In a recently released article in Pediatrics, Dr. Sally Weinstein and colleagues examined the relationship of parent and child psychosocial risk to poor asthma control among urban minority youth ages 5-16 years (10.1542/peds.2018-2758). Using validated measures for parental and child depression and post-traumatic stress disorder (PTSD), family chaos and family social support, and asthma control, the authors were able to describe several significant relationships between family dysfunction and childhood asthma treatment. More than half (55.7%) of the children in the study had uncontrolled asthma, and over a third (38.3%) had an Emergency Room visit for their asthma in the past 12 months. Strong emotion as an asthma trigger was reported by 36.8%. The authors carefully walk us through their findings with respect to the relationships between mental health measures and asthma control, and overall, both family chaos and emotional triggers were important predictors of asthma outcomes. The details are fascinating and not completely as (at least I) expected: key parental variables that I anticipated would be significantly related to asthma outcomes were, for example, either unrelated (parental PTSD), or within the normal range (Family Support).
This intriguing work confirms what many clinicians have long suspected: the burdens of mental health and family dysfunction, particularly if exacerbated by financial stress and poverty, hugely impact chronic illness outcomes for children. The use of a validated score that measures, or at least estimates, the degree of family chaos is enlightening and a key strength of this research.
I believe this study gives us a starting point in several critical directions. The first is the model’s likely applicability to other chronic illnesses of childhood, such as eczema, inflammatory bowel disease, and sickle cell disease. Recognizing the impact of family chaos and lack of routines on parental ability to monitor health and give medications reliably is essential to developing mitigating solutions. Even though the studied population included primarily Hispanic youth with parents of low educational attainment, and the studied illness was asthma, the study results seem to me very generalizable to other populations and conditions.
The second opportunity here is for research that translates the key findings into treatment interventions: these range from overarching approaches to incremental behavioral changes. If access to parental mental health care can impact that parent’s ability to provide needed medical treatment for their children, then this is an arena ripe for advocacy. As another example, permitting school personnel to supervise or administer a morning (and possibly afternoon) medication dose is a specific and concrete step that may enable compliance with daily medications. Clinicians are already developing pragmatic solutions such as this, but integrating multiple small interventions into one “chaos-control” wellness approach may be supported by the findings of this excellent and game-changing study.