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Medicine & Health
Journal of Pediatric Psychology
Volume 29, Issue 7
Pp. 475-491.
Family Influences on Pediatric Asthma

1. Astrida Seja Kaugars, PhD 1 ,
2. Mary D. Klinnert, PhD 2 , 3 and

3. Bruce G. Bender, PhD 2 , 3
+ Author Affiliations
1.
Marquette University, 2National Jewish Medical and Research Center and

University of Colorado Health Sciences Center
1. All correspondence should be sent to Astrida S. Kaugars, Department of Psychology,

Marquette University, P.O. Box 1881, Milwaukee, WI 53201-1881. E-mail:
astrida.kaugars@marquette.edu.
Received April 23, 2003.
Revision received September 15, 2003.
Revision received November 23, 2003.
Accepted November 26, 2003.
Next Section
Abstract
Objective To describe pathways by which families may influence the onset and course of a
childs asthma. Methods We critically reviewed published articles and book chapters to
identify research findings and integrated conceptualizations that demonstrate how families
affect pediatric asthma. Results Family emotional characteristics, asthma management
behaviors, and physiological factors account for key influences on pediatric asthma onset and
outcomes. Conclusions Multiple family characteristics are associated with pediatric asthma
onset and outcomes. Behavioral and physiological mechanisms may act independently or
may interact to affect asthma manifestations. Families with specific emotional characteristics
may be at an elevated risk for poorer asthma outcomes.
Key words
family
pediatric asthma
Asthma is a chronic inflammatory disease of the airways that results from a complex
interaction between genetic and environmental factors (Howard, Meyers, & Bleecker, 2003).
It includes the presence of recurrent but reversible respiratory obstruction and is characterized
by such symptoms as wheezing, coughing, chest tightness, and shortness of breath. Asthma is
a complex condition with wide variability in manifestation owing not only to physiological
factors such as allergic status or bronchial hyperresponsiveness but also to environmental
factors such as variation in exposure to tobacco smoke and other allergens. Psychosocial
characteristics of the child, parent, and family can also contribute to variability in asthma
presentation. Children with genetic predisposition for affective disorders and asthma may
represent a subgroup of children at risk for developing severe asthma (Wamboldt, Weintraub,
Krafchick, & Wamboldt, 1996). Given the increased prevalence and morbidity of pediatric
asthmain particular among young children and especially among non-Hispanic black
children (Akinbami & Schoendorf, 2002)comprehensive asthma intervention programs
have targeted impoverished inner-city communities at high risk for asthma morbidity and
mortality (Evans et al., 1999). Moreover, ongoing research seeks first to identify origins of
asthma and second to better understand the natural history of asthma, which can further
inform intervention and treatment strategies (Lemanske & Busse, 2003; Liu & Szefler, 2003).
It has become increasingly apparent that multidisciplinary approaches synthesizing
biological, sociocultural, psychological, and family perspectives are necessary to better
understand asthma (Wright, Rodriguez, & Cohen, 1998). Despite the growing number of
studies examining aspects of psychosocial functioning related to asthma, it appears that
psychological difficulties are not increased among children with mild to moderate asthma
(Bender, Annett, et al., 2000). However, psychopathology, family dysfunction, and
medication noncompliance have been found to be associated with increased risk of severe,
poorly controlled asthma (Bender & Klinnert, 1998). Thus it is important for researchers to
closely examine the relationships between psychological factors and severe asthma, since
doing so may inform an understanding of how psychological and family variables affect, or
result in, a variety of asthma manifestations.
The literature consistently demonstrates that early family social environments that include
conflict, aggression, and deficient nurturing may represent a risk profilerisky families
(Repetti, Taylor, & Seeman, 2002)that presents implications for childrens mental and
physical health. Genetic and family factors interact and may directly or indirectly contribute
to emotional, social, and biological disruptions that can continue to have an impact on
development throughout the life span (Repetti et al., 2002). Among children with asthma, the
distinction of risky families may help identify those families with similar risk factors for
whom managing a childs asthma is an additional challenge and for whom the children have
poorer asthma outcomes (Bender & Klinnert, 1998). Moreover, this distinction reflects the
overrepresentation in the literature of children with a multitude of risk factors and more
severe asthma. The National Cooperative Inner-City Asthma Study (NCICAS) was conducted
in response to the excessive burden of asthma morbidity and mortality among poor and
minority children. The study found a large number of risk factors for asthma morbidity in this
population (Kattan et al., 1997; Mitchell et al., 1997). Moreover, within this sample of innercity children and families, a variety of psychosocial variables were assessed, and the study
found that psychosocial factors were significant predictors of childrens asthma morbidity
(Wade et al., 1997; Weil et al., 1999). The present review focuses on the research linking
psychological variablesin particular, characteristics of distress in familiesto asthma
outcomes. It is important to remember that every child with severe, poorly controlled asthma
does not necessarily have family functioning characterized by distress and risk; similarly, not
all distressed families have children who go on to develop severe, poorly controlled asthma.
Previous SectionNext Section
Theoretical Model Summarizing Literature
This paper presents a selective review of the literature to describe pathways by which
families may influence the onset and course of a childs asthma. In the literature, a variety of
asthma outcomes have been examined, including health care utilization, asthma and
wheezing symptoms, quality of life, activity restrictions due to asthma, risk of death, and
school attendance (see Table I).
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Table I.
Summary of Family Characteristics, Mechanisms, and Asthma Outcomes Reviewed
First, we present a review of how family characteristics are related to pediatric asthma
outcomes (see Figure 1, Path A). Then, we examine two pathways for understanding these
associations: first, how family characteristics affect asthma management behaviors and thus
asthma outcomes (Paths B and C); second, how physiological factors may help researchers
understand the relationships between family characteristics and asthma outcomes (Paths D
and E).
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Figure 1.
Proposed relationships among factors contributing to pediatric asthma outcomes. Path A:
Diagram of direct relationship. Paths BE: Diagram of mediation.
The majority of studies described in this review examined models that exist implicitly; very
few studies explicitly delineated models that were empirically tested (e.g., Bleil, Ramesh,
Miller, & Wood, 2000; Wade et al., 1997; Weil et al., 1999). Although there is evidence in the
literature of bidirectional and reciprocal relationships among family characteristics and
asthma outcomes, Figure 1 illustrates unidirectional relationships to emphasize how family
characteristics can influence asthma outcomes. Relevant findings in each domain are
summarized herein, and applicable methodological and measurement concerns are
highlighted, as they may affect conclusions drawn from the study results. Implications for
treatment and future research is then addressed in the conclusion. Theoretically relevant
studies were selected for inclusion in the present review utilizing computer searches (e.g.,
PsychINFO and PubMed), manual searches of relevant journals, inspection of reference lists
from published studies and reviews, and consultation with pediatric psychologists. Research
conducted in the past 20 years was the focus of the review, although several seminal
historical references were included as well.
Family Functioning and Asthma

Within families, caregiver functioning, interactions between caregivers and children, and
childrens functioning influence pediatric asthma. Historically, the psychosomatic family
model introduced by Minuchin and colleagues (1975) suggested that the structure and
functioning of families could affect childrens asthma outcomes. However, empirical studies
testing the psychosomatic family model and measures of general features of family
functioning have provided limited insight into how family functioning may interact with the
disease process. Families responses to the demands of caring for a chronic pediatric illness
vary greatly and may have an effect of organizing and structuring some families but of
causing detrimental changes in others (Wamboldt & Wamboldt, 2000). Thus, it has been
useful to identify specific psychosocial characteristics of individuals and families that affect
family functioning and asthma outcomes. Recent conceptualizations have emphasized
reciprocal influences between psychological factors and asthma morbidity (Wade et al.,
1997). A bidirectional relationship between psychological functioning in the parents and
childrens physical disorders may exist such that family psychological factors contribute to
severe, poorly managed pediatric asthma. Alternatively, having a child with asthma is
challenging for families and thereby increases psychological stress and taxes psychological
functioning. Incorporating a socioecological model to better understand interactions of the
child, family, and extended environment in the context of childhood illness reflects progress
in understanding how family and system functioning are linked to childrens adaptation to
illness and its treatment (Kazak, Segal-Andrews, & Johnson, 1995).
The following section presents a review of the literature examining how family
characteristics are related to pediatric asthma outcome. The review summarizes research in
the following areas: caregivers psychological functioning, parentchild relationships,
childrens adjustment and psychopathology, and additional factors influencing family
functioning.
Caregivers Psychological Functioning

Parents and caregivers psychological functioning is a major determinant of family
functioning. A persistent theme in the literature indicates that poorer caregiver psychological
functioning is associated with the worse asthma outcomes for children. Among mothers of
children with asthma living in the inner city, almost half (47%) reported clinically significant
levels of depression (Bartlett et al., 2001). Six months after their initial report, mothers with
high levels of depressive symptoms were 40% more likely to report having taken their
children to the emergency department in the ensuing time, in comparison to mothers with low
levels of depressive symptoms. In another inner-city population, caregivers who reported
clinically significant mental health problems had children who were 1.78 times more likely to
be hospitalized in the next 9 months, when compared to caregivers whose scores of
psychopathology were not clinically significant (Weil et al., 1999). Similarly, lower caregiver
mental health scores were associated with caregiver reports of their childrens experiencing
more asthma symptoms and more acute care visits for asthma in the previous year, when
compared to those caregivers with higher mental health scores (Wood et al., 2002). Among
children seen in suburban and inner-city pediatric asthma subspecialty practices, caregiverreported symptoms of depression and negative life stressors in combination with childrens
sex (i.e., female) were the strongest predictors of childrens asthma morbidity, based on
patterns of symptoms and health service utilization (Shalowitz, Berry, Quinn, & Wolf, 2001).
Caregivers responses to high stress levels, including managing chronic stress, may affect
their psychological functioning as well as their infants respiratory problems. Caregivers
perceived stress when their infants were 2 to 3 months old was associated with an increased
risk of parent report of infant wheezing during the first 14 months of life, independent of
factors associated with stress and wheezing (Wright, Cohen, Carey, Weiss, & Gold, 2002).
While some studies demonstrate associations between caregivers psychological functioning
and asthma outcomes, more recent studies have utilized prospective designs to better
understand the directions of relationships.
Researchers must be aware of reporter bias, and they must consider how study conclusions
and generalizability are affected by the background of the participants (e.g., low
socioeconomic status) or by the studys methodology (e.g., caregiver report). All of the
studies described here included participants from low socioeconomic backgrounds and used
asthma outcome data from caregiver reports. Parental reporting of asthma outcomes may be
problematic since parental emotional status may influence caregivers reporting of the impact
of asthma; likewise, caregiver-reported asthma morbidity and actual morbidity may be
discrepant. One type of asthma outcome that has been studied, with some controversy
(Annett, 2001; Bender, 1996), is childrens and parents reporting of the impact of on the
family, including quality of life. Objective measures of disease morbidity during the year
before admission to a pediatric day program for asthma were unrelated to caregivers report
of quality of life (Price, Bratton, & Klinnert, 2002). Instead, a caregivers negative affect (i.e.,
anxiety and depression) was a significant predictor of a caregivers reporting of quality of life
at admission. This is consistent with evidence demonstrating that factors such as negative
affect, perceived vulnerability, and depressive symptoms may affect how individuals rate
their quality of life (Mishoe & Maclean, 2001). Among children and families seen at a
tertiary care hospital for asthma, parental emotional distress was the strongest significant
predictor of how parents reported the extent to which their childs asthma affected the family
(Frankel & Wamboldt, 1998). A determination of asthma severity based on parental report
was not a significant predictor of the illnesss impact on the family. This research highlights
the influence of situational factors and respondent characteristics on reports of quality of life
and potentially other asthma outcome measures, thus suggesting the importance of careful
attention to study design to limit reporter bias.
ParentChild Relationships
Child Attachment
Family relationships are associated with asthma outcomes in a number of ways. An early
observational study examined interactional difficulties among mothers and children with
asthma (Block, Jennings, Harvey, & Simpson, 1964). Similarly, a more negative affective
climate has been documented among mothers and their preschool children with asthma, in
comparison to that of healthy children (Mrazek, Anderson, & Strunk, 1985). However, causal
mechanisms were not identified in these studies (Klinnert, 1997b). Results from one small
study indicated that when compared to children without asthma, a significantly greater
proportion of preschool-age children with severe asthma were rated as insecurely attached
(Mrazek, Casey, & Anderson, 1987). Among the children with asthma, those with a secure
attachment demonstrated significantly fewer overall behavior problems than those who were
more insecurely attached. Similarly, among school-age children and adolescents with asthma,
parentchild relationships mediated the impact of impaired functional status on depressive
symptoms (Bleil et al., 2000). A secure attachment may mediate the effects of early illness on
childrens emotional development because it may enhance a childs coping capacity and
minimize the expression of psychopathology (Mrazek et al., 1987).
Parenting Difficulties
Several longitudinal studies have examined the impact of caregiving on asthma outcomes. A
prospective study of children at genetic risk for asthma demonstrated that a combination of
physical and psychosocial variablesspecifically, parenting difficulties assessed when
infants were 3 weeks oldwere predictors of asthma onset and persistence (Klinnert,
Mrazek, & Mrazek, 1994; Klinnert et al., 2001; Mrazek et al., 1999). Frequent illness in the
first year of life, elevated serum IgE levels at 6 months, and early parenting difficulties were
independently predictive of the development of childrens asthma at 3 years of age (Mrazek
et al., 1999). The parenting difficulties measured in early infancy with the elevated 6-month
IgE levels continued to be associated with the persistence of asthma in these children when
they reached 6 and 8 years of age (Klinnert et al., 2001). The predictive strength of the
parenting rating is noteworthy given that the rating was made before asthma onset when the
infants were 3 weeks old and that it focused on assessment of the emotional caregiving
environment (Klinnert et al., 1994). These findings parallel those from a different
longitudinal study where functional family interactions and social networks for children 18
months old were associated with a significantly lower risk for childrens having continuing
atopic illness at 3 years old, when compared to those with dysfunctional interactions and
networks (Gustafsson, Kjellman, & Bjorksten, 2002). Thus difficulties in parenting and the
parentchild relationship appear to be related not only to asthma onset but also to asthma
outcomes throughout early childhood.
Family Conflict
High levels of conflict among family members is a distinguishing characteristic of risky
families (Repetti et al., 2002), and it may place children at greater risk for mental and
physical health problems when compared to those children without such conflict. In a sample
of children hospitalized for asthma, those who experienced more family conflictas assessed
by parents reporting the amount of openly expressed anger, aggression, and conflict among
family memberswere more likely to experience a greater number of lifetime
hospitalizations (Chen, Bloomberg, Fisher, & Strunk, 2003). In a seminal study by Strunk and
colleagues (1985), conflict between children with asthma, their parents, and hospital staff
differentiated those children who died of asthma from a control group matched for asthma
severity. While global ratings of family discord and conflict are revealing, more proximal
measures of parentinfant or parentchild relationships that describe affective qualities of the
relationship (e.g., critical affect, emotion regulation) provide information about specific
emotional processes.
Critical parent affect has been examined as a possible mechanism through which parentchild
interactions are related to asthma. Utilizing measures of expressed emotion (EE), where
parents are asked to speak about their child in an unstructured setting (e.g., Five-Minute
Speech Sample; Magana-Amato, 1993), several studies have found that in comparison to
parents of healthy children, mothers and fathers of children with asthma made significantly
more critical remarks and showed a more critical attitude (Hermanns, Florin, Dietrich,
Rieger, & Hahlweg, 1989; Schobinger, Florin, Reichbauer, Lindemann, & Zimmer, 1993;
Schobinger, Florin, Zimmer, Lindemann, & Winter, 1992). Among children with asthma,
increased frequency of asthma attacks and asthma severity were associated with mothers
critical attitudes but not with fathers (Hermanns et al., 1989; Schobinger et al., 1993;
Schobinger et al., 1992). These investigators considered whether the association between
criticism and asthma severity may reflect critical attitude acting as a chronic stressor
(Hermanns et al., 1989; Schobinger et al., 1993) or whether critical attitude may hinder
compliance (Schobinger et al., 1993; Schobinger et al., 1992). Among hospitalized
adolescents with asthma, higher parental criticism was more likely to be associated with
greater medical noncompliance upon admission and with better response to treatment when
adolescents were separated from their parents and participating in a structured treatment
regimen (Wamboldt, Wamboldt, Gavin, Roesler, & Brugman, 1995). Thus, parental criticism
may be another marker of distressed families that may affect childrens asthma outcomes.
Emotion Regulation
Emotion regulation is developed by repeated interactions between child and caregiver in
which caregivers modulate and teach children how to regulate their emotions. Emotion
regulation is a critical dimension of behavior expression that has been demonstrated to
contribute to the development of psychopathology. Assessment of childrens behavior and
parentchild interactions during a structured, challenging task found no significant group
differences among children with and without asthma in their emotion regulation and
negativity and in their mothers emotion regulation and negativity when observed alone and
with their mothers (Klinnert, McQuaid, McCormick, Adinoff, & Bryant, 2000). However,
were related to difficulties with emotion regulation demonstrated greater asthma severity.
Furthermore, less effective emotion regulation was a significant predictor of asthma
symptoms, after controlling for asthma severity, as measured by symptom frequency and
required medications. Clinician ratings of behavior problems were associated with increasing
levels of asthma severity. As suggested by the authors, difficulties with emotion regulation
may be represented in behavior patterns that do not reach diagnostic thresholds but
nevertheless result in parentchild relationships characterized by negativity and conflict.
Child Adjustment and Psychopathology

Recent recognition of the complex relationship between childrens adjustment and illness has
resulted in closer scrutiny not only of research designs and methods used to examine this
relationship but also of the discussion regarding the mechanisms responsible for the
relationship. Children with early asthma onset (i.e., by 3 years of age), face a greater risk for
developing behavior problems, perhaps owing to their limited range of cognitive and
emotional strategies for managing symptoms, the challenges that parents face in caring for
children with asthma, and the possibility of environmental stressors having a heightened
impact on very young children (Mrazek et al., 1985; Mrazek, Schuman, & Klinnert, 1998).
McQuaid and colleagues (2001) recently completed a meta-analysis examining studies of the
behavioral adjustment of children and adolescents with asthma. They concluded that, in
comparison to healthy children, children with asthma are at greater risk for having difficulties
in behavioral adjustment, with demonstrate greater evidence for internalizing, rather than
externalizing, problems. Increases in asthma severity were related to more difficulties in
behavioral adjustment. Similarly, in a more current study, Ortega and colleagues (2002),
using a structured diagnostic interview, found that children with a history of asthma were
more likely than those without to be diagnosed with having any psychiatric disorderor
more specifically, an anxiety disorderafter controlling for potentially confounding factors.
Moreover, relationships between asthma and anxiety disorders were particularly strong for
children with histories of asthma-related hospitalization. This suggests that children with
severe asthma may be more likely to have an anxiety disorder, thereby providing further
support for the importance of examining the role of illness severity. Similar to the finding that
caregiver negative affects influences assessment of asthma outcomes (e.g. Price et al., 2002),
there is also evidence that when children were asked to respond to asthma-related quality of
life questions, childrens level of anxiety was a strong predictor of quality of life responses,
regardless of whether the anxiety was directly attributable to the childs asthma (Annett,
Bender, Lapidus, DuHamel, & Lincoln, 2001). Further unraveling the multifaceted
relationship between childrens adjustment and illness will require careful consideration of
reporters as well as an acute attention to the measures of illness being used.
It is unknown whether more severe asthma leads to behavioral difficulties or whether poor
psychological functioning leads to more severe asthma. Another possibility is that
characteristics of distressed familiesfor example, conflict; aggression; and cold,
unsupportive, neglectful homesmay be influential not only in asthma outcomes but also in
childrens socioemotional development, including the development of adjustment problems
or psychopathology (Repetti et al., 2002).
Additional Factors Influencing Family Functioning

Lack of social supportincluding not having spouses, friends, and family members who
provide material and psychological resources to a familymay be another marker of families
who are not functioning well. Clinical and empirical literature suggests that social support has
a direct positive effect on well-being and that it works to protect individuals from potentially
adverse effects of stressful events (Cohen & Wills, 1985). However, the mechanisms
mediating these relationships, particularly in pediatric populations and specifically among
children with asthma, have not been studied extensively. Even less attention has been directed
to examining social supportin particular, support from friends or peersamong
adolescents with chronic illness (LaGreca et al., 1995).
As described earlier, functional family interactions and social networks for children at 18
months of age were predictive of childrens lower risk for continuing atopic illness at 3 years
of age, when compared to children with dysfunctional interactions and networks (Gustafsson
et al., 2002). However, it is unclear how family functioning and social network functioning
may be interrelated. Social support was the strongest predictor of behavior problems among
children with mild to moderate asthma, explaining 11.6% of the variability, after accounting
for other variables (Bender, Annett, et al., 2000). However, social support was unrelated to
disease variables. Parents perceived social support, childrens absence from school, and
childrens behavior problems were the strongest predictors of parents perceptions of how the
childs illness affects the family. These results underscore how parents perceptions of
disease, rather than objective ratings of disease, affect reports about the extent of disruption
due to childrens asthma.
Intervention studies where social support needs to be quantified for research purposes offer
some clarification about what aspects of social support may affect health outcomes.
Moreover, there are a multitude of individual and community variables that may affect
whether interventions that offer social support are effective (Thompson & Ontai, 2000).
Despite an emphasis in practice of helping families establish contacts with other families who
have children with similar medical conditions, there is limited empirical evidence that such
strategies are successful. Children with asthma were one subgroup of participants in a
randomized trial of community-based support for families (Chernoff, Ireys, DeVet, & Kim,
2002). The study found that a family support interventionwhich involved visits, telephone
calls, letters, and special family events with child life specialists and experienced
mothershad a modest, positive effect on improving childrens adjustment, in particular for
children with low physical self-esteem at baseline. There were no effects of the intervention
on childrens symptom unpredictability or activity limitations. This intervention also
demonstrated a reduction in maternal symptoms of anxiety, and effects were greater for
mothers in poor health and for those with higher baseline anxiety (Ireys, Chernoff, DeVet, &
Kim, 2001). Thus, improving maternal psychological functioning via social support
interventions may in turn affect childrens adjustment, but it may also have limited impact on
aspects of physical functioning for children with a chronic illness. Research examining the
impact of social support, or lack of social support, for children with asthma and their families
must strive to further identify mechanisms by which social support affects childrens mental
and physical health.
Potential Mechanisms Accounting for Associations

Between
Family Characteristics and Asthma Outcomes
As reviewed in the previous section, there is accumulating evidence documenting
relationships between family and child characteristics and pediatric asthma outcomes.
Theoretical and empirical evidence supports two mediational models for understanding these
associations. First, family characteristics may affect asthma management behaviors and
lifestyle factors that in turn affect asthma outcomes (see Figure 1, Paths B and C). Second, an
emerging literature has been investigating physiological mechanisms that may link child and
family emotional processes and asthma outcomes (see Figure 1, Paths D and E). The next two
sections review evidence for these possible models.
Family Functioning Affects Asthma Outcomes Through Asthma Management

Effectively managing a childs asthma involves health care providers collaborating with the
entire family system and with alternative caregivers. Management of asthma includes a
complex set of behaviors, with one of the familys responsibilities being adherence to
prescribed medical regimens (Klinnert, McQuaid, & Gavin, 1997). Five general areas of
parental responsibility include symptom intervention, symptom prevention, use of medical
and educational resources, communication of caregivers, and child development and family
relationships (Wilson, Mitchell, & Rolnick, 1993).
The most well-studied and specific aspect of asthma management is adherence. It is welldocumented that child and family behaviors associated with adherence are related to asthma
outcomes (see Figure 1, Path C). Adherence to prescribed treatment regimens for children
with asthma is a pervasive problem, with adherence rates often below 50% (Bender, 2002).
Families who are unable to perform the health care behaviors required in pediatric asthma
might have children with more poorly controlled asthma. In a study monitoring inhaled
corticosteroid usage for 90 days, lower rates of compliance with inhaled corticosteroid
therapy were associated with disease exacerbation, thereby illustrating the potential risk and
impact of medication nonadherence (Milgrom et al., 1996). In the National Cooperative
Inner-City Asthma Study, children whose caregivers reported more frequent nonadherence
with a physicians recommendation for asthma management experienced significantly worse
morbidity on eight of nine measures, regardless of illness severity (Bauman et al., 2002).
While research has sought to identify factors that may potentially influence poor adherence, it
is not known what factors may facilitate high levels of adherence; furthermore, the factors
that promote adherence may be different from those that impede adherence (Drotar et al.,
2000). Four factors that do not predict adherence include health insurance or health insurance
status (e.g. Bender, Wamboldt, et al., 2000; Weinstein & Faust, 1997), asthma knowledge
(e.g. Ho et al., 2003; McQuaid, Kopel, Klein, & Fritz, 2003), illness severity (e.g. Apter,
Reisine, Affleck, Barrows, & ZuWallack, 1998), and single-parent families (e.g. Weinstein &
Faust, 1997). This section discusses how family characteristicsincluding family conflict
and distress, racial or ethnic differences, and family organization and responsibilityhave
been found to affect adherence and, in turn, asthma outcomes (see Figure 1, Paths B and C).
For families experiencing several of these predictors, asthma outcomes may be further
affected.
Conflict and Distress in Families
Family conflict and distress that undermine effective asthma management behaviors may be
manifested in relationships within the family as well as in disagreements with health care
providers. Day-to-day asthma management may be more difficult in high-conflict
relationships since effective communication, supervision, and division of responsibilities may
be compromised (Schobinger et al., 1993). A combination of psychological adjustment,
degree of family cohesiveness versus conflict, and the interaction of these two variables have
been found to predict adherence. For instance, children with high levels of family conflict and
high levels of behavior problems were at greatest risk for being nonadherent, when compared
to children with moderate or low levels (Christiaanse, Lavigne, & Lerner, 1989). Similarly,
among hospitalized adolescents with asthma, high parental criticism was associated not only
with greater noncompliance upon admission but also with better response to treatment when
the adolescents were separated from their parents and participating in a structured treatment
regimen (Wamboldt et al., 1995). Another study found that families in which parents reported
no displays of affection and where expectations and consequences for childrens behavior
were not clearly expressed had poorer medication adherence than did families with different
levels of affection and expectations (Bender, Milgrom, Rand, & Ackerson, 1998). In another
study, children with severe asthma participated in a short-term inpatient rehabilitation
program and then were followed for the subsequent year. One year later, those families who
had significantly fewer problems with intrafamilial communication, more effective ways of
managing child care, and more efficient use of resources had children who were more
compliant with treatment than families of children who were noncompliant (Weinstein &
Faust, 1997). Similarly, there is emerging evidence that conflict in relationships with health
care providers may lead to poorer asthma adherence outcomes. Difficulties communicating
effectively with a childs treating physician and with other medical personnel have been
associated with ineffective asthma management behaviors, including failure to provide
appropriate intervention for childrens asthma symptoms (Wilson et al., 1993). Physicians
reports of better treatment alliance with adolescents at discharge from an inpatient program
was associated with better medication adherence at program admission, better multifaceted
treatment adherence in the year after hospitalization, and fewer urgent office visits in the
subsequent year, when compared to reports of less-effective treatment alliance (Gavin,
Wamboldt, Sorokin, Levy, & Wamboldt, 1999). Conflict with health care providers was one
of several factors associated with poor adherence and increased risk of death in children with
asthma (Strunk et al., 1985). Accumulating evidence suggests that relationships characterized
by conflict place children and families at risk for having problems with effective asthma
management.
Parents who are suffering from psychopathology have more difficulty caring for a child with
a chronic illness than parents who are not suffering. A study with an inner-city population
distinguished between admitted nonadherence and risk factors for nonadherence. The poorer
the caregivers mental health, the more they admitted nonadherence. Also, cases in which
caregivers endorsed family characteristics and described asthma regimens that placed
themselves at risk for nonadherence were more likely to have originated from caregivers with
clinically significant mental health problems and children with clinically significant
psychological symptoms (Bauman et al., 2002). Parental psychopathology may impair
parents ability to perform behaviors necessary to effectively manage childrens asthma since
depressed patients, whether children or adults, are three times more likely to be noncompliant
with medical treatment recommendations (DiMatteo, Lepper, & Croghan, 2000). Maternal
depression has been found to be related to maternal behaviors associated with child health;
specifically, maternal depression was associated with an decreased likelihood of
administering vitamins to children, of placing a child in a car seat all or most of the time, and
of being a nonsmoker (Leiferman, 2002). Thus, depression likely affects a caregivers ability
to perform daily behaviors associated with asthma management.
Racial or Ethnic Background
A better understanding is needed of the underlying mechanisms for racial and ethnic group
differences in medical adherence and asthma outcomes. For example, one study found that
non-White children (i.e., Black and Hispanic), older children and adolescents, and children
from families with poorer functioning were more likely to have poorer adherence as recorded
by electronic recording (Bender, Wamboldt, et al., 2000). Another recent study documented
that Black and Latino children were more likely to underuse asthma preventive medications,
in comparison to White children after adjusting for sociodemographic variables and asthma
status (Lieu et al., 2002). Adolescence, Black race, and residence in rural regions
independently predicted failure of families to get oral corticosteroid prescriptions filled
following childrens hospitalization or a visit to the emergency department (Cooper &
Hickson, 2001).
Understanding racial and ethnic differences in asthma management behaviors is complex and
requires examining multiple determinants. Recent literature has suggested examining whether
asthma morbidity varies among the subgroups of Latino children based on differences in
ethnic and geographic origin (Lara, Morgenstern, Duan, & Brook, 1999). The authors called
attention to specific risk and protective factorsincluding possible genetic, environmental,
and health care factorsthat may affect differences in asthma outcomes. The most frequently
reported barriers to the treatment of asthma among parents from urban, minority backgrounds
were patient and family characteristics (43%), environmental factors (28%), health care
provider factors (18%), and health care system factors (11%; Mansour, Lanphear, & DeWitt,
2000). As noted by the authors, these responses differed considerably from widespread
beliefs that problems involving access to medical care, health insurance, and continuity of
care are primary barriers to quality asthma care. Caregiver beliefs about asthma management
(e.g., not believing the appropriateness of daily medication use without symptoms, concerns
about side effects) were significant predictors of caregiverphysician concordance about
medication (Riekert et al., 2003). Addressing patient and familys health beliefs and concepts
of disease and evaluating the cultural competence of health care system practices may be
particularly important for improving asthma outcomes (Lieu et al., 2002).
Reducing exposure to allergens and environmental tobacco smoke is another behavioral
requirement of management of pediatric asthma. Family psychosocial characteristics and
racial or ethnic group differences are related to environmental asthma management. A recent
study found patterns of family characteristics associated with smoking to be different from
those associated with pet ownership (Wamboldt et al., 2002). Specifically, household
smoking was associated with more family stress and poorer family resources (e.g., coping
resources, parental education level) than that of nonsmoking households, whereas pet
ownership was related to better family behavioral control and better asthma knowledge than
that of households with no pet ownership. Different patterns of environmental risk factors for
childhood asthma, such as environmental tobacco smoke and cat and cockroach exposure,
were found among European Americans, African Americans, high-acculturated Hispanics,
and low-acculturated Hispanics (Klinnert, Price, Liu, & Robinson, 2002). For example, the
low-acculturated Hispanics had no measurable pet dander in the home, since indoor pets are
not normative in this immigrant group. Within the African American group, better maternal
mental health was associated with lower infant urinary cotinine and cat exposure. These
findings suggest that different mechanisms may underlie families efforts and decisions to
alter their home environments consistent with treatment recommendations.
Family Organization and Responsibility
Effective management of pediatric asthma places demands on children and adults and
requires families to face ongoing and new challenges and changes. A familys ability to
organize and reorganize as new tasks emerge is central to successful adherence. Tasks that
may reflect a familys ability to organize include taking a childs developmental status into
account in dividing responsibilities for asthma management and incorporating family rituals
and routines. A shifting set of responsibilities is indicated as children grow and develop,
which is characterized by the transfer of self-management tasks from adults to children with
an appreciation for childrens socioemotional and cognitive development (Miller & Wood,
1991). Asthma management expectations for children at different developmental levels have
been delineated (as described in Wamboldt & Wamboldt, 1995). Several studies have
examined assignment of responsibilities in families of children with asthma. Paternal
involvement in caring for childrens asthmathat is, whether the father was living in the
homewas associated with mothers reporting less disruption in their daily lives due to
childhood asthma; however, Hispanic ethnicity, severity of childs asthma, and child age were
also associated with maternal report of disruption (Wasilewski et al., 1988). In the National
Cooperative Inner-City Asthma Study, older children were rated by their parents as assuming
more self-care responsibilities, but 37 children were identified as being the primary managers
for their asthma (Wade et al., 1997). Since participating children were 6 to 9 years old, this
extent of asthma management likely exceeds their developmental capacities (Klinnert,
1997a). A substantial level of disagreement concerning allocation of family responsibility for
asthma management was found in a sample of Black adolescents and their caregivers
(Walders, Drotar, & Kercsmar, 2000). Families where caregivers overestimated the level of
adolescents involvement for self-care tasks had adolescents with increased nonadherence and
greater functional morbidity. Caretakers reported decreasing responsibility for asthma
management for older adolescents, yet there was not a significant relationship between older
adolescents assuming more self-care responsibilities, a finding that highlights the need for
routine assessment of family members allocating responsibilities (Walders et al., 2000).
Family rituals may offer a protective function in families of children with asthma and offer
stability, organization, and meaning (Markson & Fiese, 2000). Age-appropriate division of
responsibility among family members as well as routines and continuity, which may be
absent or diminished in homes characterized by conflict and unsupportiveness, are essential
in maintaining adequate asthma management.
In summary, distressed families may be unable to effectively manage asthma, owing to
numerous factors. In addition, racial or ethnic group differences and family organization may
also influence asthma management behaviors. It is notable that family factorsnot illness
severity or institutional barriers, as frequently hypothesizedhave been found to be
predictive of adherence behavior. Given the pervasive problem of nonadherence among
children with asthma and their families, research and clinical work can be advanced with
increasing knowledge about what family characteristics predict adherence, which may in turn
affect asthma outcomes.
Family Functioning Affects Asthma Outcomes Through Physiological Factors

Several physiological mechanisms have been proposed to better understand how emotional
factors in the context of family functioning may be related to pediatric asthma outcomes.
Specifically, three mechanisms may reflect interactions between psychological and
physiological processes: first, functioning of the hypothalamic pituitary adrenal (HPA) axis
and the immune system; second, autonomic nervous system functioning; and, third, symptom
perception. Evidence supporting these proposed mechanisms is the result of integrating
multidisciplinary perspectives. Although the evidence at this time is largely theoretical, we
nonetheless reviewed the preliminary data in support of these mechanisms.
HPA Axis and Immune System
The HPA axis may mediate the relationship between emotional factors and asthma in two
ways. First, the HPA axis may be involved in the regulation of inflammation, which is a
central component of asthma. Second, the impact of emotional factors on the HPA axiss
functioning has primarily been examined within the context of better understanding
individuals responses to stress.
There is accumulating theoretical and empirical evidence suggesting that the HPA axis
regulates allergic disease expression and allergic inflammatory responses. The interaction
between immune and nervous systems may affect susceptibility and resistance to
inflammatory diseases (Sternberg, 2001). In particular, neuroendocrine regulation of
inflammatory and immune responses and disease may occur through the release of
glucocorticoids by stimulation of the HPA axis, the presence of glucocorticoids in immune
organs, and the release of neuropeptides and neurohormones at sites of inflammation. While
glucocorticoids generally have anti-inflammatory and immunosuppressive effects, excess
stress hormone responses are associated with enhanced susceptibility to infection whereas
inadequate stress hormone responses are associated with enhanced susceptibility to
inflammatory, autoimmune, and allergic diseases. The interplay between endogenous cortisol
production and allergic inflammation may be evident in a variety of ways: lung function
varies with plasma cortisol levels; the number of circulating inflammatory cells varies with
plasma cortisol levels; and low levels of endogenous cortisol may be associated with risk for
asthma (Schleimer, 2000).
Recent promotion of a biopsychological model of stress and asthma explains how
psychological stressors can modulate interactions among the central nervous system and the
immune system, which may affect inflammatory processes (Wright et al., 1998). Also, stressrelated effects on the central nervous system and immunologic changes can alter responses to
pathogens. Several researchers have suggested that early caregiver stress and quality of
caregiving may affect alterations in immune development (Klinnert et al., 2001; von Hertzen,
2002; Wright et al., 2002). Sustained maternal stress during pregnancy may be associated
with sustained excessive cortisol secretion that could in turn alter the developing immune
system of the fetus (von Hertzen, 2002). In particular, cortisol might influence helper T cell
phenotype differentiation and increase susceptibility to atopy and asthma in genetically
predisposed children. The ways in which infants and children respond to stress, including
developing strategies to modulate their emotions and behavior, may have an effect on their
physiological functioning. Numerous psychosocial factorssuch as trauma history, quality of
caretaking in infancy and childhood, psychopathology, or temperamentmay be associated
with alterations in the HPA axis (Kelsay, Wamboldt, Kaugars, Klinnert, & Robinson, 2004).
These alterations in the HPA axiss functioning may interact with current stressors in children
with asthma to affect the severity of their asthma. In addition, exposure to violence can be
considered a psychological and environmental stress that may affect onset of asthma by
triggering exacerbations through neuroimmunological mechanisms (Wright & Steinbach,
2001).
There is emerging evidence that individuals with atopic conditions may also have an altered
HPA axis response. Adolescents with a history of atopic illnesses demonstrated an attenuated
cortisol response to the stress of laboratory procedures, in particular a blood draw, in
comparison to adolescents who had no history of atopic illness or to those with positive skin
tests and no clinical symptoms (Wamboldt, Laudenslager, Wamboldt, Kelsay, & Hewitt,
2003). The authors suggested that an attenuated cortisol response to a stressor may increase
the likelihood that an individual develops an inflammatory response to the stress and thus
have ones symptoms worsened after the stress. Furthermore, children with allergic asthma, in
comparison to children without, demonstrated significantly attenuated cortisol responses to
psychosocial stress (Buske-Kirschbaum et al., 2003), thereby extending the existing
literatures examination of HPA axiss responsiveness among individuals with atopic
conditions.
Further investigation of neuroendocrine regulation of inflammatory and immune diseases is
necessary. A better understanding is needed of HPA axis activity among individuals with
atopic conditions and the manner in which HPA axis activity may be altered in response to
chronic and situation-specific stress. Longitudinal studies, preferably beginning in infancy,
are indicated to better understand the interplay of endocrine and immune systems in the
development of atopy and asthma. Moreover, research is needed to examine how differences
in the way children regulate their responses to different types of stress are related to the
neuroendocrine systems functioning throughout the course of development.
Autonomic Nervous System
A second mechanism that has been examined as a possible link between emotional factors
and asthma is vagal mediation of the autonomic nervous system. In a review of the empirical
literature on possible effects of suggestion and emotional arousal on pulmonary function
(Isenberg, Lehrer, & Hochron, 1992), the authors proposed a model of parasympathetic
mediation. In particular, increases in vagus nerve activity may mediate psychological
influences resulting in constriction of the upper airways. Results of the review pointed toward
a discrete subgroup of individuals with asthma who respond to particular emotionally charged
stimuli with increased bronchial obstruction.
Similarly, Miller and colleagues have proposed a model of psychophysiologically vulnerable
asthma (Miller & Strunk, 1989; Miller & Wood, 1997). The model suggests that increased
cholinergic activation in despairing, depressed, and hopeless states and cholinergically
mediated airway reactivity in asthma result in a psychophysiologically vulnerable affective
state (i.e., autonomic dysregulation and cholinergic bias), which may in turn cause increased
morbidity and mortality. In support of this model, sadness was found to evoke patterns of
autonomic influence that are consistent with cholinergically mediated airway constriction
(Miller & Wood, 1997). In contrast, states of happiness may be accompanied by autonomic
patterns, which would be consistent with better pulmonary function. The authors
hypothesized that psychophysiologically reactive temperaments or previous emotionally
traumatic experiences may place some children at greater risk for developing psychologically
vulnerable asthma. In a retrospective controlled study comparing children who died of an
acute attack of asthma with children who survived a life-threatening attack of asthma,
significantly more children who died had experienced recent or impending separation or loss
and exhibited emotional states of hopelessness and despair in the days preceding their deaths
(Miller & Strunk, 1989).
This research contributes to a literature that examines how emotional factors within families
affect asthma outcomes. More investigation is indicated to better understand the specific
mechanisms underlying the observed relationship. Replication and extension of existing
findings are needed, with particular attention to measurement and a comprehensive
understanding of the subgroup of children for whom emotional factors contribute to a
particular type of asthma vulnerability.
Symptom Perception
Emotional factors may affect ones accurancy in perceiving symptoms and asthma outcomes.
Perceptual accuracy is defined as the degree to which subjective assessment of asthma
symptomatology/severity corresponds with an objectively measured rating of severity (Fritz,
Yeung, et al., 1996, p. 158). Empirical work on perceptual accuracy in children with asthma
has utilized various objective and subjective measures of respiratory status and symptoms
(Fritz & Wamboldt, 1998; Fritz, Yeung, et al., 1996). More accurate symptom perception has
been found to be related to fewer emergency medical visits and fewer days of school absence,
after controlling for asthma severity (Fritz, McQuaid, Spirito, & Klein, 1996). While few
associations between psychological constructs (e.g., anxiety symptoms, internalizing
behavior, externalizing behavior) and accuracy of symptom perception have been
demonstrated, children with higher cognitive ability had more accurate symptom perception
than children with lower ability (Fritz, McQuaid, et al., 1996). Future research directions for
this area include developing appropriate methodologies for assessing symptom perception,
replicating existing studies with children who have varying degrees of asthma severity,
examining how symptom perception contributes to adherence, and investigating the
relationship between anxiety disorders and symptom perception (Fritz & Wamboldt, 1998).
In summary, HPA axis functioning, autonomic nervous system functioning, and symptom
perception have been proposed as potential mechanisms that mediate relationships between
emotional factors in families and asthma outcomes. While a significant amount of research is
still needed to understand each of these mechanisms, it is important to examine interactions
among multiple mechanisms and to understand how the mechanisms may function differently
among subtypes of pediatric asthma.
Conclusion
Childhood asthma is strongly affected by family factors, including the psychological
functioning of the parent, the interactions between the parent and the child, and the childrens
functioning. Some families may be particularly at risk for difficulties in managing asthma,
owing to problems in their family social environment (risky families; Repetti et al., 2002)
and to risk factors such as poverty and minority status.
This literature review intends to summarize existing knowledge about relationships between
family characteristics and asthma outcomes. Although this provides us with an overview of
the fields progress, significant gaps exist in the literature that preclude development of more
sophisticated models that can examine the direction of relationships and test mediating and
moderating factors. Specifically, prospective longitudinal designs are essential first to
delineate characteristics of premorbid functioning of caregivers and children and second to
evaluate changes in functioning in response to asthma. More information is needed about
normative development of the HPA axis among individuals with atopic conditions so that
individual differences in illness manifestation and responses to stress can be better
understood.
Future research will benefit from attention to numerous additional methodological concerns.
Since many of the proposed relationships among aspects of psychological functioning and
asthma outcomes may be bidirectional, more complex research designs need to take into
account the multiple factors potentially contributing to asthma onset, manifestation, and
morbidity. Sampling bias is rarely acknowledged in study limitations, yet it is evident that the
factors determining selection of participants (e.g., socioeconomic background, asthma
severity) greatly affect findings and subsequent generalizations. Although samples that
represent population extremes (i.e., severe caregiver psychopathology) may provide
significant relationships with asthma outcomes, such samples characterizing extremes may
not necessarily be representative of the functioning of all children with asthma and their
caregivers. Small sample sizes also limit generalizability of findings and require replication.
Finally, what will advance this field of research is attention to reporter bias and the utilization
of objective, multimethod assessment measures of psychological characteristics and asthma
outcomes.
We have proposed that two pathways may explain the association between family
characteristics and asthma outcomes. First, family conflict and distress may affect the asthma
management behaviors in which families engage (see Figure 1, Paths B and C). Greater
family conflict and distress are associated with poorer adherence and thus worse asthma
outcomes. Moreover, family organization and membership in certain racial or ethnic groups
have also been found to influence asthma outcomes via asthma management behaviors.
Second, theoretical models with some empirical evidence explain how HPA axis functioning,
autonomic nervous system functioning, and symptom perception may contribute to the
relationships between family characteristics and asthma onset and outcomes (see Figure 1,
Paths D and E). Whereas much of the literature illuminates cross-sectional relationships,
longitudinal designs would help examine complicated, intertwining relationships throughout
the developmental process. This is an exciting area for future research that can utilize
multidisciplinary approaches to better understand the complexity of pediatric asthma. Most
elements of the proposed theoretical model have not been empirically tested; however, it is
our hope that proposing this model will stimulate future research in this area.
If the morbidity associated with pediatric asthma is to improve, it will be critical that
assessment and treatment take into account the various emotional, behavioral, and
physiological factors within families that affect pediatric asthma outcomes. Integrating
research findings into treatment could benefit child and family functioning as well as asthma
outcomes. As discussed in this review, multiple facets of family functioning, which in some
cases could be altered with intervention, may be influential in pediatric asthma. As the
treatment guided by research develops, not only could it minimize the functional and
emotional impact of asthma on children and families, but it could also help children and
families effectively manage asthma, with the aims of decreasing disruption and integrating
asthma management into their lives. As we advance our understanding of developmental
processes, we will gain better insight into where and how to intervene to improve asthma
outcomes.
Acknowledgments
This work was supported by a National Institute of Mental Healthfunded institutional
postdoctoral research training program, the Development of Maladaptive Behavior 5 T32
MH15442; by the Developmental Psychobiology Research Group at the University of
Colorado Health Sciences Center, Denver, Colorado; and by a National Institute of Child
Health and Human Developmentfunded National Research Service Award, Individual
Postdoctoral Fellowship 1 F32 HD042894.
Journal of Pediatric Psychology vol. 29 no. 7 Society of Pediatric Psychology

2004; all rights reserved.
Previous Section
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View Current Issue (Volume 40 Issue 2 March 2015)

Medicine & Health

Journal of Pediatric Psychology

Volume 29, Issue 7

Family Influences on Pediatric Asthma

2. Mary D. Klinnert, PhD 2 , 3 and

Marquette University, 2National Jewish Medical and Research Center and

1. All correspondence should be sent to Astrida S. Kaugars, Department of Psychology,

Received April 23, 2003.

Revision received September 15, 2003.

Revision received November 23, 2003.

Accepted November 26, 2003.

Theoretical Model Summarizing Literature

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Family Functioning and Asthma

Caregivers Psychological Functioning

Child Adjustment and Psychopathology

Additional Factors Influencing Family Functioning

Potential Mechanisms Accounting for Associations

Family Functioning Affects Asthma Outcomes Through Asthma Management

Family Functioning Affects Asthma Outcomes Through Physiological Factors

Journal of Pediatric Psychology vol. 29 no. 7 Society of Pediatric Psychology

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