Vol. 15 •Issue 2 • Page 43
Adolescent Angst and Asthma
Teenage psychology can complicate control efforts.
Asthma doesn’t stop Jerome Bettis from breaking tackles and scoring touchdowns for the Pittsburgh Steelers.
It couldn’t keep Theodore Roosevelt or John F. Kennedy out of the White House, never seemed to hamper Leonard Bernstein on the podium, and didn’t thwart Che Guevera from healing sick peasants and fighting guerilla wars in steamy South American jungles.
But asthma can pose a frustrating and formidable obstacle to an emotionally tender teenager tentatively navigating the minefield of adolescence.
Asthma can torpedo teenagers’ often fragile self-esteem and cause them to feel different from others, estranged and left out. They can feel too ashamed or self-conscious to use their inhalers, opening themselves up to serious health risks, even death.
In short, asthma saddles many adolescents with a negative self-image, according to Chitra Dinakar, MD, associate professor of allegy at Children’s Mercy Hospital, Kansas City, Mo. “Adolescents (with asthma) are the hardest group to treat,” she said. “Many of them will not even admit they are wheezing.”
Dr. Dinakar recently surveyed 100 asthmatics ages 8 to 18. One-third of them told her their diagnosis made them feel different from their peers, while 45 percent felt restricted or excluded from school activities. And more than one-third felt uncomfortable using an inhaler in front of friends.
Anxiety associated with asthma
Teens with asthma suffer in higher numbers than healthy adolescents from a persistent fear of normal social situations, unfamiliar people or scrutiny by others, research shows.
A survey of 765 high school students on Staten Island found that teens with asthma suffered significantly more than healthy classmates from social phobias and anxiety, regardless of the severity of their disease.
“Teens with asthma tend to fear negative comments by peers,” lead researcher Jean-Marie Bruzzese, PhD, explained at the 2005 American Thoracic Society conference. “There is clear evidence of an association between anxiety and asthma, in part because both share symptoms like dyspnea.”
Still, only 32 percent of asthmatics surveyed said their disease kept them from attending social events.
“Teens with asthma have greater social anxiety than healthy teens, but they don’t let this interfere with going to the movies, etc.,” said Dr. Bruzzese, assistant professor of psychiatry at the NYU Child Study Center, NYU School of Medicine, New York.
As teens with asthma grow older, however, their emotional problems may linger and deepen.
“Patients with asthma tend to be more psychologically distressed than the general population,” Bruce Bender, PhD, reported at a recent allergy symposium, citing a 2003 study.1
Psychological distress can alter immune functioning and significantly undermine asthma control, said Dr. Bender, head of the division of pediatric behavioral health at the National Jewish Medical and Research Center, and professor of psychiatry at the University of Colorado School of Medicine, both in Denver.
“Asthma patients with psychiatric complications tend to consume more health care resources and show a sixfold increase in office visits and a fivefold increase in ER visits,” he said.
Furthermore, when these psychologically distressed individuals grow up and become parents, their children are more at risk to develop asthma, perpetuating a vicious generational cycle, said Dr. Bender, citing a 2002 study on wheezing in infants.2
Nonadherence common among teens
Behavioral problems pose the greatest danger when they cause young asthma patients to stray from their medical regimens.
Nonadherence among teenage asthmatics “is extremely common, in fact, it’s probably the norm. Adherence is probably abnormal,” said Harold Farber, MD, author of “Control Your Child’s Asthma: A Breakthrough Program for the Treatment and Management of Childhood Asthma.”
“Teens think, ‘I feel good, why do I want to take meds? They taste bad and don’t seem to do anything. Whereas this quick reliever, I can feel it do something.'”
Problem is the more teens rely solely on that bronchodilator, the more likely they are to land in the hospital, in the emergency room, even die.
“Cranking through more than 10 albuterol canisters a year without inhaled steroids significantly increases your risk of asthma mortality,” said Dr. Farber, medical director of the pediatric asthma care management program at Vallejo Medical Center, Vallejo, Calif. “It’s extremely well-documented.”
His advice to caregivers: Approach nonadherence as a differential diagnosis. Find out what factors contribute to it. Changing this behavior, he said, is a process of negotiation, not dictation.
For example, Dr. Farber finds ways for teens to incorporate asthma management as part of their daily routine.
“I had one patient say, ‘I leave my meds with my cell phone. When I pick up my phone to make calls in the morning and at night, I take it,'” he recalled. “And it worked for him. It wouldn’t work for me; I can’t keep track of where my cell phone is.”
One of his patients has even programmed her cell phone to prompt her to take her meds.
Be sure to give teens with asthma plenty of empathy, Dr. Farber added. “A teenager who says, ‘Yeah, doc, I take it when I remember to, but life is busy,’ at least intends to comply; she’s just having trouble actually doing it. We’ve all planned to do things we should do but haven’t gotten around to yet.”
Dr. Dinakar echoed that advice. She admits to teen asthma patients that she forgets to give her children multivitamins sometimes. “This allows them to admit that they sometimes forget their inhaler,” she said.
Chatting vs. lecturing
Realize, too, that many young patients with asthma deny their symptoms, Dr. Dinakar coached. Simply asking, “How are you doing?” will often elicit the rote response, “Good.” And “Are you taking your inhalers?” will likely be met with, “Yeah, I am.”
“This is not good questioning,” she said. “You must try to get at it in different ways. If you ask, ‘How are you doing in sports or other activities?’ you may find out they don’t take part in them. Then you can ask, ‘Do you want to? Why don’t you?’ This line of questioning may get more at what they feel.
“Another way is to ask, ‘Who is your hero?’ Say it’s Michael Jordan or whomever. This helps you find out about an activity they are interested in, like basketball. You can elicit more information if you just chat with them about other things than asthma.”
And take heart: Even parents often fail to crack through a teenager’s stony, stoic front. “Most children have more symptoms than their parents realize,” Dr. Dinakar said. “Parents are often surprised if their child takes himself or herself out of a game due to wheezing.”
Many parents are also under a false impression that their child faithfully self-manages. Probing questions from a caregiver often reveal otherwise.
Lasting behavior change
How do clinicians convince teens to take responsibility for their own well-being?
“Our parents used guilt,” Dr. Farber said. “That didn’t work.”
Lasting behavior change requires a more scientific approach, especially when the teen has asthma, is remiss in taking her meds and otherwise caring for herself.
Four years ago, Dr. Farber found just such an approach, and he’s used it ever since. He presented it to much acclaim at the ATS meeting in 2005.
It’s the stages of change theory developed by James O. Prochaska, PhD, to cure adults of tobacco and other substance abuse and to foster healthy behavior change. (See Box, page 44.) Dr. Farber has adapted it for youth with asthma.
“As I began to better understand this model, I realized it was applicable to the broad range of behavior changes needed to achieve asthma control,” Dr. Farber said.
The task for caregivers is to identify what stage a patient is at and what prevents him or her from moving to the next stage.
“If the stage is pre-contemplation about inhaled steroids, is it that they taste nasty, that they must take too many puffs, or is it that the patient doesn’t have as a goal daily control of his asthma like you do?” Dr. Farber said. “What must I do to get them to the contemplation stage?”
Dr. Farber uses the model when working with pediatric asthma care managers. His approach encourages team effort.
“Perhaps the most important thing that I find is that I am no longer butting heads with my patients,” he said.
He recalled a case of a teenager with severe persistent asthma. Her parents smoked, she was allergic to the family pets, and she wouldn’t commit to regular asthma controller medication use or to regular medical follow-up.
Dr. Farber spent time with her discussing strategies including staying away from the parents when they smoke, getting the family to keep the pets in the garage rather than in the house, and using HEPA filters. He found out her likes and dislikes about medication, educated her about the role of asthma controller medicines, the harm of quick reliever overuse, and the goals of asthma therapy. They collaborated on a medication regimen that she was able to put into practice.
“The written asthma action plan that patients get is one they had input into developing, so it’s not mine, it’s theirs,” Dr. Farber said. “Adherence to implementing asthma control measures improves.”
Asked if he has ever treated a patient who simply would not comply with a treatment program, he sounded conciliatory but determined.
“Usually, you have ebbs and flows. Have I had extremely difficult patients? Yes. Have I had to cut back on my goals? If my goal is to get their asthma under perfect control, and their goal is to just deal with the crisis, yes, sometimes I’ve had to compromise.
“Sometimes time makes changes. One year, no way do they want to control it. Next year, they want to control it. People move at different speeds.”
Michael Gibbons is senior associate editor of ADVANCE. He can be reached at firstname.lastname@example.org
For a list of references, please call Michael Gibbons at (610) 278-1400, ext. 1167, or visit www.advanceweb.com/respmanager.
The Stages of Change Model
1. Pre-contemplation. Patient doesn’t intend to change behavior. Caregiver must discover barriers to change, discuss the value of change, and find out what patient and parents are willing to do.
2. Contemplation. Patient intends to change behavior within next six months — but not now. Caregiver must problem-solve to overcome behavioral obstacles and build the patient’s confidence.
3. Preparation. Patient plans to change behavior within the month. Caregiver must identify specific changes to make, make specific plans for implementing change, and role play the changes.
4. Action-implementation. Patient has changed behavior within past six months. Caregiver must provide positive reinforcement, ask about lapses, and discuss ways to recover from them.
5. Maintenance. Patient changed behavior more than six months ago. Temptation to relapse is less but still exists. Caregiver must discuss lapses or temptation to lapse and provide positive reinforcement.