Journal of Asthma, 45:465–472, 2008Copyright C© 2008 Informa Healthcare USA, Inc.ISSN: 0277-0903 print / 1532-4303 onlineDOI: 10.1080/02770900802040050

ORIGINAL ARTICLE

Parenting Asthmatic Children: Identification of Parenting Challenges

ALINA MORAWSKA,1,∗ JENNIFER STELZER,1 AND SCOTT BURGESS2

1Parenting and Family Support Centre, School of Psychology, University of Queensland2Department of Paediatrics, Redland Hospital, Brisbane

Asthma is the most common chronic illness of childhood, affecting up to 14% of children. Poor asthma management and non-adherence to treatmentregimens are a pervasive problem in this population and are related to exacerbation of symptoms. Effective management of pediatric asthma involvesa complex set of interactions between the parent and child, yet there is a paucity of literature examining these interactions. The main purpose of thisstudy was to identify the child behavior and asthma management tasks parents experience difficulty with. It was hypothesized that the more asthmabehavior problems reported, the more problems parents experience in asthma management tasks. Participants in this study were 255 parents of 2-to 10-year-old asthmatic children, recruited via an advertisement placed in school newsletters throughout Australia. Results indicated that the mostproblematic child asthma behaviors were oppositional behavior, hyperactivity, and aggression, and anxiety was also identified by parents as a concern.The main problematic asthma parenting tasks were entrusting the school, entrusting caregivers, identifying unique symptoms, and identifying andavoiding triggers. More problem asthma behaviors were associated with higher levels of parenting difficulty and more general levels of behaviorproblems. Parents who reported more dysfunctional parenting styles reported more difficulties with their child’s asthma behavior. Based on the resultsit is suggested that an appropriate parenting intervention program would target basic behavioral management skills, in addition to applying thesebehavior management principles to asthma management.

Keywords asthma management, child behavior, parenting, family intervention

INTRODUCTION

Childhood asthma is the most common chronic illness ofchildren, with approximately 14% of Australian children di-agnosed with the condition, and prevalence has increased overthe past 2 decades (1). Asthma accounts for the highest per-centage of visits to general practitioners and hospitalizationsin preschool and primary school children, and the burden ofdisease tends to be highest in childhood. Asthma is a contrib-utor to school absenteeism and places a large burden on thepublic health system (2, 3).

While there is consistent evidence as to the benefits of arange of medical interventions, such as preventive medica-tion and written action plans, only a minority of children usethese strategies (2), and adherence to management plans isgenerally poor. Studies examining adherence rates with pre-ventive medication by asthmatic children have shown that onaverage only 50% to 77% of prescribed doses were receivedduring the study period (4, 5), and there is some evidence thatolder children may have poorer adherence (6). Poor adher-ence with asthma management plans and treatment regimensis not a trivial problem and has been associated with poordisease control (5), increased symptoms, activity limitation(7), an increased risk of hospital admission (8), and an in-creased mortality rate (9). Childhood asthma is also linkedto lower caregiver emotional adjustment and restrictions infamily activities (10).

Asthma Action Plans (AAPs) have formed part of nationalguidelines for the management of asthma since 1989 (11).

∗Corresponding author: Parenting and Family Support Centre, Schoolof Psychology, University of Queensland, St. Lucia 4072; E-mail:alina@psy.uq.edu.au

These practice guidelines for managing asthma emphasizepatient and family strategies to prevent and treat asthmaepisodes, in partnership with a health care provider (12). Themedical management of pediatric asthma involves pharma-cological and behavioral recommendations to both preventand control asthma attacks (13). A typical treatment regimenfor children with frequent or persistent asthma includes pro-phylactically taking medication on a regular basis (14). Be-havioral recommendations include the avoidance of certainallergens (e.g., dog hair, dust, pollens), avoiding other triggers(e.g., cigarette smoke), engaging in regular exercise (15, 16),recognition of symptoms of an impending episode, and un-derstanding the use of quick-relief medications for symptomsand controller medications for symptom prevention (17).

When a child is diagnosed with the disease, asthmamanagement becomes a family affair (18). Ensuring thatmedications are taken on time, prescriptions are filled, andenvironmental controls are implemented is primarily the re-sponsibility of adult family members, not the pediatric patient(19). Therefore, effective management not only requires theparent to acquire and use a variety of different skills, but theimplementation of such skills (e.g. taking a regularly sched-uled medication) requires a complex set of interactions be-tween parent and child (17).

Given the pervasive problem of non-adherence among chil-dren with asthma, research and clinical work can be advancedby understanding how families approach the managementof the child’s asthma and reasons for non-adherence (20).A number of factors may be related to medication adher-ence. These include general child behavior, child behaviorrelated to asthma, family functioning and its relationship withasthma, and execution of parental asthma management tasks,including parents’ ability and confidence in performing tasks.

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466 A. MORAWSKA ET AL.

Asthma and Child Behavior ProblemsThere is much research showing that children with asthma

are at high risk of behavioral problems that further impairtheir ability to manage their illness and contribute to increasedasthma morbidity (13, 21–24). The more severe the asthma,the higher the rates are of these problems (25), and the ear-lier the onset of asthma the greater the risk of developingbehavioral problems (26).

Asthma and Family CharacteristicsFamily home asthma management is central to reducing

asthma morbidity and asthma mortality (12) because childand family behaviors associated with adherence are relatedto asthma outcomes (26). Emerging literature identifies fam-ily characteristics associated with poor adherence (18) suchas poor family functioning (27), low confidence (28), andparental criticism (29).

There are a number of mechanisms that are believed toaccount for associations between family functioning andasthma outcomes. Family characteristics may affect asthmamanagement behaviors that in turn affect asthma outcomes(26). For example, parents who suffer psychopathology (i.e.,depression) have difficulty performing the behaviors neces-sary to effectively manage children’s asthma (30). Difficultiesin parenting and the parent-child relationship appear to be re-lated not only to asthma onset but also to asthma outcomesthroughout early childhood (26).

Parents of asthmatic children have to manage a large num-ber of potentially difficult interactions with the child severaltimes a day (31), and parents’ confidence during these inter-actions affects adherence. When parents are afraid that a dis-agreement with the child may lead to crying and potentiallyto breathing difficulties, or they feel particular sympathy fora child because of illness, they may back off and accede tothe child’s wishes in the hopes of avoiding conflict and up-set (31). This may be particularly true for families with noprior experience of asthma who may be anxious and uncer-tain about the best way to manage their young child (31). Indoing so, however, they may inadvertently exacerbate nega-tive cycles of interaction between themselves and the child,with increased negativity, tantrums, and coercive behavior inthe child leading to greater conflict (32).

Parental criticism and parent-child relationship marked byconflict have been associated with non-adherence (26). Inaddition, it has been found that in comparison with parentsof healthy children, mothers and fathers of children withasthma make significantly more critical remarks and showa more critical attitude (26). For caregivers, parenting a childwith asthma may contribute to increased parenting stress andmore critical parenting-child interactions (33). Thus, the pres-ence of a chronic illness may result in increasing caregiver orchild distress that in turn contributes to poorer adherence andincreased morbidity (28). Although not characteristic of allfamilies, this reciprocal relationship between family distressand asthma morbidity has the potential to lead to an escalat-ing spiral of psychological symptoms and asthma morbidity(28). For example, day-to-day asthma management may bemore difficult in high-conflict and critical relationships be-cause effective communication, supervision, and division ofresponsibilities may be compromised (33).

Asthma Management by ParentsWhile studies of the association between family processes

and asthma outcomes have emphasized the role of broad fa-milial and cultural factors (33, 34), a few recent studies haveexplored specific challenges that parents have related to themanagement of their child’s asthma. In a study by Peterson-Sweeney et al. (35), 10 of 13 parents indicated that remem-bering, administering, or the child receiving medications ona daily basis was the most difficult aspect of asthma care. Inaddition, many parents described initial struggles with theirchildren who resisted taking medication. However, as chil-dren adjusted to the medication routine cooperation followed(35). Contrary to this is the finding that, in some instances,parents lack effective techniques to gain the child’s coopera-tion in taking medication, resulting in a struggle with the childand a failure to get the child to take the medication (26). Inaddition, it is widely cited that parents experience concernsabout potential side effects and even doubt about the efficacyof the medication (20, 35). Clearly, medication administra-tion is initially a major concern, and over time, can continueto be a problem for many families caring for their child withasthma (13). Other challenges included providing emotionalsupport for the child and managing discipline and behaviorproblems (35). Further problems for parents included diffi-cultly distinguishing the severity of different symptoms ofasthma (36), reducing exposure to environmental allergens,especially tobacco smoke, which may call for a different setof skills (37), and conflict or communication difficulties withthe healthcare provider (35).

Aims of Current StudyIn light of the role that child behavior and parental manage-

ment of asthma tasks appear to play in pediatric asthma man-agement, and the current paucity of literature on the subject,it follows that this topic deserves further attention. The keyissues associated with noncompliance highlighted in the liter-ature include general child behavior difficulties (such as hy-peractivity and anxiety), specific asthma behavior challenges(such as difficulty taking medication, poor parental confi-dence, and dysfunctional parenting), and discipline styles in-volving conflict, criticism, and failure to obtain the child’scooperation. There are a number of key gaps in the literatureincluding knowledge of the specific asthma behaviors andtasks that are problematic for parents and appropriate mea-surement tools for identifying the specific problems. Thisknowledge can be used to develop an intervention to addressthe challenges for parents.

This study seeks to fill the gap in the literature with themajor research question “What child behavior and asthmamanagement tasks do parents of asthmatic children experi-ence difficulty with?” In answering this question, key asthmaparenting tasks with clear behavioral descriptions were de-termined. The first aim was to determine key child asthmabehavior and asthma parenting tasks that parents experiencedifficulty with. It was hypothesized that the more asthma be-havior problems parents report, the more problems parentswould experience with asthma parenting tasks. Furthermore,it was hypothesized that the more problematic asthma be-havior and asthma parenting tasks were, the lower the par-ents’ confidence in dealing with these problems. Finally, it

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PARENTING ASTHMATIC CHILDREN 467

was hypothesized that higher levels of general child behaviordifficulties would be associated with more asthma behaviorproblems.

METHOD

ParticipantsParticipants in this study were 255 parents of asthmatic

children, with the target age range for the asthmatic childbeing 2- to 10-years of age. If the parent had more than oneasthmatic child within this age range they were instructedto complete the survey based on the youngest child. Parentswere recruited from the general community as well as a clinicpopulation. To recruit parents from the community, informa-tion was e-mailed to schools throughout Australia asking foran advertisement to go in the school newsletter. Once the no-tification had been placed in the school newsletter, parentscould then choose to log-on to the internet to the web addresssupplied or contact the researchers for a pen-paper versionof the survey. Parents from a clinic population were recruitedthrough the Asthma Clinic at Redland Hospital, Brisbane.

The majority of the respondents were the child’s mother(96.8%), with the remaining respondents being the child’s fa-ther (3.2%). The majority of the respondents had more thanhigh school education (67.8%), with 28.3% holding a tradequalification or college certificate and 39.6% having tertiaryqualifications. Almost half (43.1%) the respondents reporteda household income of between $25,001 and $75,000, withanother 39.5% reporting an annual household income be-tween $75,001 and $150,000. Almost 7% of households hadan annual income of less that $25,000, and 10.5% had an an-nual income over $150,000. Most of the parents were married(76.8%), with 63.1% of respondents and 96.1% of respon-dents’ partners in paid employment.

The mean age of the target child was 6.3 (SD = 2.18),and there were 154 males (60.4%) and 101 females (39.6%).The majority of children identified with a white ethnic group(98.8%), with the remaining 1.2% identifying with an Abo-riginal/Torres Strait Islander ethnic group. Most of the chil-dren were part of their original family (82.5%), with the re-mainder part of a sole-parent family (10.7%), or a stepfamily(6.7%). The average age of child at diagnosis with asthmawas 2.56 (SD = 1.83), and 66.5% of children had been hos-pitalized for their asthma. The average number of hospital-izations over the child’s lifetime was 3.68 (SD = 4.84). Inthe 2 weeks before completion of the questionnaire, 35.8%of children had no asthma episodes, 29.1% had 1 to 3 asthmaepisodes each less than 2 hours, 20.9% had 4 or more asthmaepisodes or 1 or more episodes that temporarily interferedwith activity, play, school, or sleep, and 14.2% had 1 or moreepisodes lasting longer than 2 hours or resulting in shorteningnormal activity or seeing a physician or going to hospital.

MeasuresFamily Demographics. A Family Background Question-

naire (FBQ) was used to assess socioeconomic status (includ-ing income, occupational status, and parent education), ethnicbackground, single parenting, and parent age, as well as childage, gender, and health. An additional five questions relatingto asthma were also included, covering the age at which thechild was diagnosed with asthma, the number of occurrences

of hospitalization due to asthma difficulties, the number andseverity of asthma episodes over the past 2 weeks, how theresponsibility for the child’s asthma was shared, and detailsof the child’s prescribed asthma medication.

Child Behavior and AdjustmentChild behavior was assessed using the Strengths and Dif-

ficulties Questionnaire (SDQ) (38), a screening measure thatis used to identify children’s emotional and behavioral prob-lems over the previous 6 months. The measure consists of 25items that address 5 factors: hyperactivity, conduct problems,emotional symptoms, pro-social behavior and peer problems,and 5 items that assess the impact of the problems on var-ious aspects of the child’s life. Each of the 5 subscales ismeasured by 5 items, and responses are measured using a3-point scale. Parents respond according to how correct theyfeel each statement is for their child and options are (0) nottrue, (1) somewhat true, and (2) certainly true. A total diffi-culties score is produced by summing all of the deficit scorestogether excluding pro-social behavior, giving a total scoreranging from 0 to 40. A total impact score is generated by thescores on the 5 impact questions, all of which are measuredon a 4-point scale.

The SDQ has been shown to reliably discriminate betweenclinic and non-clinic children with a total score cut-off forthe normal range of 13 of 40. Scores of 14 to 16 are consid-ered borderline and a score of 17 or more indicates clinicallyelevated difficulty. The SDQ has well- established reliabilityand validity, and Australian data show moderate to good in-ternal consistency for each subscale (ranging from α = 0.67to α = 0.80) and total difficulties scores (α = 0.73) (39).The SDQ has also been found to have good external valid-ity shown by correlations between the SDQ and diagnosticstatus as measured by a recent Australian study (40). Thescale displayed moderate internal consistency in the presentsample (α = 0.72).

Parenting StyleThe Parenting Scale (PS) (41) is a 30-item questionnaire

measuring three dysfunctional discipline styles: laxness (per-missive discipline), over-reactivity (authoritarian discipline,displays of anger), and verbosity (overly long reprimands orreliance on talking). Each item has a more effective and aless effective anchor, and parents indicate on a 7-point scalewhich end better represents their behavior. The total scorehad good internal consistency in this sample (α = 0.89) andthe scale has good test-retest reliability (r = 0.84), and theclinical cutoff used was 3.2.

Asthma Behavior Checklist (ABC [42])This questionnaire was designed for the current study and

consists of 22 behaviors that parents with asthmatic childrenoften have to manage (e.g. Refuses to take medication toschool). To complete the measure parents rated on a 7-pointLikert scale to what extent the behavior had been a problemfor them with their child. Response options for each behaviorranged from 1 (Not at all) to 7 (Very much). There weretwo spaces for parents to note if their child engaged in anyother behavior related to asthma or its management that theparent found difficult. The same rating scale applied to these

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468 A. MORAWSKA ET AL.

two items. In addition, for each item, parents also noted howconfident they were that they could successfully deal withthe behavior, on a scale ranging from 1 (Certain I can’t doit) to 10 (Certain I can do it). The Extent and ConfidenceScales scale had high internal consistency (α = 0.89 and 0.98,respectively) in this sample. Principal components analysiswith orthogonal rotation was conducted, indicating a three-factor structure. Factor 1 was labeled Oppositional Behaviorbecause most of the items pertained to disruptive avoidancebehaviors surrounding medication use; factor 2 was labeledImpact of Asthma because many of the items pertained todescribing asthma symptoms and refusal of activities. Thethird factor was labeled Practicalities as high-loading itemspertain to the child forgetting to have medication with themor forgetting to take it. Together these three factors explained48.58% of the variance.

Asthma Parent Tasks Checklist (APTC [43])This questionnaire was designed for the current study. The

APTC consists of a list of 17 asthma management tasks thatparents with asthmatic children often have to manage and rep-resents a range of features thought to be essential for asthmamanagement (e.g., Identifying your child’s asthma triggers).To complete the measure parents rated on a 7-point Likertscale to what extent the task had been a problem for them.Response options for each task ranged from 1 (Not at all)to 7 (Very much). There were two spaces for parents to noteif there were any other asthma management tasks that theyfound difficult. The same rating scale applied to these twoitems. In addition, for each item, parents also noted how con-fident they were that they could successfully deal with the taskon a scale ranging from 1 (Certain I can’t do it) to 10 (Cer-tain I can do it). The Extent and Confidence Scales scale hadhigh internal consistency (α = 0.95 and 0.96, respectively) inthis sample. Principal components analysis with orthogonalrotation was conducted, indicating a three-factor structure.Factor 1 was labeled Practicalities of Management becausemost of the items pertained to giving the child medicationand educating others. Factor 2 was labeled Global Manage-ment because many of the items pertained to responding toattacks and emergencies. The third factor was labeled Trig-gers as both high- loading items pertain to identification andavoidance of triggers. Together these three factors explained69.85% of the variance.

ProcedureParents accessed the survey on-line and were presented

with an information page about the study and a consent page.Each questionnaire was on a separate page and on completingeach one participants clicked the “next” button to continueto the next page. Each question could be answered by click-ing the appropriate radio button, selecting from a drop-downmenu, or typing words or a number into an allocated box.Participants could exit the survey at any time.

Throughout the data collection period, parents made tele-phone inquiries about the study to the research team. Thesecalls resulted in the parents accessing the study online or re-questing a pen-paper version of the survey. All requests fora pen-paper version of the survey were fulfilled by posting a

copy of the survey, with a reply-paid envelope included. Thesurvey was attached to a cover letter and information sheetabout the study and a consent form. Parents recruited throughthe Asthma Clinic at Redland Hospital were provided with apen-paper version of the survey at the time of request. Datafrom completed pen-paper versions of the surveys were en-tered into the online survey system as they were received.All data from the online program were downloaded enablingdirect export of data to an SPSS data file.

RESULTS

Preliminary AnalysesData were analyzed with the use of SPSS 14.0 for Win-

dows. Of the 271 parents who completed the survey, 6 wereremoved because they failed to complete most of the survey;3 participants were removed as key demographic informa-tion was missing; 4 participants were removed because thechild’s age was listed as more than 10 years; 1 participantwas removed because they failed to complete the two asthmaquestionnaires; leaving 255 parents for whom data was an-alyzed. The decision was made to retain cases and replacemissing values with the series mean so that total sample sizewould not be reduced.

General Relationships between MeasuresCorrelations (Pearson’s r ) between key measures are

shown in Table 1. Parents who reported more difficulties withtheir child’s behavior reported more difficulties with asthma-related behavior, more difficulties in managing asthma par-enting tasks, and more dysfunctional parenting. The PS Totalwas positively correlated with both ABC Extent and APTCExtent, indicating that higher levels of dysfunctional dis-cipline styles were associated with higher asthma behaviorproblems and asthma parenting task problems. Finally, sig-nificant negative correlations between the extent of asthmabehavior problems and confidence in dealing with the behav-ior revealed that more problematic behavior was associatedwith lower parental confidence in dealing with the problem.Also, a significant negative correlation between the problemrating of parenting tasks and the confidence ratings of taskssuggested that the more a task was a problem for the parent,the lower confidence they had in executing that task.

Important Child Asthma Behaviors and Management TasksTo answer the research question of what child behavior

and parenting tasks parents of asthmatic children experiencedifficulty with, means of each item were ranked to reveal themost problematic items.

TABLE 1.—Correlations between Key Outcome Measures.

ABCExtent

ABCConfidence

APTCExtent

APTCConfidence

SDQTotal

PSTotal

ABC Extent 1 −0.321∗∗ 0.408∗∗ −0.331∗∗ 0.312∗∗ 0.181∗∗ABC Confidence 1 −0.200∗∗ 0.772∗∗ −0.083 −0.097APTC Extent 1 −0.349∗∗ 0.164∗∗ 0.231∗∗APTC Confidence 1 −0.097 −0.126SDQ Total 1 0.393∗∗PS Total 1

∗∗ p < 0.01.

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TABLE 2.—ABC Items Ranked by the Extent of the Problem.

ABC Extent ABC ConfidenceABC Items M (SD) M (SD)

23—Extra behavior listed by participant 4.26 (2.12) 6.83 (2.49)24—Extra behavior listed by participant 3.95 (2.46) 4.50 (3.02)

8—Becomes anxious when having a breathing problem 3.30 (1.88) 8.22 (2.10)12—Complains about asthma symptoms 2.54 (1.60) 8.80 (1.91)22—Forgets to take their medication 2.42 (1.76) 8.63 (2.12)

7—Forgets to have inhaler with them 2.29 (1.74) 8.65 (2.18)2—Complains about having mask applied to face 2.19 (1.73) 8.78 (2.31)3—Uses preventer incorrectly 2.09 (1.74) 9.00 (2.01)1—Complains about taking preventer medication 2.03 (1.48) 9.23 (1.81)

21—Complains about having asthma 1.92 (1.42) 9.00 (1.88)4—Complains about the taste of preventer medication 1.87 (1.61) 9.17 (1.95)

14—Refuses or resists using spacer device correctly 1.84 (1.58) 8.91 (1.91)13—Complains about taking reliever before exposure to trigger 1.75 (1.44) 9.11 (1.84)15—Whines about asthma 1.74 (1.23) 8.94 (1.95)19—Behaves disruptively when taking medication/using puffer 1.73 (1.37) 8.80 (2.07)

9—Refuses to take medication when having a breathing problem 1.70 (1.33) 8.84 (1.95)10—Refuses to go to school 1.66 (1.33) 8.95 (2.10)11—Refuses to participate in activities 1.65 (1.33) 8.84 (2.08)18—Argues about having preventive medication or using a spacer 1.62 (1.27) 8.97 (2.01)17—Throws a tantrum about having preventive medication 1.53 (1.30) 8.87 (2.09)16—Yells about using medication 1.40 (1.04) 9.12 (1.92)20—Uses asthma to avoid tasks or activities 1.40 (1.12) 9.03 (2.00)

6—Refuses to take medication to school 1.37 (1.16) 9.14 (2.05)5—Refuses to go to the doctor 1.31 (.93) 9.35 (1.77)

Child asthma behaviorsAs shown in Table 2, the responses were negatively skewed.

The most problematic behaviors were represented by items23, 24, and 8. All other behaviors had a mean of less than3, indicating that the child behavior was either only a littleproblem or not at all a problem. Most items had a confidencerating of 8 or more indicating that parents were confident indealing with the behavior. Item 8 referred to children becom-ing anxious when they had difficulty breathing. Items 23 and24 had mean confidence ratings of less than 8. These itemsgave parents the opportunity to list any extra behaviors thatthey found problematic. The most common behaviors listedin these items could be categorized as Hyperactive behavior(e.g., hyperactive from medication), Oppositional behavior(e.g., oppositional behavior increases as asthma worsens),and Aggressive behavior (e.g., becomes argumentative andbreaks things in anger).

Asthma parenting tasksAs shown in Table 3, the responses were negatively skewed,

with the most problematic tasks represented by items 18, 19,2, and 1. All other items had a mean of less than 3, indicat-ing that the parenting task was only a little problem or not aproblem. Items 1 and 2 refer to the parent’s ability to iden-tify and avoid the child’s asthma triggers. The most commonresponses provided by parents to items 18 and 19 could be cat-egorized as Entrusting the school (e.g., Entrusting the schoolto look out for asthma symptoms), Entrusting other caregivers(e.g., Having other carers recognise the importance of med-ication), and Identifying unique symptoms (e.g., Identifyingcold symptoms versus start of asthma symptoms).

Responsibility for asthma managementIn this sample most parents indicated that they were ei-

ther completely (51.4%) or mostly (30.2%) responsible for

TABLE 3.—APTC Items Ranked by the Extent of the Problem.

APTC Extent APTC ConfidenceItems on APTC M (SD) M (SD)

18—Extra task listed by participant 4.79 (2.03) 5.85 (2.51)19—Extra task listed by participant 3.82 (2.46) 7.00 (2.70)

2—Helping your child avoid asthma triggers 3.80 (1.95) 7.02 (2.47)1—Identifying your child’s asthma triggers 3.67 (1.90) 7.15 (2.48)

15—Managing an asthma attack 2.79 (1.83) 8.02 (2.16)12—Recognizing an asthma attack 2.69 (1.93) 8.05 (2.32)11—Monitoring your child’s asthma symptoms 2.68 (1.80) 8.14 (2.21)16—Responding to an emergency 2.62 (1.94) 8.03 (2.27)10—Getting your child to breathe correctly into the puffer 2.58 (1.83) 8.66 (1.96)

6—Washing your child’s spacer regularly 2.45 (1.86) 8.79 (2.17)13—Talking to teachers about your child’s asthma 2.37 (2.00) 8.71 (2.10)

7—Attending regular medical review with your child 2.38 (1.94) 8.90 (2.14)14—Talking to other caregivers about your child’s asthma 2.36 (1.99) 8.67 (2.12)

8—Following your child’s asthma management plan 2.34 (1.98) 8.68 (2.17)5—Giving your child’s regular preventive medication 2.25 (1.78) 8.63 (2.21)4—Giving your child reliever medication pre-exercise 2.20 (1.74) 8.62 (2.14)

17—Taking responsibility for following asthma management plan 2.11 (1.86) 8.80 (2.00)3—Giving your child reliever medication for symptoms 2.11 (1.72) 8.91 (2.00)9—Using the puffer and spacer as prescribed 1.93 (1.78) 9.14 (1.85)

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470 A. MORAWSKA ET AL.

managing the child’s asthma. However, 16.1% of parentsindicated that the parent and child take equal responsibil-ity, while a small minority (2.4%) indicated that the child ismostly or completely responsible for managing their asthma.

General child behavior and asthma behavior difficultiesIn this sample, over 20.9% of children were rated by their

parent as being in the clinical range on SDQ Total Difficul-ties, based on published cut-offs, 13.7% were in the border-line range, and 65.5% were in the normal range. A one-wayanalysis of variance (ANOVA) was conducted to test for sig-nificant differences between means on ABC total for those inthe normal range compared with those in the abnormal rangeon the SDQ Total Difficulties score. Children who were in theabnormal range on the SDQ had higher ABC Extent scores,M(SD) = 48.35(20.08), than children whose scores fell in thenormal range on SDQ, M (SD) = 38.41(14.43), F (1, 205)= 14.82, p < 0.001.

Parenting and asthma behavior difficultiesMost parents reported low levels of dysfunctional parent-

ing, PS Total M (SD) = 2.70 (.70), however, a substantialminority (22.7%) of parents rated in the clinical range. Aone-way ANOVA was conducted to test for significant dif-ferences between means on ABC total for those in the non-clinical range compared with those in the clinical range onthe PS Total score. Parents who scored in the clinical rangeon PS Total reported more asthma behavior difficulties, M(SD) = 47.83 (19.52), compared with those who scored inthe non-clinical range on PS Total, M (SD) = 40.31 (16.84),F (1, 222) = 7.28, p < 0.01.

DISCUSSION

The study aimed to identify key child asthma behaviordifficulties and key parenting tasks associated with asthma.Overall, parents reported relatively low levels of behaviorproblems or parenting difficulties in relation to their child’sasthma. However, there were several key areas where parentsreported significant difficulties. The main problematic behav-iors identified in this study can be summarized as anxiety, op-positional behavior, hyperactivity, and aggression, with theimpact of asthma (such as reporting asthma symptoms) andpracticalities (such as the child forgetting to have medicationwith them) playing a smaller role. The results fit with the gen-eral theoretical constructs that have been documented in theliterature. The problem behavior of anxiety and hyperactivityis consistent with previous findings that children with asthmaare more likely than children without asthma to experienceboth internalizing and externalizing difficulties (25, 44, 45).

The main problematic asthma parenting tasks can be sum-marized as entrusting the school, entrusting caregivers, iden-tifying unique symptoms, identifying and avoiding triggers,the practicalities of management (such as giving medication),and global management tasks (such as responding to emer-gency situations). Many of these results are consistent withfindings from the literature. For example, distinguishing be-tween asthma symptoms (36), identifying what triggers theirchild’s asthma, and effectively reducing exposure to triggers(20, 37) have been reported as challenges for parents. Ad-ministering medication on a routine basis has been cited as a

persistent problem for parents (13, 20, 35), a finding that wassupported by the current study. Finally, the problematic tasksof entrusting the school and entrusting other caregivers werenot cited in previous research and therefore provide a uniquecontribution to the field. These factors may be of importancein the current climate where there is a high proportion ofboth parents working and an upward trend of the proportionof children in formal child care (46).

As predicted, asthma behavior problems were associatedwith more difficulties in managing asthma parenting tasks. Inaddition, the more problematic asthma behavior and asthmaparenting tasks are, the lower the confidence in dealing withthe behavior or task. Thus, parents who reported more dif-ficulties with their child’s behavior tended to report moreproblems and lower confidence in managing their child’sasthma. Children’s general behavior difficulties were alsoassociated with more asthma behavior difficulties. Childrenwho were rated in the clinical range of the Strengths and Diffi-culties Questionnaire had significantly higher asthma behav-ior difficulties. Consistent with literature linking parenting tochild behavior (47), the study also found that higher levels ofasthma behavior problems were associated with more reportsof dysfunctional parenting.

LimitationsParents rated few of the asthma behaviors or parenting tasks

as problematic. however, many of the extra tasks that par-ents indicated were a problem, such as entrusting school andentrusting caregivers, were represented by items that werealready listed on the measure. When parents listed their ownitems, they rated these as much more problematic. This pro-vided evidence that the behavioral descriptions of the itemswere not adequate. There are two possible reasons for this.First, in responding to the questions, parents were thinking ofa particular situation rather than a global score and thereforehad a preference to write the description in their own words.Secondly, the descriptions did not include a definition of keyterms and some terms may have encompassed different mean-ings for different people. For example, in the item “Talkingto other caregivers about your child’s asthma” a participantmay have only considered their nanny to be a caregiver, butnot the child’s biological father in a separated family. Eachbehavioral description could include examples or definitionsto ensure that participants respond to the item as intended.Furthermore, it is unknown whether parents had adequateknowledge of appropriate asthma management techniques.For example, item 10 “Getting your child to breathe cor-rectly into their puffer” assumes that parents know what thecorrect technique is. Parents may not perceive this task to bea problem; however, observation may reveal that an incor-rect technique is used. Forgetting to take medication or usingrelievers correctly was not identified as a major problem byparents; however, it is unknown to what extent parents werefollowing the prescribed medical advice, and thus to whatextent they encounter problems.

Implications for PracticeThis study has provided insight to behavior issues that

affect parents’ ability to carry out a prescribed program ofasthma care. Physicians need to be aware of the potential

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PARENTING ASTHMATIC CHILDREN 471

barriers to effective implementation of recommendationsmade to parents. The ABC and APTC questionnaires couldbe used as an adjunct to traditional parental asthma educa-tion, to discuss practical aspects of children’s asthma man-agement with parents, and to allow healthcare professionalsand parents to focus together on specific action pathways forcommon situations.

More formally, the ABC and APTC have the potential toserve as a systematic method to collect information regardingparent challenges in asthma management (48). While resultsof problem behaviors and tasks appear to generalize acrossparticipants, and therefore a standard intervention could bedeveloped, the effort to individualize intervention programsto meet the needs of families is considered a central ele-ment of intervention effectiveness (49). Therefore, the ABCand APTC could be completed and analyzed before inter-vention to ensure that the intervention in its standard formwill adequately address the families’ problems. Furthermore,the ABC and APTC could be used to evaluate the impact ofthe implemented intervention. Measuring changes in parentalasthma management before and after the intervention or be-tween control and intervention groups would complementother outcome measures such as asthma symptoms, qualityof life, healthcare utilization, and school absenteeism.

The results indicated that behavior problems were not iso-lated to asthma and that problematic asthma behavior is asso-ciated with asthma parenting task problems. While causalitycannot be inferred from correlations, the results give sup-port to the assumption that an appropriate intervention wouldtarget general behavioral management skills of parents. Em-phasis should be placed on parents managing their child’sbehavior, in addition to applying these behavior managementprinciples to asthma management. Furthermore, participantswith high levels of dysfunctional parenting had higher ratingsin asthma behavior problems indicating that dysfunctionaldiscipline style may be an impediment to effective asthmabehavior management.

Responses indicated that some parents attributed child be-haviors to the asthma medication that was prescribed. An ele-ment of parent education may include helping parents to iden-tify if the behavior is a result of the medication or if parentsare inaccurately attributing the problem behavior to medica-tion, rather than dysfunctional discipline style and behaviormanagement processes. When providing behavior manage-ment skills in an intervention, it would therefore be importantto ensure that functional discipline styles are reinforced.

The results of this study emphasize the clinical importanceof effective child behavior management to increase adherenceto asthma parenting tasks. An appropriate parenting inter-vention should provide families with concrete and explicittools for managing their child’s behavior. A clear, specificfocus on how the family manages their child’s behavior andasthma management tasks could lead to greater adherenceto asthma management plans and reductions in functionalmorbidity.

REFERENCES

1. Australian Bureau of Statistics. National Health Survey. Canberra: ABS;2002.

2. Australian Centre for Asthma Monitoring. Asthma in Australia. Canberra:AIHW; 2005.

3. Queensland Health. Health Outcome Plan: Background Paper. Brisbane:Queensland Government; 2001.

4. Gibson NA, Ferguson AE, Aitchison TC, Paton JY. Compliance with inhaledasthma medication in preschool children. Thorax 1995; 50:1274–1279.

5. Milgrom H, Bender B, Ackerson L, Bowry P, Smith B, Rand C. Noncompli-ance and treatment failure in children with asthma. J Allergy Clin Immunol1996; 98:1051–1057.

6. Zuckerman IH, Stuart B, Magder LS, Bollinger ME, Weiss SR. Adherenceto asthma treatment guidelines among children in the Maryland Medicaidprogram. Curr Therapeutic Res 2000; 61:912–924.

7. McQuaid EL, Mitchell DK, Walders N, et al. Pediatric asthma morbidity:The importance of symptom perception and family response to symptoms.J Pediatr Psychol 2007; 32:167–177.

8. Ordonez GA, Phelan PD, Olinsky A, Robertson CF. Preventable factors inhospital admissions for asthma. Arch Dis Childhood 1998; 78:143–147.

9. Robertson CF, Rubinfeld AR, Bowes G. Pediatric asthma deaths in Victoria:the mild are at risk. Pediatr Pulmonol 1992; 13:95–100.

10. Halterman JS, Yoos HL, Conn KM, et al.The impact of childhood asthmaon parental quality of life. J Asthma 2004; 41:645–653.

11. Comino EJ, Bauman A, Mitchell C, Ruffin RE, Antic R, Zimmerman PV.The Australian National Asthma Campaign - Effects of public educationactivities based on mass media. Am J Prevent Med 1997; 13:251–256.

12. National Asthma Council Australia. Asthma Management Handbook 2006.Available at www.nationalasthma.org.au. Downloaded 1/4/07. Melbourne;2006.

13. Lamanek K. Adherence issues in the medical management of asthma.J Pediatr Psychol 1990; 15:437–458.

14. Rowe BH, Spooner CH, Ducharme FM, Bretzlaff JA, Bota GW. Corti-costeroids for preventing relapse following acute exacerbations of asthma.Cochrane Rev 2000

15. Murray AB, Ferguson AC. Dust-free bedrooms in the treatment of asthmaticchildren with house dust or house dust mite allergy: A controlled trial.Pediatrics 1983; 71:418–422.

16. Nickerson BG, Bautista DB, Namey MA, Richards W, Keens TG. Distancerunning improves fitness in asthmatic children without pulmonary com-plications or changes in exercise-induced bronchospasm. Pediatrics 1983;71:147–152.

17. McQuaid EL, Penza-Clyve SM, Nassau JH, Fritz GK. The Asthma Respon-sibility Questionnaire: Patterns of family responsibility for asthma manage-ment. Children’s Health Care 2001; 30:183–199.

18. Fiese BH, Wamboldt FS. Tales of pediatric asthma management: Familybased strategies related to medical adherence and health care utilization. JPediatr 2003; 143:457–462.

19. Englund A-CD, Rydstrom I, Norberg A. Being the parent of a child withasthma. Pediatr Nurs 2001; 27:365–375.

20. Leickly FE, Wade SL, Crain E, Kruszon-Moran D, Wright EC, Evans RI.Self-reported adherence, management behaviour, and barriers to care afteran emergency department visit by inner city children with asthma. Pediatrics1998; 101:1–8.

21. Creer TL. Self-management in the treatment of childhood asthma. J Allergyand Clin Immunol 1987; 80:500–505.

22. Weil CM, Wade SL, Bauman LJ, Lynn H, Mitchell H, Lavigne J. Therelationship between psychosocial factors and asthma morbidity in inner-city children with asthma. Pediatrics 1999; 104:1274–1280.

23. Blackman JA, Gurka MJ. Developmental and behavioral comorbidities ofasthma in children. J Developmental Behav Pediatr 2007; 28:92–99.

24. Wade SL, Islam S, Holden G, Kruszon-Moran D, Mitchell H. Division of re-sponsibility for asthma management tasks between caregivers and childrenin the inner city. J Developmental Behav Pediatr 1999; 20:93–98.

25. Eksi A, Molzan J, Savasir I, Guler N. Psychological adjustment of childrenwith mild and moderately severe asthma. Eur Child & Adolesc Psychiatry1995; 4:77–84.

26. Kaugars AS, Klinnert MD, Bender BG. Family influences on pediatricasthma. J Pediatr Psychol 2004; 29:475–491.

27. Weinstein AG, Faust D. Maintaining Theophylline compliance/adherencein severely asthmatic children: The role of psychologic functioning of thechild and family. Ann Allergy, Asthma Immunol 1997; 79:311–318.

J A

sthm

a D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y M

ichi

gan

Uni

vers

ity o

n 11

/04/

14Fo

r pe

rson

al u

se o

nly.

472 A. MORAWSKA ET AL.

28. Wade SL. Psychosocial components of asthma management in children. DisManagement Health Outcomes 2000; 8:17–27.

29. Wamboldt FS, Wamboldt MZ, Gavin LA, Roesler TA, Brugman SM.Parental criticism and treatment outcome in adolescents hospitalized forsevere, chronic asthma. J Psychosom Res 1995; 39:995–1005.

30. DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for non-compliance with medical treatment: Meta-analysis of the effects of anxietyand depression on patient adherence. Arch Intern Med 2000; 160:2101–2107.

31. Calam R, Gregg L, Simpson B, Morris J, Woodcock A, Custovic A. Child-hood asthma, behavior problems, and family functioning. J Allergy ClinImmunol 2003; 112:499–504.

32. Horner SD, Surratt D, Smith SB. The impact of asthma risk factors on homemanagement of childhood asthma. J Pediatr Nurs 2002; 17:211–221.

33. Schobinger R, Florin I, Zimmer C, Lindemann H, Winter H. Childhoodasthma: Paternal critical attitude and father-child interaction. J PsychosomatRes 1992; 36:743–750.

34. Hermanns J, Florin I, Dietrich M, Rieger C, Hahlweg K. Maternal criticism,mother-child interaction, and bronchial asthma. J Psychosomatic Res 1989;33:469–476.

35. Peterson-Sweeney K, McMullen A, Yoos HL, Kitzman H. Parental percep-tions of their child’s asthma: Management and medication use. J PediatrHealth Care 2003; 17:118–125.

36. Wilson SR, Mitchell JH, Rolnick S, Fish L. Effective and ineffective man-agement behaviors of parents of infants and young children with asthma. JPediatr Psychol Feb 1993; 18:63–81.

37. Fiese BH, Wamboldt FS, Anbar RD. Family asthma management rou-tines: connections to medical adherence and quality of life. J Pediatr 2005;146:171–176.

38. Goodman R. The Strengths and Difficulties Questionnaire: a research note.J Child Psychol Psychiatry 1997; 38:581–586.

39. Mellor D. Normative data for the Strengths and Difficulties Questionnairein Australia. Australian Psychol 2005; 40:215–222.

40. Hawes DJ, Dadds MR. Australian data and psychometric properties of theStrengths and Difficulties Questionnaire. Australian and New Zealand JPsychiatry 2004; 38:644–651.

41. Arnold DS, O’Leary SG, Wolff LS, Acker MM. The Parenting Scale: a mea-sure of dysfunctional parenting in discipline situations. Psychol Assessment1993; 5:137–144.

42. Morawska A, Burgess SW. Asthma Behaviour Checklist. Brisbane: Parent-ing and Family Support Centre, University of Queensland; 2007.

43. Morawska A, Burgess SW. Asthma Parent Tasks Checklist Bris-bane: Parenting and Family Support Centre, University of Queensland;2007.

44. McQuaid EL, Kopel SJ, Nassau JH. Behavioral adjustment in childrenwith asthma: a meta-analysis. J Develop & Behav Pediatrics 2001; 22:430–439.

45. Vila G, Nollet-Clemencon C, de Blic J, Mouren-Simeoni MC, ScheinmannP. Prevalence of DSM IV anxiety and affective disorders in a pediatricpopulation of asthmatic children and adolescents. J Affective Disorders2000; 58:223–231.

46. Australian Bureau of Statistics. Child Care (Cat No. 4402.0). Re-trieved October 5, 2007, from http://www.ausstats.abs.gov.au/ausstats/subscriber.nsf/0/825293289E6DCB 1BCA257191007C1EC5/$File/44020jun%202005%20(reissue).pdf. 2005.

47. Patterson GR. Coercive family process. Eugene, Oregon: Castalia Publish-ing Co.; 1982.

48. McQuaid EL, Walders N, Kopel S, J., Fritz GK, Klinnert MD. Pediatricasthma management in the family context: the family asthma managementsystem scale. J Pediatr Psychol 2005; 30:492–502.

49. Deaton AV. Adaptive noncompliance in pediatric asthma: The parent asexpert. J Pediatr Psychol 1985; 10:1–14.

J A

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/04/

14Fo

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