Psychosocial Issues in Paediatrics

Psychosocial Issues in Paediatrics with Severe Asthma

Psychosocial issues can interplay with several aspects of severe asthma:

• Anxiety and depression are more common in children with asthma than in children who do not have asthma (Dudeney et al. 2017)
• Anxiety and depression in children with asthma is associated with poorer asthma control (Lehrer et al. 2002)
• Psychosocial issues within the family are associated with poorer asthma outcomes in children (Kaugars et al. 2004), and are a significant risk factor for childhood deaths from asthma (Fitzgerald et al. 2015)
• Some asthma treatments including corticosteroids and montelukast are associated with sleep disturbance, anxiety and depression (Aldea Perona et al. 2016)

Anxiety has a complex relationship with asthma. It may act as a trigger for an asthma exacerbation, mimic symptoms of an asthma exacerbation or worsen an exacerbation. Children and adolescents with asthma are three times more likely to suffer from an anxiety disorder than those who do not have asthma and when present, anxiety is associated with an increase in asthma symptoms.

Depression is associated with higher morbidity and mortality in children with asthma. It may also contribute to poor self-management including reduced medication compliance, poor symptom awareness and a reduced ability to identify worsening symptoms. On the other hand, an improvement in depressive symptoms can lead to an improvement in asthma control. The role of asthma medications in depression should also be considered.

It is imperative that children are screened for anxiety or depression as part of their routine assessment. Possible screening tools are:

• The Children’s Depression Inventory – Short Form (CDI-S; (Kovacs, 1992, Children’s Depression Inventory Manual)) for depressive symptoms. Information available here
• The Spence Child Anxiety Scale – Parent or Child report (SCAS-P; (Nauta et al. 2004) and SCAS-C; (Spence 1998)) for anxiety symptoms. Information available here
• Strength and Difficulties Questionnaires for emotional and behavioural assessment. Information available here

Treatments that target children’s knowledge, beliefs and behaviours are likely to improve compliance, management and long-term prognosis for children with asthma and psychological comorbidity. Cognitive behavioural therapy (CBT), which may involve education, relaxation training, targeting unhelpful thinking styles, exposure to fears and increasing approach behaviours is an efficacious treatment for children with asthma and anxiety (Papneja et al. 2006, Marriage et al. 2012, Sicouri et al. 2017), however further research is needed.

Severe asthma can have a range of psychosocial effects on children, including:

• School absence
• Avoidance of sporting activities
• Missing school camps
• Reduced parental attention for siblings
• Parental stress and psychological symptoms
• Bullying
• Post-traumatic stress disorder following a life-threatening exacerbation
• Increased risk-taking behaviours (e.g. inhaler misuse associated with cigarettes, alcohol, marijuana or other drugs)