disorder, it is conceivable that high levels of anxiety in the parent over the child’s illness could result in increased anxiety in the child him or herself, increasing the risk of onset of an anxiety disorder in the child. It may also be that other environmental factors play a role in these potential pathways. These include lower socioeconomic status, urban-rural environment, and other familyemotional environmental factors. What are some potential mechanisms of the relationship between parental mental illness and health outcomes in youth? The reason for the association between parents’ mental health and asthma attacks in their children cannot be determined from these data, but there are several suppositions. The fear or worry of asthma attacks in offspring alone may lead to mental distress in parents, yet it seems more likely that this may be only one of several contributing factors to a highly stressful environment. It is possible that parents of children with asthma may develop heightened anxiety over threats to the child’s health, such as severe asthma attacks, associated physical morbidity, and even risk of mortality. Alternatively, parents of children with asthma may feel more overwhelmed with everyday stressors and demands associated with childrearing, which may progress to anxiety and depression. These results extend previously documented associations in clinical samples that suggest these possible mechanisms, and they demonstrate that the associations may be applicable in the general community of island Puerto Rican children and not necessarily be due to treatment-seeking bias or be found in only those with severe asthma. Study Limitations Use of parental report as our index of asthma attacks is a limitation of the present study. In this study, there were no formal physician diagnoses or assessment of asthma in the youth, nor were pulmonary function tests carried out to confirm parental report of diagnosis. Therefore, it should be noted that replication of these findings is needed with more objective measures of asthma status, as parental reports of asthma attacks are likely subject to bias. Further, as is the case with any cross-sectional, descriptive data, there may be other residual factors, such as stress, that explain the relations. We are also unable to make claims regarding directionality or causation. For instance, we do not know whether the parents’ mental health problems occurred long before the asthma attacks in their progeny, shortly before, or even after asthma onset, which is a major limitation of our data. Unfortunately, in the present study, we are only able to demonstrate associations. There could also be potential co-occurrence of childhood internalizing disorders and asthma attacks. Future research implementing longitudinal
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designs is necessary to assess the temporal relationships and potential causal links among these variables. Conclusions This study suggests that parental mental health problems and the frequency of those problems are associated with asthma attacks in offspring in the community in Puerto Rico, and these associations persist even after adjusting for the effects of childhood anxiety and depression. Clinicians and researchers should be mindful of the potential role of parental mental health in pediatric asthma patients. Such awareness may help facilitate better clinical decision-making, including recommending intervention on family stressors for some children with asthma. ACKNOWLEDGMENTS This work was supported by US Public Health Service, National Institute of Mental Health grants R01-MH54827 and P01-MH59876, and by the National Center on Minority Health and Health Disparities grant P20-MD000. The authors thank Mr Pedro Garcia and Dr John Rizzo for help in the analysis of data.
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