Vol. 14 •Issue 4 • Page 16
Allergy & Asthma
Transitioning Asthma Care From Adult to Child
Adolescents with asthma often have a difficult time learning to manage their own disease. However, a successful transition of care from parent to child is essential if we’re to prevent hospitalizations, emergency room visits, and the long-term consequences of asthma.
As children reach the teenage years, they seek to gain independence, which in turn may generate family conflict that interferes with adherence to prescribed asthma action plans. Adolescent responses to peers, overriding time conflicts from extracurricular activities, or experimentation with drugs and alcohol also may lower compliance.
Frequently, teenagers are given responsibility for their asthma care when they’ve never learned asthma management skills or how to assume responsibility for other challenges in life. Children who take over their asthma management without adequate instructions tend to require more emergency treatment of their asthma.1
Many young patients are reluctant to take a medication when they’re not having symptoms, and they haven’t “bought in” to the idea that daily prevention therapy is superior to episodic treatment. It isn’t always possible to teach children the true value of asthma prevention because their concept of “future consequences” may not be developmentally mature.
LACK OF SUPERVISION
The transition of asthma care from caregiver to child usually occurs during adolescence, but family situations may demand that it occur in younger children. Parents or caregivers often work at hours precluding their supervision of their child’s asthma medication administration.
In one study, responsibility for unsupervised asthma care was found to be passed to children as young as 9 years old.2 Children in this study who held the most responsibility for their asthma care also didn’t receive adequate medication to control their disease.
Even worse, these researchers found that children needing the most medications or with the most complex asthma plans are usually the most unsupervised.
Another study of pediatric asthma responsibility in children as young as 6 years old observed that children were more responsible for their asthma care than their parents. This is quite disturbing, as lack of supervision of asthma medication delivery is a major risk factor for significant morbidity and mortality amongst asthmatic children.
LESSONS LEARNED FROM DIABETES
Asthma isn’t the only disease with transition of care issues. These issues are common among children with a wide variety of chronic illnesses. Childhood insulin-dependent diabetes is one of the specific diseases that we can learn successful strategies for transitioning responsibilities for medical care.
With diabetes, parental monitoring is deemed necessary even during adolescence. Family conflict concerning management of adolescent diabetes has been noted to decrease adherence to a prescribed management plan.3
An approach shown to be effective with transitioning care for diabetic children is that parental support is maintained even as responsibility is shifted to the child.4 In this study, researchers found that families who employed a teamwork approach had teenagers with better adherence and control over their diabetes.
We decided to test whether a teamwork approach to transitioning daily asthma care from parent to child, such as that used with diabetic children, would be effective in improving teenage adherence.
A TEAMWORK APPROACH
Data from our practice established that our patients with asthma have an adherence rate with maintenance asthma inhalers of about 65 percent.5 This is consistent with adherence level data previously reported in the literature for pediatric asthma patients.
Paradoxically we found that the highest adherence rates were in those families with the highest parental stress and most difficult child behavior. However, this suggests the possibility that familial conflict in asthma management reflects an active role for parents regarding asthma medication delivery.
In our study, both the parents and children were taught how to share responsibility for asthma management.6 In addition, parents and children were taught methods to decrease conflict in the family as it related to increasing child independence and increasing responsibility for asthma care by the child.
To teach children how to share responsibility, guidelines for parental supervision were instituted. Both parents and child were taught these guidelines so that “nagging” by the parents decreased, and the children had a clear expectation of what was required for minimal parental supervision.
For example, parents and children went through various levels of medication supervision, with parents decreasing their oversight as children proved themselves more and more capable.
First, children were directly observed taking their asthma medications for six doses. If this was done successfully, parents then checked the inhaler for actuation after each dose for six doses.
This was followed by the caregivers checking the inhaler for actuation at the end of the day for three days. Caregiver verification of asthma inhaler use was then spaced to every other day and then finally every three days.
If parents noted that the child had missed doses, they reminded the child of the agreed upon expectation of taking the asthma medication and returned to the previous level of supervision.
At each visit, goals for parental supervision of asthma were clearly outlined between parent and child and, to minimize conflict, positive communication strategies were taught such as not shouting, allowing one party to finish speaking before replying, and being nonjudgmental when speaking. Planning for further changes in shared responsibilities also occurred at some study visits.
These methods were presented to families with the idea that parental responsibility would gradually fade to the appropriate level required to maintain asthma adherence. Explicitly, the goal wasn’t to completely remove parental supervision of child medication delivery.
In our teamwork interventions study, we found that adherence rates markedly improved in those families in which a teamwork approach to asthma therapy was taught compared to a control group in which standard asthma education was performed or a group in which no intervention was performed.
Parents noted that conflict with teenagers over their asthma medicine decreased in the teamwork intervention group, as did the time they put into supervising their children. Teenagers thought the amount of conflict increased.
Ultimately, parents and children were highly satisfied with the teamwork approach to asthma management.
Compliance with asthma medications is always an issue due to the inherent nature of asthma with its chronic inflammation but only episodic symptoms.
When the patient is a child, these problems are even more complicated. Transitioning daily care from the parent to the child often is difficult and all too often unsuccessful. This failure may lead to considerable morbidity and even death.
Multiple factors may play a role in the lack of success in allowing children to assume control of their asthma management plan. Issues such as familial conflict, peer pressure, teenage experimentation with drugs/alcohol, or previous inexperience with responsibility may lead children to have decreased adherence to their asthma medications.
Our data suggest that a teamwork intervention approach consisting of teaching methods to decrease conflict in the family, outlining goals for transitioning asthma care at each visit, and teaching positive communication strategies improves asthma adherence while allowing for less long-term parental oversight.
Mary Beth Hogan, MD, and Nevin W. Wilson, MD, are in the department of pediatrics, section of allergy and immunology, at the West Virginia University School of Medicine, Morgantown.
For a list of references, please call John Crawford at (610) 278-1400, ext. 1499, or visit www.advanceweb.com/respmanager.