Behavior Problems Precede the Development of Wheeze in Childhood
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Slide 1 :
Behavior Problems Precede the Development of Wheeze in Childhood Rachel Calam et al University of Manchester, UK Academic Division of Clinical Psychology Rachel Calam Lynsey Gregg The North West Lung Research Centre Angela Simpson Bridget Simpson Ashley Woodcock Adnan Custovic On behalf of the National Asthma Campaign Manchester Asthma and Allergy Study Group
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NAC Manchester Asthma and Allergy Study Large prospective prenatally recruited cohort What aspects of risk, and exposure in the physical environment are important for the development of asthma? (Custovic et al, Lancet, 2001, 358, 188-193)
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In addition… Might psychosocial factors such as child behaviour and parental mood have an impact on respiratory symptoms and physical health?
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Background Behavioural problems are higher in asthmatic children (McQuaid et al, 2001) Early parenting difficulties are associated with early development of asthma (Klinnert et al 2001, Mrazek et al, 1998) Behaviour problems associated with higher levels of wheeze (Weil et al, 1999)
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The NAC Manchester Asthma and Allergy Study (NACMAAS) Prospective, prenatally recruited cohort Antenatal screening Parent skin test Parent history of asthma and allergy
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NACMAAS High risk (both parents SPT positive) Medium risk (one parent SPT positive) Low risk (neither parent SPT positive, no family history of allergic disease)
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NACMAAS 3 years Parentally reported symptoms Physician diagnosed illness Medication Respiratory questionnaire SPT
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Questions at age 3 Do families of children with respiratory symptoms show higher scores for behaviour problems and parental distress? Does level of biological risk contribute? Are behaviour problems associated with recurrent wheeze?
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3 year psychosocial measures Eyberg Child Behaviour Inventory (ECBI: Robinson et al 1980: Burns & Patterson 2001) Hospital Anxiety and Depression Scale (HAD: Zigmond & Snaith, 1983) General Health Questionnaire (GHQ: Goldberg, 1978) Family Relationships Index (FRI: Moos & Moos, 1986) Calam et al, Childhood asthma, behavior problems and family functioning. Journal of Allergy and Clinical Immunology 2003, 122;499-504
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Psychosocial factors and asthma symptoms at age 3 years ECBI Intensity scores were higher for children with respiratory symptoms Elevated behaviour ratings were significantly associated with recurrent wheeze Symptomatic low-risk children were particularly likely to have elevated behaviour ratings Levels of parental mental health and family functioning were generally not significantly different depending on asthma status
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At age 3 we concluded that… Three year olds with respiratory symptoms are rated as having higher levels of behavioural difficulty Children at low biological risk appeared particularly vulnerable
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From age 3 to age 5 Do behavior problems increase the risk of subsequent development of wheeze? Do other family psychosocial factors increase the risk of subsequent development of wheeze?
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33 lost to follow up 754 questionnaire packs returned Age 5: 721 children attended the follow up 163 transient early wheeze 84 persistent wheeze Age 3: questionnaire packs to 946 families 38 could not classify 39 late onset wheeze 397 never wheezed
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Proportion of children above cut-offs for ECBI Intensity and Problem
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Individual ECBI Problem ratings: never wheezed vs late wheeze
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Family Relationship Index scores: parents of children never wheezed vs late onset wheeze
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Parental ratings, HAD and GHQ: never wheezed vs late onset wheeze
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Risk factors for late onset wheeze (Stepwise forward wald regression) Entered: Maternal asthma Maternal smoking at child age 3 Gender Family cohesion Conflict ECBI Intensity
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Significant risk factors for late onset wheeze Maternal asthma (OR 4.0, CI 1.6-9.7, p=.003) Maternal smoking (OR 3.7, CI 1.5-9.4, p=.005) ECBI Intensity above cut-off (OR 4.5, CI 1.7-12.1,p=.003)
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Conclusions Children who show late onset wheeze are more likely to be described as difficult by their parents This finding is consistent with Stevenson (2003) i.e. behavior is not secondary to respiratory symptoms
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Hyperactivity/inattention ? The kinds of problems parents reported for late onset wheezers might indicate more hyperactivity/inattention at age 3 However, parent report is not a sensitive indicator of hyperactivity Cross sectional studies suggest links between hyperactivity and asthma medication Our sample had not been medicated
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Family factors Some indication that ratings of family dysfunction were higher in families of children with late onset wheeze Parental anxiety, depression and GHQ scores were not related to late onset of wheeze
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Do behavior problems cause wheeze ? We are not saying this Behavior problems may be a marker for some causal factor common to both Smoking might be an example: implicated in both Attention Deficit Hyperactivity Disorder and respiratory symptoms
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Developing theory Multiple routes into asthma Developmental pathways Stability and predictability of wheeze and other respiratory symptoms
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Considerations for clinical practice We only detected significant differences when we looked at cut-offs i.e. children with most marked behavior problems apparently at risk of wheeze This could be helpful in targeting interventions
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Potential areas for intervention Identifying psychological processes which optimise parenting may influence the course of disease and effectiveness of medical intervention managing asthma managing the child’s behaviour and emotion
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