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Purpose Early adolescence is an important developmental period where youth take primary responsibility for asthma self-management. Helpful caregiver support during this time is pivotal in determining whether early adolescents successfully develop asthma self-management behaviors. AIM2ACT is a dyadic mobile health intervention designed to increase helpful caregiver support as early adolescents engage in asthma self-management behaviors. We conducted a pilot randomized controlled trial to determine the feasibility and acceptability of AIM2ACT and conduct preliminary tests of efficacy. Methods We randomized adolescents (12–15 years old) and a caregiver to receive AIM2ACT (n = 17) or a self-guided attention control condition (n = 16) for 20 weeks. We conducted assessment visits at baseline, postintervention, and 4-month follow-up. Outcomes included family asthma management (primary outcome), adolescent asthma control, lung function (forced expiratory volume in 1 second), asthma-related quality of life, asthma management self-efficacy, and family communication. Results We randomized 33 dyads and had 100% retention in the trial among AIM2ACT participants. Dyads frequently engaged with AIM2ACT (M = 21 days for adolescents, 32.65 days for caregivers) and reported very high satisfaction with content, functionality, and helpfulness. Participants randomized to AIM2ACT had significant improvements in asthma control scores (p = .04) compared to control that surpassed the minimally clinically important difference threshold. Although not statistically significant, the magnitude of improvements in family asthma management, asthma-related quality of life, and family communication was larger in the AIM2ACT group. Conclusions AIM2ACT is a feasible and acceptable dyadic mobile health asthma self-management intervention that improves asthma control.

Objectives Asthma and obesity disproportionately affect urban minority children. Avoidance of physical activity contributes to obesity, and urban children with asthma are at risk for lower levels of physical activity. We examined associations between lung function and moderate to vigorous physical activity (MVPA) and moderators of this association in a diverse sample of children with asthma. Methods Urban children (N = 142) ages 7–9 with persistent asthma and their caregivers completed a study of asthma and physical activity. Longitudinal mixed effects models examining daily-level asthma and physical activity evaluated the association between asthma and MVPA, and the moderating effect of weight, and cultural/contextual factors on this association. Results Average daily MVPA was below recommended guidelines. Differences in MVPA were found by racial/ethnic group (p = .04) and weight (p = .001). Poorer asthma status was associated with lower MVPA in Latino and Black participants (p’s < .05), and in normal weight youth (p = .01). Body mass index (BMI) moderated the association between asthma and MVPA. Those with lower BMI had more optimal asthma status and higher MVPA levels, whereas associations attenuated for participants with higher BMI (p = .04). Caregivers’ perceptions of neighborhood safety and fear of asthma were marginally associated with children’s symptoms and MVPA: as perceptions of safety decreased and fear increased, associations between asthma and MVPA weakened (p’s = .09 and .07, respectively). Conclusions Suboptimal asthma status is associated with less MVPA in urban children. Weight status and cultural/contextual factors play a role in the association and are worthy targets for future research and intervention.

Objective Adherence to asthma controller medications is suboptimal among adolescents. We evaluated predictors of adherence and longitudinal patterns of medication use between 8th and 10th grade among a sample of youth of diverse race/ethnicity. Methods Eighth graders with asthma on controller medications (N = 62; 40.0% non-Latino white; 23.7% Black; 37.3% Latino; 37.3% female) completed measures of medication beliefs, responsibility for asthma management, and family cohesion. Objective methods tracked medication use longitudinally. Results Adherence declined during the high school transition, from 48.0% in eighth grade to 34.1% in tenth grade (F = 5.35, p < .01). Males had lower adherence (b = −10.11, SE = 5.37, p = .02, f2 = 0.11), as did Latino youth (b = −12.21, SE = 8.23, p = .03, f2 = 0.12). Family cohesion was associated with higher adherence (b = 4.38, SE = 1.98, p = .04, f2 = 0.06). Latent class models (LCMs) suggested a three-class model of longitudinal adherence patterns. This included low, declining adherence (Class 1 = 29%; higher proportion male, p = .02), high, sustained adherence (Class 2 = 26%, high family cohesion, p = .05, higher proportion female, p = .02), and low, sustained adherence (Class 3 = 45%; higher proportion Latino, p = .05, higher proportion male, p = .02). Conclusions Asthma medication adherence declined between 8th and 10th grade. LCMs indicated some youth have stable patterns of adherence (high or low), whereas others demonstrate declines. Gender differences were observed, and family cohesion was associated with higher, sustained adherence. Interventions building on family resources and targeting the barriers adolescents face are necessary to improve asthma management during this vulnerable period.

BACKGROUND: Asthma disproportionately impacts youth from marginalized minority backgrounds. Aspects of core asthma management (asthma management and medication beliefs) were examined among a cohort of diverse families. METHODS: Caregiver-youth dyads (N= 92; M(age)= 13.8 years; non-Hispanic/Latinx White (NLW) = 40%; Black/African-American = 25%; Hispanic/Latinx= 35%) completed a medication beliefs questionnaire (Medication Necessity, Medication Concerns) and a semi-structured interview (Family Asthma Management System Scale (FAMSS)). FAMSS subscales (Asthma Knowledge, Symptom Assessment, Family Response to Symptoms, Child Response to Symptoms, Environmental Control, Medication Adherence, Family-Provider Collaboration, and Balanced Integration) were used for analyses. RESULTS: More Hispanic/Latinx families were at or below the poverty line (75%) relative to NLW (22%) and Black/African-American (39%) families (p < .001). Adherence (p< .01), Knowledge (p< .001), and Symptom Assessment (p< .01) were higher for NLW relative to Black/African-American families. Collaboration was higher among NLW (p= .01) and Hispanic/Latinx families (p= .05). Effect sizes were moderate (η(2)= .10 – .12). Parental race/ethnicity moderated the relationship between adherence and parental perceived medication concern and necessity for NLW and Hispanic/Latinx families. As medication concerns increased, medication adherence decreased, however, only for NLW and Hispanic/Latinx families. CONCLUSIONS: In this sample, racial/ethnic differences emerged for elements of asthma management. Interview-based ratings of asthma management among Black/African-American families depicted lower asthma knowledge, lower levels of family-provider collaboration, and lower medication adherence. The relationship between medication concerns and adherence appeared to differ by ethnic group. Future research is needed to elucidate cultural factors that influence family-provider relationships and health-related behaviors, like medication use/adherence.

OBJECTIVE: Community Health Workers (CHWs) have been effective in improving health outcomes in vulnerable communities by providing health education and management services. We review CHW-led asthma education and management interventions for children and their families. Next, we describe the selection and training of CHWs in pediatric asthma management in the Rhode Island Integrated Response Asthma Care Implementation Program (RI-AIR). METHODS: We queried the MEDLine, Cochrane, PubMed, and EMBASE databases with keywords (“community health worker”, “asthma”, “health worker”, “lay worker”, “pediatric”, “child”, and “childhood”) from inception until September 2019. Criteria for study inclusion included: published in English, conducted in the United States, approved with an ethics notification, published in peer-reviewed journal, and involved CHWs as the interventionists. The initial search identified 216 manuscripts. Fifteen studies met criteria for inclusion. RESULTS: CHWs provide asthma management and education services, including home environmental trigger assessments, strategies to reduce environmental trigger exposure, resource linkage, and community referrals. We describe RI-AIR, and its CHW-led asthma education and management interventions. CONCLUSIONS: CHWs are effective and vital supports for positive asthma outcomes. More research is needed to guide models of intervention using CHWs, specifically addressing integration in interdisciplinary teams, training, and reimbursement for CHW services. IMPLICATIONS FOR IMPACT STATEMENT: CHWs are effective in helping children with asthma and their families learn to manage asthma. It is important to develop programs that prepare CHWs to work with other medical professionals and health care models to pay for their services.

Urban minority preschool children are disproportionately affected by asthma with increased asthma morbidity and mortality. It is important to understand how families manage asthma in preschool children to improve asthma control.To evaluate family asthma management and asthma outcomes among a low-income urban minority population of Head Start preschool children.The family asthma management system scale (FAMSS) evaluates how families manage a child's asthma. A total of 388 caregivers completed the FAMSS at baseline. Asthma outcomes were evaluated at baseline and prospectively at 6 months, including asthma control (based on the Test for Respiratory and Asthma Control in Kids), courses of oral corticosteroids (OCSs) required, and caregiver health-related quality of life (Pediatric Asthma Caregiver's Quality of Life Questionnaire [PACQLQ]). Multiple regression models evaluated the relationship between the FAMSS total score, FAMSS subscales, and asthma outcomes.Higher FAMSS total scores were associated with fewer courses of OCSs required (b = -0.23, P.01) and higher PACQLQ scores (b = 0.07, P.05). At baseline, higher integration subscale scores (b = -0.19, P.05) were associated with fewer courses of OCSs required, and higher family response scores were associates with higher PACQLQ scores (b = 0.06, P.05). Nevertheless, higher collaboration scores were associated with lower PACQLQ at baseline (b = -0.06, P.05) and 6 months (b = -0.07, P.05).Among this population of low-income minority preschool children, understanding how a family manages their child's asthma may help identify gaps for education to possibly improve caregiver asthma-related quality of life and reduce courses of OCSs.ClinicalTrials.gov Identifier: NCT01519453 (https://clinicaltrials.gov/ct2/show/NCT01519453); protocol available from meakin1@jhmi.edu.

Meeting nutritional needs of children with food allergy (FA) may be challenging without affordable, quality foods. Food purchase location may impact availability of FA-safe foods; however, no research examining food purchase location in families of children with FA exists. This study compared caregiver report of food insecurity (FIS; food insecure vs. food secure), FA risk, and history of food-induced anaphylaxis (FIA) in families of children with FA, who primarily purchase food items at grocery/supermarkets (n = 140) or convenience marts/bodegas (CB; n = 32). Caregivers (N = 172; 49% mothers, 49% fathers, 2% grandparent/other relative) of children with FA (57% male; Mage = 7.5 years; 66% White [22% Latinx and 44% non-Latinx] and 23% Black) completed an online survey. Variables included demographics, history of FIA, and caregiver perceptions of FIS and FA risk. Caregivers who purchased food items from CB versus supermarkets reported higher perceived risk of accidental ingestion (χ2 = 20.49, p < .001, 94% vs. 50%), severe reaction (χ2 = 15.05, p < .001, 97% vs. 61%), death (χ2 = 27.48, p < .001, 91% vs. 49%), FIS (χ2 = 21.69, p < .001, 94% vs. 49%), and FIA (χ2 = 11.96, p = .001, 94% vs. 32%). Effect sizes were small–moderate (Cramer’s V = .26–.40). Families who purchased food at CB reported greater food allergen concerns and FIS than families who purchased food at supermarkets. Differences in FA-related perceived risks may reflect the health disparity and adversity these families face to meet basic nutritional needs, such as FA-related constraints. Point-of-care efforts are needed to provide early screening for families who may be at risk for experiencing FIS.

Background Urban minority children experience high levels of asthma morbidity. Poor school performance can be an indicator that asthma is in poor control. Little attention has been paid to examining real-time links between asthma and academic performance, particularly in high-risk groups. Objective Examine 1) academic performance across a range of indicators in a group of urban children with asthma and urban children without chronic illness and ethnic differences in these associations, and 2) associations between asthma and academic performance in the group of urban children with asthma and ethnic differences in these associations. Methods Two hundred sixteen black/African American (33%), Latino (46%), and non-Latino white (21%) urban children, ages 7 to 9 years completed a clinic- and home-based protocol that assessed asthma and allergy status, objective measurements of lung function, and academic functioning. Results Analyses revealed that children with asthma experienced a higher number of school absences when compared with healthy controls. Greater disparities in academic outcomes emerged when examining ethnic differences within the groups of children with and without asthma. Poor academic outcomes were observed in Latino children with asthma. Furthermore, a strong correspondence of poor asthma outcomes and decrements in academic performance were seen in the full sample, and these associations emerged across ethnic groups. Conclusion Asthma activity contributes to poorer academic outcomes across a range of indicators, and urban minority children with asthma, particularly Latino children, may be at heightened risk for poorer academic performance. School management guidelines for asthma need to be consistently implemented and tailored for school staff, caregivers, and students with asthma to address challenges of managing asthma within the urban school setting.

Asthma symptoms impact children’s sleep quality. However, it is unclear how families’ daily management of their child’s asthma is associated with sleep quality. We examine associations between family asthma management components and sleep duration and quality for urban children (ages 7–9 years). Additionally, we examine these associations by racial/ethnic group. Data were collected as part of a longitudinal study that examined the co-occurrence of asthma, allergic rhinitis, sleep quality, and academic functioning for urban children diagnosed with persistent asthma ( N = 196). A semi-structured interview assessed family asthma management practices. Sleep quality data were collected via actigraphy. Our visual depiction of sleep outcomes show that those with higher family asthma management ratings present with longer sleep duration and better sleep quality. Among specific family asthma management components, we found a significant association between children’s adherence to asthma medications and number of nighttime awakenings. For non-Latino Black (NLB) children, we found a significant association between environmental control and sleep duration. For urban children with asthma, clinical strategies to enhance overall family asthma management have the potential to support improved sleep quality. Additionally, for NLB children, asthma management interventions that provide environmental control practices may increase sleep duration.

Key Points Question In children with acute lymphoblastic leukemia receiving oral mercaptopurine, can an intervention consisting of education and daily text message reminders to prompt directly supervised therapy result in a higher proportion of patients with mercaptopurine adherence 95% or higher, compared with education alone? Findings In this parallel-group, unblinded, randomized clinical trial including 444 children with acute lymphoblastic leukemia, the proportion of patients with mercaptopurine adherence rates 95% or higher did not differ between the intervention and education groups. In exploratory analyses, children aged 12 years and older with baseline adherence less than 90% had higher mean adherence in the intervention group. Meaning This study provides evidence for limiting future trials to older children with acute lymphoblastic leukemia who have low baseline adherence to oral mercaptopurine., This randomized clinical trial examines whether a multicomponent intervention results in a higher proportion of pediatric patients with acute lymphoblastic leukemia maintaining mercaptopurine adherence rates of 95% or higher compared with education alone., Importance Suboptimal adherence to oral mercaptopurine treatment in children with acute lymphoblastic leukemia (ALL) increases the risk of relapse. A frequently expressed barrier to adherence is forgetfulness, which is often overcome by parental vigilance. Objective To determine whether a multicomponent intervention, compared with education alone, will result in a higher proportion of patients with ALL who have mercaptopurine adherence rates 95% or higher, for all study participants and among patients younger than 12 years and vs those aged 12 years and older. Design, Setting, and Participants The adherence intervention trial was an investigator-initiated, multi-institutional, parallel-group, unblinded, randomized clinical trial conducted between July 16, 2012, and August 8, 2018, at 59 Children’s Oncology Group institutions in the US, enrolling patients with ALL diagnosed through age 21 years and receiving mercaptopurine for maintenance. The date of final follow-up was January 2, 2019. Data analysis was performed from February to October 2019. Interventions Patients were randomized 1:1 to education alone or the intervention package, which consisted of education and personalized text message reminders daily to prompt directly supervised therapy. Four weeks of baseline adherence monitoring were followed with a 16-week intervention. Main Outcomes and Measures The primary end point was the proportion of patients with adherence rates 95% or higher over the duration of the intervention for all study participants, and for those younger than 12 years vs those aged 12 years and older. Results There were 444 evaluable patients (median age, 8.1 years; interquartile range, 5.3-14.3 years), including 230 in the intervention group and 214 in the education group. Three hundred two patients (68.0%) were boys, 180 (40.5%) were non-Hispanic White, 170 (38.3%) were Hispanic, 43 (9.7%) were African American, and 51 (11.5%) were Asian or of mixed race/ethnicity. The proportion of patients with adherence rates 95% or higher did not differ between the intervention vs education groups (65% vs 59%; odds ratio, 1.33; 95% CI, 1.0-2.0; P = .08). Exploratory analyses showed that among patients aged 12 years and older, those in the intervention group had higher mean (SE) adherence rates than those in the education group (93.1% [1.1%] vs 90.0% [1.3%]; difference, 3.1%; 95% CI, 0.1%-6.0%; P = .04). In particular, among patients aged 12 years and older with baseline adherence less than 90%, those in the intervention group had higher mean (SE) adherence rates than those in the education group (83.4% [2.5%] vs 74.6% [3.4%]; difference, 8.8%; 95% CI, 2.2%-15.4%; P = .008). No safety concerns were identified. Conclusions and Relevance Although this multicomponent intervention did not result in an increase in the proportion of patients with ALL who had mercaptopurine adherence rates 95% or higher, it did identify a high-risk subpopulation to target for future adherence intervention strategies: adolescents with low baseline adherence. Trial Registration ClinicalTrials.gov Identifier: NCT01503632

OBJECTIVE: The Childhood Health and Asthma Management Program (CHAMP) is a behavioral family lifestyle intervention for youth with overweight or obesity (OV/OB) and asthma. This pilot randomized controlled trial examined the feasibility, acceptability, and preliminary efficacy of CHAMP. METHODS: A sample of 24 children (M(age) = 8.67) with asthma and a BMI ≥ 85(th) percentile and their caregivers participated in a pilot randomized controlled trial. Families were recruited from local pediatrician offices and pediatric pulmonary and allergy clinics and randomized to CHAMP or a health education attention control condition. Children’s height, weight, lung function, asthma control, and asthma-related quality of life (QOL) were collected at baseline, post-intervention, and 6-months post-treatment. Analysis of covariance and standardized mean differences were used to assess changes in outcome variables among participants attending > 50% of sessions (n = 12). RESULTS: Families participating in CHAMP reported high satisfaction; however, there were a number of barriers to recruitment and regular session attendance. There were no statistically significant between group differences at post-intervention or long-term follow-up. From baseline to post-intervention, there were small to large effect sizes favoring CHAMP for BMI z-scores, asthma control, and measures of lung function. There were small to medium effect sizes favoring CHAMP at long-term follow-up for BMI z-scores, asthma control, and asthma-related QOL. CONCLUSIONS: CHAMP had adequate acceptability in this trial. We did not find significant results favoring CHAMP in comparison to the control group, however, lessons learned provide important directions for modifications in anticipation of a larger trial.

Objective Significant disparities exist in asthma outcomes. Racial and ethnic minorities have lower controller medication adherence, which may contribute to differences in asthma morbidity between minority and non-minority groups. The objective of this review is to identify individual, patient–provider communication, and systems issues that contribute to this pattern of medication underuse and to discuss potential strategies for intervention. Data Sources Data were gathered from numerous sources, including reports of pharmacy and medical records, observational studies, and trials. Study Selections Studies analyzed factors contributing to patterns of asthma medication adherence that differ by race and ethnicity. Results There is clear evidence of underuse of asthma controller medications among racial and ethnic minorities in prescription receipt, prescription initiation, and medication use once obtained. Individual factors such as medication beliefs and depressive symptoms play a role. Provider communication is also relevant, including limited discussion of complementary and alternative medicine use, difficulties communicating with patients and caregivers with limited English proficiency, and implicit biases regarding cultural differences. Systems issues (eg, insurance status, cost) and social context factors (eg, exposure to violence) also present challenges. Culturally informed strategies that capitalize on patient strengths and training providers in culturally informed communication strategies hold promise as intervention approaches. Conclusion Disparities in controller medication use are pervasive. Identifying the sources of these disparities is a critical step toward generating intervention approaches to enhance disease management among the groups that bear the greatest asthma burden.

Adherence to medications is dependent upon a variety of factors, including individual characteristics of the patient, the patient’s family and culture, interactions with healthcare providers, and the healthcare system itself. Because of its association with worse outcomes, poor medication adherence is considered a potential contributor to disparities in health outcomes observed for various conditions across racial and ethnic groups. While there are no simple answers, it is clear that patient, provider, cultural, historical, and healthcare system factors all play a role in patterns of medication use. Here, we provide an overview of the interface between culture and medication adherence for chronic conditions; discuss medication adherence in the context of observed health disparities; provide examples of cultural issues in medication adherence at the individual, family, and healthcare system/provider level; review potential interventions to address cultural issues in medication use; and provide recommendations for future work.

This study examines the longitudinal relationships between child smoking and secondhand smoke exposure (SHSe). Participants were 222 parent–child dyads. The parents smoked, had a child with (48%) or without asthma, and were enrolled in a smoking/health intervention. Parent-reported child SHSe was measured at baseline and 4, 6, and 12-month follow-ups; self-reported child smoking was assessed at these points and at 2-months. A parallel process growth model was used. Baseline child SHSe and smoking were correlated (r = 0.30). Changes in child SHSe and child smoking moved in tandem as evidenced by a correlation between the linear slopes of child smoking and SHSe (r = 0.32), and a correlation between the linear slope of child smoking and the quadratic slope of child SHSe (r = − 0.44). Results may inform interventions with the potential to reduce child SHSe and smoking among children at increased risk due to their exposure to parental smoking.

IntroductionAsthma is a leading cause of youth morbidity in the USA, affecting >8% of youth. Adherence to inhaled corticosteroids (ICS) can prevent asthma-related morbidity; however, the typical adolescent with asthma takes fewer than 50% of their prescribed doses. Adolescents are uniquely vulnerable to suboptimal asthma self-management due to still-developing executive functioning capabilities that may impede consistent self-regulation and weaken attempts to use problem solving to overcome barriers to ICS adherence.Methods and analysisThe aims of this project are to improve adherence to ICS as an important step towards better self-management among adolescents aged 13–17 years diagnosed with asthma by merging the efficacious behaviour change strategies found in behavioural health interventions with scalable, adaptive mobile health (mHealth) technologies to create the Responsive Asthma Care for Teens programme (ReACT). ReACT intervention content will be developed through an iterative user-centred design process that includes conducting (1) one-on-one interviews with 20 teens with asthma; (2) crowdsourced feedback from a nationally representative panel of 100 adolescents with asthma and (3) an advisory board of youth with asthma, a paediatric pulmonologist and a behavioural health expert. In tandem, we will work with an existing technology vendor to programme ReACT algorithms to allow for tailored intervention delivery. We will conduct usability testing of an alpha version of ReACT with a sample of 20 target users to assess acceptability and usability of our mHealth intervention. Participants will complete a 4-week run-in period to monitor their adherence with all ReACT features turned off. Subsequently, participants will complete a 4-week intervention period with all ReACT features activated. The study started in October 2018 and is scheduled to conclude in late 2019.Ethics and disseminationInstitutional review board approval was obtained at the University of Kansas and the University of Florida. We will submit study findings for presentation at national research conferences that are well attended by a mix of psychologists, allied health professionals and physicians. We will publish study findings in peer-reviewed journals read by members of the psychology, nursing and pulmonary communities.

Background: Asthma is the most common chronic childhood illness and is a leading cause of emergency department visits in the United States. Obesity increases the risk of poor health outcomes, reduced quality of life, and increased health care expenditures among youth with asthma. Weight loss is crucial for improving asthma outcomes in children with obesity. Our study team developed the Childhood Health and Asthma Management Program (CHAMP), a 16-session behavioral family lifestyle intervention (BFI) for school-age children with asthma and obesity and evaluated CHAMP in a randomized controlled trial compared with attention control. There were medium effect sizes favoring CHAMP for changes in body mass index z-scores, asthma control, and lung function among completers (ie, those who attended ≥9 of 16 sessions). Despite high rates of satisfaction reported by families, attendance and trial attrition were suboptimal, which raised concerns regarding the feasibility of CHAMP. Qualitative feedback from participants indicated 3 areas for refinement: (1) a less burdensome intervention modality, (2) a more individually tailored intervention experience, and (3) that interventionists can better answer health-related questions. Objective: We propose to improve upon our pilot intervention by developing the Mobile Childhood Health and Asthma Management Program (mCHAMP), a nurse-delivered BFI, delivered to individual families, and supported by a mobile health (mHealth) app. This study aims to (1) identify structural components of mCHAMP and (2) develop and test the usability of our mCHAMP app. Methods: Participants will be recruited from an outpatient pediatric pulmonary clinic. We will identify the structural components of mCHAMP by conducting a needs assessment with parents of children with asthma and obesity. Subsequently, we will develop and test our mCHAMP app using an iterative process that includes usability testing with target users and pediatric nurses. Results: This study was funded in 2018; 13 parents of children with asthma and obesity participated in the needs assessment. Preliminary themes from focus groups and individual meetings included barriers to engaging in health-promoting behaviors, perceived relationships between asthma and obesity, facilitators to behavior change, and intervention preferences. Participatory design sessions and usability testing are expected to conclude in late 2019. Conclusions: Outcomes from this study are expected to include an mHealth app designed with direct participation from the target audience and usability data from stakeholders as well as potential end users. International Registered Report Identifier (IRRID): DERR1-10.2196/13549

Background Suboptimal sleep has been documented in at-risk groups such as urban minority children, particularly those with asthma. It is therefore critical to examine differences in sleep outcomes across specific racial and ethnic groups and to identify factors that contribute to such variations in sleep outcomes to inform tailored interventions to improve sleep health. Objectives The objectives were to examine racial/ethnic differences in sleep outcomes among urban children with and without asthma and to evaluate the extent to which asthma status and aspects of sleep hygiene and the sleep environment contribute to racial/ethnic differences in sleep outcomes in this sample. Methods Two hundred and sixteen African American, Latino, or non-Latino white (NLW) urban children, ages 7-9 years, with (n = 216) and without asthma (n = 130) and their primary caregivers were included. Objective sleep duration and efficiency were assessed via actigraphy. Asthma status was assessed by a study clinician. Caregiver-reported sleep hygiene and exposure to noise were assessed using a questionnaire. Results Minority children in the sample had, on average, shorter sleep duration compared to NLW children during the monitoring period (mean difference Latino vs NLW = −22.10, SE = 5.02; mean difference AA vs NLW = −18.69, SE = 5.28) Additionally, several racial/ethnic group differences in sleep outcomes emerged and were dependent on whether or not children had asthma. Specifically, Latinos had lower mean number of awakenings compared to NLWs but only among control participants with no asthma. Furthermore, specific aspects of sleep hygiene and exposure to nighttime noise in the home and neighborhood contributed to racial/ethnic differences in sleep outcomes. Conclusion Considering urban stressors and asthma status when treating pediatric populations is important, as factors related to urban stress and asthma management may influence sleep hygiene practices and sleep outcomes.

Introduction Studies consistently show that children living in poor neighborhoods have worse asthma outcomes. The objective of our study was to assess the association between negative neighborhood factors (ie, neighborhood risk) and pediatric asthma hospital use. Methods This retrospective study used data from children aged 2 to 17 years in a statewide (Rhode Island) hospital network administrative database linked to US Census Bureau data. We defined an asthma visit as an International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) code of 493 in any diagnosis field. We used 8 highly correlated measures for each census-block group to construct an index of neighborhood risk. We used maps and linear regression to assess the association of neighborhood risk with average annual census-block-group rates of asthma emergency department visits and hospitalizations. We used multivariable analyses to identify child characteristics and neighborhood risk associated with an asthma revisit, accounting for the child's sociodemographic information, season, and multiple measurements per child. Results From 2005 through 2014, we counted 359,195 visits for 146,889 children. Of these, 12,699 children (8.6%) had one or more asthma visits. Linear regression results showed 1.18 (95% confidence interval, 1.06-1.30) more average annual emergency departments visits per 100 children and 0.41 (95% confidence interval, 0.34-0.47) more average annual hospitalizations per 100 children in neighborhoods in the highest-risk index quintile than in neighborhoods in the lowest-risk index quintile. Conclusion Interventions to improve asthma outcomes among children should move beyond primary care or clinic settings and involve a careful evaluation of social context and environmental triggers.

Family connectedness has been linked to better than expected asthma health in youth at risk for asthma disparities, yet it is unclear whether benefits exist across child development. The association between family connectedness and asthma management was examined in 245 youth (6–15 years), as well as whether this relationship varied by child age and race or ethnicity. Youth and caregivers completed family connectedness and asthma management semi-structured interviews. Higher levels of family connectedness were related to better asthma management across racial/ethnic groups. Child age was a significant moderator of the relation between family connectedness and asthma management for non-Latino White youth only, suggesting that for this group, the effect of family connectedness on asthma management was weaker for older youth. Conversely, family connectedness may consistently promote asthma management for Latino and non-Latino Black youth throughout development.

Aims We tested two aims: (1) the teachable moment (TM): whether second-hand smoke exposure (SHSe) feedback motivates cessation in parents of children with asthma versus parents of healthy children (HC); and (2) whether greater intervention intensity [enhanced-precaution adoption model (PAM)] produces greater cessation than a previously tested intervention (PAM). Design and interventions Aim 1: two home visits (asthma education or child wellness), and cessation induction using motivational interviewing and SHSe feedback. Aim 2: post-home-visits, parents with asthmatic children were randomized to PAM (n = 171; six asthma education calls) or enhanced-PAM (n = 170; six asthma education/smoking cessation calls + repeat SHSe feedback). Setting Rhode Island, USA. Participants Parents of asthmatic (n = 341) or healthy (n = 219) children who did not have to want to quit smoking to enroll. Measurements Measurements were given at baseline, 2, 4, 6 and 12 months. Abstinence was bioverified. Outcomes were 7-day and 30-day point prevalence abstinence (ppa) and SHSe (primary) and asthma morbidity (secondary). Findings Aim 1: the TM was supported: parents of asthmatic children were more than twice as likely to achieve 30-day [odds ratio (OR) = 2.60, 95% confidence interval (CI) = 1.22–5.54] and 7-day ppa (OR = 2.26, 95% CI = 1.13–4.51) at 2 months (primary end-point) and have non-detectable levels of SHSe than HCs. Greater treatment intensity yielded stronger TM effects (OR = 3.60; 95% CI = 1.72–7.55). Aim 2: enhanced-PAM was more likely to achieve 30-day ppa at the primary end-point, 4 months (OR = 2.12, 95% CI 1.09–4.12) and improved asthma outcomes versus PAM. Conclusions Smoking cessation intervention (Motivational Interviewing plus biomarker feedback) appear to motivate smoking cessation more strongly among parents of asthmatic children than among parents of healthy children. Increased intervention intensity yields greater smoking cessation among parents of asthmatic children and better asthma outcomes.

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

OBJECTIVE This study determined if secondhand smoke (SHS) exposure is related to asthma-related functional morbidity by examining racial/ethnic differences in non-Latino White (NLW), African American, and Latino families and whether racial/ethnic SHS exposure differences across families persist when accounting for smoking factors. METHODS Participants were 305 caregiver smokers of children with asthma. Two passive dosimeters measured secondhand smoke: one in the home and one worn by the child. RESULTS Higher SHS exposure was related to greater asthma-related functional morbidity. African Americans had higher levels of home SHS exposure than did Latinos (p = .003) or NLWs (p = .021). SHS exposure as assessed by the child-worn dosimeter did not differ across race/ethnicity. African American families were less likely to report a household smoking ban (46.4%) compared to Latinos (79.2%) and NLWs (67.9%; p < .05). African Americans were less likely to report having two or more smokers in the home (37.2%) compared to NLWs (53.6%; p < .05). NLWs reported the highest number of cigarettes smoked daily (Mdn = 15.00) compared to Latinos (Mdn = 10.00; p = .001) and African Americans (Mdn = 10.00; p < .001). SHS home exposure levels were regressed on race/ethnicity and relevant covariates. Household smoking ban (p < .001) and only one smoker in the home (p = .005) were associated with lower levels of SHS in the home; race/ethnicity was not significant. CONCLUSIONS Differences in SHS exposure across race/ethnicity exist among children with asthma, possibly due to differential presence of a household smoking ban and number of smokers in the home.

This cohort study uses data from the Population Assessment of Tobacco and Health from 2015 to 2018 to examine the association between wheezing and past-year use of e-cigarettes among youths., Key Points Question Is wheezing associated with e-cigarette use among youths? Findings In this cohort study of 7049 adolescents in waves 3 and 4 of the Population Assessment of Tobacco and Health, the odds of wheezing in the past 12 months were higher for adolescents who had used e-cigarettes during the past year compared with those who had not used e-cigarettes. In the adjusted model, the association of e-cigarette use with wheezing was not significant. Meaning The findings suggest that e-cigarette use alone might not be associated with increased odds of wheezing., Importance Use of e-cigarettes (ECs) among youths has increased in recent years. e-Cigarette aerosol contains chemical constituents, such as diacetyl or benzaldehyde, which are known to affect the respiratory system. Objective To examine the association between EC use and self-reported wheezing in a cohort of US adolescents. Design, Setting, and Participants This cohort study used data from waves 3 and 4 (October 19, 2015, to January 3, 2018) of the Population Assessment of Tobacco and Health (PATH) study, a longitudinal, nationally representative cohort survey. Adolescent respondents aged 12 to 17 years who did not have asthma were included. Exposures e-Cigarette use during the previous year. Main Outcomes and Measures Self-reported wheezing in the past 12 months (yes or no) and EC use (no use in past year or never use, use in past year, use in past 30 days, and use in past 7 days). Survey-weighted logistic regression models adjusted for demographic characteristics and other risk factors. Results Among 7049 adolescents without asthma from waves 3 and 4 of the PATH study, 49.9% were female and 54.4% were non-Hispanic White. In unadjusted models, the odds of wheezing in the past 12 months were higher for youths who had used ECs in the past year compared with those who had not (odds ratio, 1.74; 95% CI, 1.22-2.48; P = .003). In the adjusted model, after controlling for the variables of race/ethnicity, household rules about the use of tobacco, contact with a smoker in the previous 7 days, and current use of combustible tobacco products, the association of EC use with wheezing was not significant (adjusted odds ratio for EC use in the past year, 1.37 [95% CI, 0.91-2.05]; in the past 30 days, 1.35 [95% CI, 0.63-2.88]; in the past 7 days, 0.74 [95% CI, 0.28-1.97]; P = .33). Conclusions and Relevance In this cohort study, use of ECs alone was not associated with increased odds of experiencing wheezing episodes. Future studies incorporating the use of objective data appear to be needed to more accurately understand the potential respiratory harms associated with vaping among adolescents.

Formative research is needed to develop effective interventions that eliminate secondhand smoke exposure (SHSe) and prevent tobacco use (TU) among children with asthma. This online study included 300 parents who smoke and had a child with asthma (ages 10–14) and evaluated their perceptions about prototypes of parent-directed and child-directed feedback intervention messages focused on reducing child SHSe and future TU; correlates of perceptions were explored. Parents rated examples of parent-directed messages on motivation and helpfulness for eliminating SHSe and promoting conversations about TU and also rated child-directed messages on acceptability and helpfulness for promoting conversations about TU. Messages differed by level of personalization, theoretical background, or message content. Parents found all parent-directed messages similarly motivating and helpful and all child-directed messages similarly acceptable and helpful for reducing child tobacco exposure. Differences in perceptions about feedback emerged based on parent gender, parent readiness to quit, smoking ban status, and the presence of additional smokers in the home. Overall, parents rated parent-directed and child-directed feedback message prototypes positively, including established and novel types of feedback. Parent–child feedback interventions may hold promise for breaking the intergenerational transmission of smoking among families with a parent who smokes and a child with asthma.

BACKGROUND Asthma is a common childhood illness with high morbidity and mortality among minority and socio-economically disadvantaged children. Disparities are not fully accounted for by differences in asthma prevalence, highlighting a need for interventions targeting factors associated with poorer asthma control. One such factor is psychological stress. OBJECTIVE Here, we examine the feasibility and acceptability of "I Can Cope (ICC)," a school-based stress management and coping intervention for children with asthma. METHODS A parallel randomized pilot trial was conducted. One hundred and four low-income children (mean age 10 years; 54% male; 70% African American) with persistent asthma were recruited from 12 urban schools and randomized to the following: (a) ICC or one of two control conditions: (b) "Open Airways for Schools (OAS)"-an asthma education intervention or (c) no treatment. RESULTS Seventy one percentage of eligible children participated in the study, with a dropout rate of 12%. ICC was rated as highly acceptable by participating children and parents. Preliminary efficacy data suggest that when compared with no treatment, ICC resulted in decreased symptoms of depression, perceived stress and child-reported symptoms of asthma, and improvements in sleep quality and child-reported asthma control. There were no intervention-related changes in objective measures of asthma morbidity. The magnitude of intervention effects on psychological function did not differ between the ICC and OAS groups. CONCLUSIONS Results support the feasibility and acceptability of utilizing school-based interventions to access hard to reach children with asthma. Preliminary findings offer support for future, large-scale efficacy studies of school-based interventions designed to target multiple factors that contribute to asthma disparities.

BACKGROUND: Depressive symptoms are elevated in parents of asthmatic children compared with parents of healthy children. The role of depression in smoking cessation and pediatric asthma outcomes in this population is unclear. PURPOSE: To prospectively examine the effect of parent depression on smoking cessation and child asthma outcomes. METHODS: Secondary analysis from a cessation induction trial involving Motivational Interviewing (MI) and biomarker feedback on secondhand smoke exposure (SHSe). Parents (n=341) had an asthmatic child (mean age=5.2 years) and did not have to want to quit smoking to enroll. Intervention included asthma education, MI, and SHSe feedback plus randomization to six counseling (MI; repeated feedback) or control calls (brief check on asthma) for 4 months. Depressive symptoms were defined as scoring ≥22 on the Center for Epidemiologic Study-Depression scale. Smoking outcomes were bioverified 7- and 30-day point-prevalence abstinence (ppa). Child asthma outcomes were past month functional limitation, health care utilization, and number of days with asthma symptoms. Data were obtained at baseline, 2, 4, and 6 months. RESULTS: Parental depression was associated with lower odds of abstinence (7-day ppa odds ratio [OR]=0.38, 95% confidence interval [CI]=0.23, 0.64; 30-day ppa OR=0.27, 95% CI=0.15, 0.47), greater odds of child health care utilization for asthma (OR=1.71, 95% CI=1.01, 2.92), and greater child asthma functional limitation (B=0.16, SE=0.06, p=.03) even after controlling for smoking status. Depression predicted a greater number of child asthma symptom days (B=1.08, SE=0.44, p=.01), but this became nonsignificant after controlling for smoking status. CONCLUSIONS: Among parents who smoke, both depressive symptoms and smoking should be targeted for treatment aimed at improving pediatric asthma.

RationaleStress is associated with asthma morbidity in Puerto Ricans (PRs), who have reduced bronchodilator response (BDR).ObjectivesTo examine whether stress and/or a gene regulating anxiety (ADCYAP1R1) is associated with BDR in PR and non-PR children with asthma.MethodsThis was a cross-sectional study of stress and BDR (percent change in FEV1 after BD) in 234 PRs ages 9-14 years with asthma. We assessed child stress using the Checklist of Children's Distress Symptoms, and maternal stress using the Perceived Stress Scale. Replication analyses were conducted in two cohorts. Polymorphisms in ADCYAP1R1 were genotyped in our study and six replication studies. Multivariable models of stress and BDR were adjusted for age, sex, income, environmental tobacco smoke, and use of inhaled corticosteroids.Measurements and main resultsHigh child stress was associated with reduced BDR in three cohorts. PR children who were highly stressed (upper quartile, Checklist of Children's Distress Symptoms) and whose mothers had high stress (upper quartile, Perceived Stress Scale) had a BDR that was 10.2% (95% confidence interval, 6.1-14.2%) lower than children who had neither high stress nor a highly stressed mother. A polymorphism in ADCYAP1R1 (rs34548976) was associated with reduced BDR. This single-nucleotide polymorphism is associated with reduced expression of the gene for the β2-adrenergic receptor (ADRB2) in CD4(+) lymphocytes of subjects with asthma, and it affects brain connectivity of the amygdala and the insula (a biomarker of anxiety).ConclusionsHigh child stress and an ADCYAP1R1 single-nucleotide polymorphism are associated with reduced BDR in children with asthma. This is likely caused by down-regulation of ADRB2 in highly stressed children.

Objective Develop a measure that evaluates effective pediatric food allergy (FA) management, child and parent FA anxiety, and integration of FA into family life. Methods A semistructured family interview was developed to evaluate FA management using a pilot sample (n = 27). Rating scales evaluated eight dimensions of FA management (FAMComposite), child anxiety, parent anxiety, and overall balanced integration (BI). Families of children with IgE-mediated food allergies (n = 60, child age: 6-12) were recruited for interview and rating scale validation. Results FAMComposite was correlated with physician ratings for families' food avoidance and reaction response readiness. FA anxiety was correlated with general anxiety measures for children, but not parents. Parents' FA anxiety was correlated with expectations of negative outcomes from FA. Low BI was associated with poor quality of life and negative impact on family functioning. Conclusions Preliminary analyses support Food Allergy Management and Adaptation Scale validity as a measure of family adaptation to pediatric FA.

In this study, we examine the association of asthma (asthma symptoms, asthma control, lung function) and sleep problems in a group of urban children. The role of allergic rhinitis (AR), a comorbid condition of asthma, on children's sleep problems is also examined. Finally, we investigate whether sleep hygiene moderates the association between asthma and sleep problems, and whether there are differences in these associations based on ethnic background.Non-Latino White, Latino, and African American urban children with asthma (n = 195) ages 7-9 (47% female) and their primary caregivers participated in a baseline visit involving interview-based questionnaires on demographics, asthma and rhinitis control, and caregiver report of children's sleep problems and sleep hygiene. Children and their caregivers participated in a clinical evaluation of asthma and AR, followed by a month monitoring period of children's asthma using objective and subjective methods.Total sleep problem scores were higher in children of the sample who were from African American and Latino backgrounds, compared to non-Latino white children. Poor asthma control was predictive of higher levels of sleep problems in the entire sample. Poorer AR control also was related to more sleep problems, over and above children's asthma in the sample. This association was more robust in non-Latino white children. Poor sleep hygiene heightened the association between poor asthma control and sleep problems in the entire sample and in African American children.Multidisciplinary interventions integrating the co-management of asthma, AR, and the effects of both illnesses on children's sleep, need to be developed and tailored to children and their families' ethnic background.

Early adolescents have difficulties performing asthma self-management behaviors, placing them at-risk for poor asthma control and reduced quality of life. This paper describes the development and plans for testing an interactive mobile health (mHealth) tool for early adolescents, ages 12–15 years, and their caregivers to help improve asthma management. Applying Interactive Mobile health to Asthma Care in Teens (AIM2ACT) is informed by the Pediatric Self-management model, which posits that helpful caregiver support is facilitated by elucidating disease management behaviors and allocating treatment responsibility in the family system, and subsequently engaging in collaborative caregiver-adolescent asthma management. The AIM2ACT intervention was developed through iterative feedback from an advisory board composed of adolescent-caregiver dyads. A pilot randomized controlled trial of AIM2ACT will be conducted with 50 early adolescents with poorly controlled asthma and a caregiver. Adolescent-caregiver dyads will be randomized to receive the AIM2ACT smartphone application (AIM2ACT app) or a self-guided asthma control condition for a 4-month period. Feasibility and acceptability data will be collected throughout the trial. Efficacy outcomes, including family asthma management, lung function, adolescent asthma control, asthma-related quality of life, and self-efficacy for asthma management, will be collected at baseline, post-treatment, and 4-month follow-up. Results from the current study will inform the utility of mHealth to foster the development of asthma self-management skills among early adolescents.

Objective To assess sleep hygiene and the sleep environment of urban children with and without asthma, and examine the associations among urban stressors, sleep hygiene, and sleep outcomes. Methods Urban children, 7-9 years old, with (N = 216) and without (N = 130) asthma from African American, Latino, or non-Latino White backgrounds were included. Level of neighborhood risk was used to describe urban stress. Parent-reported sleep hygiene and daytime sleepiness data were collected using questionnaires. Sleep duration and efficiency were assessed via actigraphy. Results Higher neighborhood risk, not asthma status, was associated with poorer sleep hygiene. Controlling for neighborhood risk, sleep hygiene was related to daytime sleepiness. Asthma status, not sleep hygiene, was related to sleep efficiency. In children with asthma, poorer sleep hygiene was associated with shorter sleep duration. Conclusion Considering urban stressors when treating pediatric populations is important, as factors related to urban stress may influence sleep hygiene practices and sleep outcomes.

OBJECTIVE: This study examined, among parents who smoke and have children with asthma, perceptions about child secondhand smoke exposure (SHSe), child tobacco use initiation, and parent willingness to participate in child-focused tobacco interventions. METHODS: Participants were 300 caregivers who smoked and had a child with asthma (ages 10–14). Parents completed an online survey and self-reported perceptions about child SHSe elimination, child tobacco use prevention, and willingness to participate in three types of interventions with and without their child (SHSe reduction intervention, tobacco prevention intervention, and the combination of the two). Correlates of perceptions and willingness were examined. RESULTS: Parents who were ready to quit smoking and who reported home smoking bans (HSBs) were more motivated to eliminate SHSe (p’s < .05). Being white, younger, ready to quit, and having HSBs were associated with greater confidence to eliminate SHSe (p’s < .05). Parents with HSBs reported higher perceived importance about preventing child tobacco use (p’s < .05). Parents were less confident about preventing male children from using tobacco (p = 0.001). Parents were highly willing to participate in all of the described intervention approaches, with or without their child. CONCLUSIONS: Parents were willing to participate in child-focused tobacco interventions, with or without their child with asthma, including interventions that address both child SHSe and tobacco use prevention. This research demonstrates the acceptability of child-focused tobacco interventions among a high-risk population and may be a foundational step for intervention development.

Caregivers of children with asthma smoke at a rate similar to the general population. Research on the relative importance of structural or functional social support in smoking cessation has been mixed. Participants were smokers (N=154) who were caregivers of children with asthma. Both functional (perception of social support measured by the Interpersonal Support Evaluation List) and structural social support (living with another smoker, partner status, and the proportion of smoking friends) were measured at baseline. Participants received an asthma-education and smoking cessation intervention based on Motivational Interviewing. Biochemically-verified abstinence was assessed at 6-months post treatment. Hierarchical logistic regression analyses indicated that functional support predicted smoking abstinence even when controlling for relevant covariates and structural support (OR = .896, p=.025). Exploratory analyses revealed that this effect was driven primarily by the self-esteem ISEL subscale. Structural support (lower proportion of smoking friends), but not functional support, predicted making a 24-hour quit attempt (OR = 1.476, p=.031) but this effect became non-significant when the effect of functional support was accounted for. Smoking cessation that focuses on building general functional support, particularly self-esteem support, may be beneficial for smoking cessation in caregivers of children with asthma.

Objectives of this study were to survey parents and children independently regarding feelings of helplessness specific to asthma and to examine the relationship between helplessness and the child's symptom-free days.Parent-child dyads (children 7-12 years) from Rochester, NY were enrolled (November 2011-August 2012) from general pediatric clinics, pulmonary clinics, an Emergency Department, and area youth and asthma programs. Assessments included demographics, symptoms, ratings of helplessness related to asthma and parent social support. A multivariate linear regression was conducted to examine the relationship between feelings of helplessness and symptoms-free days: post hoc analysis assessed the moderating role of social support.Overall, 107 parent-child dyads enrolled (participation rate: 72%); 104 were included in analysis. Most children were male (58%), 7-9 years (58%) and White (46%). The child's feelings of helplessness scores were positively correlated with symptom-free days indicating less feelings of helplessness as symptom-free days increased (rs = 0.273, p = 0.01). In a stratified analysis, among parents who reported minimal social support (1 sources of support), child's helplessness scores were positively correlated with symptom-free days (rs = 0.335, p = 0.02). Conversely, among parents reporting2 supports, no relationship was found (rs = 0.195, p = 0.15).This study found less feelings of helplessness among children with asthma as symptom-free days increased. Social support appears to moderate this relationship; however further studies to confirm these findings are needed.

Allergic rhinitis (AR) is a risk factor for the development of asthma, and if poorly controlled, it may exacerbate asthma. We sought to describe AR symptoms and treatment in a larger study about asthma, sleep, and school performance. We examined the proportion (1) who met criteria for AR in an urban sample of school children with persistent asthma symptoms, (2) whose caregivers stated that they were not told of their child's allergies, (3) who had AR but were not treated or were undertreated for the disease, as well as (4) caregivers and healthcare providers' perceptions of the child's allergy status compared with study assessment, and (5) associations between self-report of asthma and AR control over a 4-week monitoring period. One hundred sixty-six children with persistent asthma participated in a clinical evaluation of asthma and rhinitis, including allergy testing. Self-report of asthma control and rhinitis control using the Childhood Asthma Control Test (C-ACT) and Rhinitis Control Assessment Test (RCAT) were measured 1 month after the study clinic session. Persistent rhinitis symptoms were reported by 72% of participants; 54% of rhinitis symptoms were moderate in severity, though only 33% of the sample received adequate treatment. AR was newly diagnosed for 53% during the clinic evaluation. Only 15% reported using intranasal steroids. Participants with poorly controlled AR had poorer asthma control compared with those with well-controlled AR. This sample of urban school-aged children with persistent asthma had underdiagnosed and undertreated AR. Healthcare providers and caregivers in urban settings need additional education about the role of allergies in asthma, recognition of AR symptoms, and AR's essential function in the comanagement of asthma. Barriers to linkages with allergy specialists need to be identified.

This study examines factors associated with recruitment and retention of Latino, Dominican (DR) and mainland Puerto Rican (PR), and non-Latino White (NLW) families into a pediatric asthma study. Over eleven hundred (n = 1,185) families were screened, and 489 (n = 174 NLW, n = 160 DR, n = 155 PR) were enrolled. Rates of recruitment by source of recruitment and rates of retention differed by ethnic group. Families whose caregiver had never married had lower odds of completing the study. The findings highlight the need for further study to examine the effectiveness of specific recruitment and retention strategies with Latino and non-Latino White families.

Crohn's disease and ulcerative colitis, collectively known as inflammatory bowel diseases (IBD), are chronic, immune-mediated diseases of the gastrointestinal tract. Incidence of IBD is increasing among youth in the United States; 25 to 30% of patients with IBD have onset of symptoms before the age of 18 years 1. IBD is characterized by unpredictable remissions of disease activity followed by relapses of symptoms including abdominal pain, diarrhea, rectal bleeding, weight loss, growth and pubertal delay, fever, fatigue, and arthritis 2. Managing IBD requires attention to complicated medication regimens, side effects, disease symptoms, and nutritional modifications or supplementation. In addition, youth with IBD require frequent medical appointments, and may be faced with recurrent school absences and needing to answer potentially embarrassing questions from friends and relatives 3. Youth with IBD have higher rates of school absences compared to healthy peers 1, 4, and up to 35% of patients experience permanent growth failure 5. They may appear younger than their chronological age, thereby increasing their risk of peer teasing or difficulty developing age-appropriate peer relationships. Given these challenges, the prevalence of emotional difficulties including depression among youth with IBD has been a topic of ongoing interest 6, 7. An accurate understanding of the prevalence and nature of mood disturbance in youth with IBD has important clinical and research implications. Decisions on how best to allocate clinical resources are guided based on perceived need, and documentation of base rates of depressive symptoms in youth with IBD is one indication of perceived need. Further, a better understanding of how youth with IBD compare to healthy youth on somatic symptoms of depression is needed to delineate the potential role of physical illness in elevating rates of depressive symptoms for those patients reporting difficulties. Youth with IBD reporting both higher levels of barriers to medication adherence as well as anxiety/depressive symptoms reported lower medication adherence, suggesting that the presence of depressive symptoms has important implications for disease management 8. Depressive symptoms have been of particular interest because of their potential association with steroid treatments and the inflammatory processes involved in IBD 9, 10. Findings regarding depressive symptoms in youth with IBD have been mixed, however. Mackner and Crandall 11 reported that, compared to parents of healthy adolescents, parents of adolescents with IBD rated their adolescents as experiencing greater difficulties with anxiety and/or depression on the Child Behavior Checklist, a standard questionnaire assessing global emotional and behavior functioning. Adolescents at least one-year post diagnosis, however, self-reported emotional functioning comparable to their healthy peers 12. An early study, limited by a small sample size of 20 youth with IBD, found higher rates of self-reported depressive and parent-reported internalizing symptoms for youth with IBD compared to a healthy control group 13. A recent meta-analytic review of psychosocial adjustment in youth with IBD differentiated the prevalence of depressive symptoms versus depressive disorders 6. A formal diagnosis of depression requires the presence of a sufficient number and chronicity of depressive symptoms and is typically derived via diagnostic clinical interview whereas depressive symptoms may exist in isolation of one another and are commonly measured via patient report on checklists or questionnaires. When measured using self-report on the Children's Depression Inventory 14, a standardized questionnaire assessing depressive symptoms, youth with IBD did not report elevations in symptoms when compared to both healthy youth and youth with other chronic illnesses. However, youth with IBD were found to experience higher rates of depressive disorders as measured via diagnostic interview when compared to youth with other chronic illnesses (odds ratio = 5.80) 6. A psychiatric diagnostic interview is considered the most reliable and valid methodology for diagnosing depression with highest sensitivity and specificity. However, in standard clinical practice, depressive symptoms are most commonly assessed via patient report, and the majority of the research on emotional functioning in patients with IBD is based on self or parent-report via questionnaires 6. There are mixed findings on the relationship between emotional functioning and IBD disease activity, suggesting that psychosocial factors need to be considered in addition to illness related factors when predicting emotional outcomes 15. Maternal depression, stressful life events, family dysfunction, and steroid usage have been shown to relate to higher rates of depressive symptoms 16, 17. Though not specific to youth with IBD, lower socioeconomic status is an additional risk factor for depressive symptoms 18. Given that youth with IBD are disproportionately from relatively advantaged backgrounds 19, 20 risk associated with lower SES may be less relevant for this population. Ambiguity in the literature on whether youth with IBD experience elevated rates of depressive symptoms and disorders has led to increasing interest in symptoms that could be accounted for by both physical illness and depression 10, 21. IBD is characterized by disease symptoms that overlap with somatic symptoms of depression including fatigue, changes in eating patterns, and sleep disturbance 11. Consequently, scores from self or parent proxy-reports of depression in youth with IBD may be conflating mood disturbance with disease symptoms and producing elevated rates of depressive symptoms for some patients that are at least partially due to disease activity. Recently, the factor structure of the Children's Depression Inventory was evaluated in adolescents with IBD, with results yielding a 3-factor structure of mood, behavioral/motivational, and somatic complaint symptoms 21. Items comprising the somatic complaints factor assess reduced appetite, tiredness, worry about aches and pains, and sleep problems. Interestingly, only the somatic complaint factor predicted IBD disease severity above and beyond current steroid dose, highlighting the overlap of somatic symptoms in physical illness and depressive symptomatology. Conversely, youth with IBD have been shown to experience lower levels of symptoms on the majority of items on the CDI, including somatic items, following cognitive-behavioral therapy for depression10. Decreases in somatic symptoms were independent of changes in disease severity for the most part, suggesting that somatic symptoms of depression may be responsive to psychological treatment regardless of disease activity. The first aim of the current study was to compare self-report of depressive symptoms by youth with IBD on the Children's Depression Inventory to a community sample from a similar geographic region with particular attention to somatic symptoms. The second aim was to examine the relationship between symptoms of depression and measures of disease activity. Interpretation of findings sought to (1) provide evidence of how youth with IBD compare to peers on symptoms of depression and (2) differentiate symptoms of mood disturbance from somatic symptoms potentially attributable to disease activity in order to gain a clearer understanding of how depressive symptoms are experienced by youth with IBD.

Objective The current study sought to evaluate patterns of complementary and alternative medicine (CAM) use in a sample of Latino and non-Latino white (NLW) children with asthma to determine whether parental beliefs about conventional medications and barriers to obtaining these medications were related to CAM use and to assess whether CAM use was associated with decreased adherence to controller medications. Methods Participants included 574 families of children with asthma from NLW, Puerto Rican (PR), and Dominican backgrounds from Rhode Island (RI) and from Island PR. All parents completed a brief checklist of barriers to medication use and an assessment of CAM approaches. A subsample of 259 families had controller medication use monitored objectively for approximately 1 month by MDILog (fluticasone propionate), TrackCap (montelukast), or dosage counter (fluticasone/salmeterol combination). Results Prevalence of CAM use was high among Latino families. Perceived barriers to obtaining medication were related to increased CAM use in PR families from RI. Elevated medication concerns were positively associated with CAM use among NLW and Island PR families. CAM use was positively related to objective adherence within NLW families, and unrelated in other groups. Conclusions CAM use is common among Latino families with asthma. Among some families, CAM use may be initiated as a way to cope with barriers to obtaining medication or when parents have concerns about conventional medications. Families who report CAM use do not appear to be substituting CAM for conventional asthma medication.

Pediatric asthma disparities exist with Latino children, especially from Island Puerto Rico (PR), experiencing greater asthma prevalence and morbidity than non-Latino White (NLW) children. Families must balance attention to child asthma with other child and family needs, defined as the "balanced integration of asthma." This study examined the impact of culturally related factors on the balanced integration of asthma in NLW and Latino families in Rhode Island (RI) and PR, as well as associations between balanced integration and asthma morbidity. Participants included 601 caregivers and their children with asthma (7-16 years) from NLW and Latino backgrounds in RI and PR. Caregivers and children completed interview-administered assessments and a semistructured interview related to family asthma management. Balanced integration of asthma differed significantly by ethnic group/site (p < .001), with Island PR families having the lowest levels of balanced integration. Higher balanced integration was associated with fewer concerns about asthma medications, higher levels of Spanish proficiency in RI Latino families, lower levels of functional limitation, and no emergency department visits in the last year (all ps < .05). Findings suggest that Latino families may experience more difficulty adjusting to child asthma in the context of other child and family demands. Medication beliefs and language proficiency may begin to explain these differences. Our study suggests the importance of continuing to understand how families balance asthma with other aspects of daily life, as culturally appropriate interventions to improve family adjustment to asthma may serve to reduce child asthma morbidity.

The objective of this article is to examine the effectiveness of a culturally tailored asthma intervention in a sample of Latina mothers of children with asthma. Mothers (n = 115) participated in a community-based intervention designed to improve asthma outcomes in their children. Participants provided asthma knowledge and beliefs about asthma medications data pre- and post intervention. Maternal asthma knowledge increased during the intervention period, and certain changes in medication beliefs were moderated by poverty level, maternal educational level, acculturative stress, and depressive symptoms. Culturally tailored interventions can be effective, but participants with fewer resources may require more intensive intervention.

While the pediatric psychology literature underscores the importance of illness related aspects of the home environment for optimal family asthma management, little is known about the contribution of more global aspects of the home environment (e.g., family routines/schedule, quality of stimulation provided to child) to asthma management in ethnic minority and urban families. The goals of this study were to: 1) explore ethnic/racial group differences in global and specific dimensions of home environment quality among Latino, non-Latino white (NLW), and African American urban children with asthma; and 2) examine associations between the quality and quantity of support and stimulation within the home environment, as measured by the HOME Inventory, and family asthma management in this sample. Urban, low-income children (N=131) between the ages of 6 and 13 with asthma and a primary caregiver participated in a multi-modal assessment including an in home observation and semi structured interviews to assess aspects of home environment quality and family asthma management practices. While controlling for poverty, no ethnic group differences were found in the global home environment; however, there were significant differences in specific dimensions (e.g. Family Participation in Developmentally Stimulating Experiences, and Aspects of the Physical Environment) of home environment quality. Across the whole sample, home environment quality predicted family asthma management. When examining this association for specific ethnic groups, this finding did not hold for the Latino subsample. The results highlight the need to consider ethnic group differences in non-illness specific aspects of the home environment when addressing families’ asthma management strategies.

Objective Caregiver depressed mood and stress are associated with increased child asthma functional morbidity (AFM) and secondhand smoke exposure (SHSe), whereas social support (SS) reduces risk. This study extends previous literature by examining (1) longitudinal patterns of pediatric AFM and SHSe and (2) how caregiver stress, depressed mood, and SS are related to child SHSe and AFM changes. Method Participants were 334 caregivers who smoked, had a child with asthma, and were enrolled in a smoking cessation induction/asthma intervention. SHSe and AFM were measured at baseline and 4, 6, and 12 months. All measures were caregiver self-report. We used an autoregressive latent trajectory model to examine the intercept, linear, and quadratic growth factors and autoregressive and cross-lagged effects of SHSe and AFM. Results After an asthma exacerbation, decreases in child AFM and SHSe were followed by respective increases over time. Child SHSe at 4 months and 6 months predicted subsequent child AFM. Autoregressive paths were significant for only AFM. Higher baseline caregiver depressed mood and stress predicted higher baseline child AFM but not other growth factors. Higher baseline caregiver self-esteem SS was associated with only lower baseline child AFM and fewer increases in AFM across time. Exploratory analyses indicated higher baseline caregiver depressed mood and stress were associated with less-favorable changes in child SHSe and AFM. Conclusions Caregiver depressed mood, stress, and SS should be considered when addressing pediatric SHSe and AFM. Caregiver support may be needed to maintain intervention gains. (PsycINFO Database Record

The aim of this study was to determine ethnic and site differences in quality of life (QOL) in a sample of Latino (Puerto Rican [PR] and Dominican) and non-Latino white caregivers of children with asthma in mainland US and Island PR. We also investigated ethnic and site differences in associations between caregiver QOL and indicators of asthma morbidity.Seven hundred and eighty-seven children with asthma (7-16 years of age) and their primary caregivers participated in the study. Primary caregivers completed a measure of QOL, child asthma control, and emergency department utilization, among other measures.Ethnic and site differences were found on total QOL scores (ΔF(1,783) = 29.46, p.001). Island PR caregivers reported worse QOL scores than Rhode Island (Rl) Latino and non-Latino white caregivers; Rl Latino caregivers reported significantly worse QOL scores than non-Latino white caregivers. In Rl Latino and Island PR children, worse caregiver QOL was associated with asthma that was not in control and with one or more emergency department visits.Latino caregivers may be experiencing a greater level of burden related to their child's asthma than non-Latino white caregivers. Caregiver QOL in pediatric asthma may be a reflection of broader contextual stress that some Latino caregivers experience on a daily basis (e.g., cultural beliefs, acculturation). Future research should continue to investigate mechanisms that explain the burden associated with pediatric asthma in Latino families, as well as whether QOL assessments should consider the impact of everyday stressors on caregiver QOL in pediatric asthma.

Significant disparities in emergency department (ED) rates exist for Latinos; however, few studies have investigated the factors that may account for these disparities.To examine individual/family and health system factors among Latino and non-Latino white (NLW) children with asthma to explain disparities in ED rates.The study was carried out in Puerto Rico (PR) and Rhode Island (RI) with the same design: a cross-sectional, observational approach with repeated measurements of selected variables.The sample was composed of 804 children ages 7 to 15 years, with 405 from PR and 399 from RI. Latino children from both sites had significantly higher rates of ED use as compared with NLWs from RI. Regression analyses showed site, asthma control, parental reported severity of asthma and public insurance to be significantly associated with ED use.Latino ethnicity and public insurance were among the most important factors related to frequent ED use. Revisions of the policies driving public insurance to assure better access to specialists, preventive education, and evidence-based treatment are needed. The results also suggest the need for the development of interventions in the ED that are geared toward educating families on how best to use emergency services.