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2.  Integrating Research Into Clinical Internship Training Bridging the Science/Practice Gap in Pediatric Psychology 
Journal of Pediatric Psychology  2012;37(2):149-157.
Existing literature highlights a critical gap between science and practice in clinical psychology. The internship year is a “capstone experience”; training in methods of scientific evaluation should be integrated with the development of advanced clinical competencies. We provide a rationale for continued exposure to research during the clinical internship year, including, (a) critical examination and integration of the literature regarding evidence-based treatment and assessment, (b) participation in faculty-based and independent research, and (c) orientation to the science and strategy of grantsmanship. Participation in research provides exposure to new empirical models and can foster the development of applied research questions. Orientation to grantsmanship can yield an initial sense of the “business of science.” Internship provides an important opportunity to examine the challenges to integrating the clinical evidence base into professional practice; for that reason, providing research exposure on internship is an important strategy in training the next generation of pediatric psychologists.
doi:10.1093/jpepsy/jsr114
PMCID: PMC3282283  PMID: 22286345
empirically supported treatments; internship; training
3.  Integrating Asthma Education and Smoking Cessation for Parents: Financial Return on Investment 
Pediatric pulmonology  2012;47(10):950-955.
Summary
Background
Caregivers who smoke and have children with asthma are an important group for intervention. Home-based interventions successfully reduce asthma morbidity, yet are costly. This study evaluated the financial return on investment (ROI) of the Parents of Asthmatics Quit Smoking (PAQS) program, a combined asthma education and smoking cessation intervention.
Methods
Participants included caregivers (n = 224) that smoked, had a child with asthma, and were enrolled in a Medicaid managed care plan. Participants received nurse-delivered asthma education and smoking counseling in three home visits. Program implementation costs were estimated, and health care expenses were obtained from insurance claims data 12 months pre- and 12 months post intervention. ROI was calculated for all participants, children < 6 years, children 6–18 years, and children with moderate/severe persistent asthma.
Results
Total program implementation cost was $34,481. After intervention, there was increased mean annual refills of beta-agonist (0.51 pre, 1.64 post; p<0.001), and controller medications (0.65 pre, 2.44 post; p<0.001). Reductions were found in mean annual emergency department visits (0.33 pre, 0.14 post; p<0.001), hospitalizations (0.23 pre, 0.08 post; p<0.001), and outpatient visits (2.33 pre, 1.45 post, p<0.001). The program had negative ROI (−21.8%) for the entire sample. The ROI was positive (+106.9) for children < six years, negative (−150.3) for children 6–18, and negligible for moderate/severe persistent asthma (+6.9%).
Conclusion
PAQS was associated with increased medication use and decreased health care utilization. While the overall ROI for PAQS was negative, PAQS had a positive ROI for caregivers of young children with asthma.
doi:10.1002/ppul.22559
PMCID: PMC3407822  PMID: 22467563
Asthma; Pediatrics; Smoking Cessation; Education
4.  Ethnic Differences in Caregiver Quality of Life in Pediatric Asthma 
Objective
The aim of this study was to determine ethnic and site differences in quality of life (QOL) in a sample of Latino (Puerto Rican and Dominican) and non-Latino White (NLW) caregivers of children with asthma in mainland US and Island PR. We also investigated ethnic and site differences in associations between caregiver QOL and indicators of asthma morbidity.
Method
Seven-hundred and eighty-seven children with asthma (7–16 years of age) and their primary caregivers participated. Primary caregivers completed a measure of QOL, child asthma control, and emergency department utilization, among other measures.
Results
Ethnic and site differences were found on total QOL scores (ΔF(1, 783) = 29.46, p < .001). Island PR caregivers reported worse QOL scores than RI Latino and NLW caregivers; RI Latino caregivers reported significantly worse QOL scores than NLW caregivers. In RI Latino and Island PR children, worse caregiver QOL was associated with asthma that was not in control and with 1 or more ED visits.
Conclusion
Latino caregivers may be experiencing a greater level of burden related to their child’s asthma than NLW caregivers. Caregiver QOL in pediatric asthma may be a reflection of broader, contextual stress that some Latino caregivers experience on a daily basis (e.g., cultural beliefs, acculturation). Future research should continue to investigate mechanisms that explain the burden associated with pediatric asthma in Latino families, as well as whether QOL assessments should consider the impact of everyday stressors on caregiver QOL in pediatric asthma.
doi:10.1097/DBP.0b013e318264c2b7
PMCID: PMC3463809  PMID: 23027132
pediatric asthma; quality of life; caregivers; disparities; ethnicity
5.  Medication Adherence Among Latino and Non-Latino White Children With Asthma 
Pediatrics  2012;129(6):e1404-e1410.
OBJECTIVE:
Latino children of Caribbean descent remain at high risk for poorly controlled asthma. Controller medications improve asthma control; however, medication adherence remains suboptimal, particularly among minorities. This study assessed socioeconomic, family-based, and parent factors in medication adherence among children with asthma from Rhode Island (RI; Latino and non-Latino white [NLW]) and Puerto Rico.
METHODS:
Data collection occurred as part of a multicenter study of asthma disparities. Our sample included children (ages 7–16) prescribed objectively monitored controller medications (n = 277; 80 island Puerto Rico, 114 RI Latino, 83 RI NLW). Parents completed questionnaires regarding family background and beliefs about medications. Families participated in an interview regarding asthma management. Multilevel analyses (maximum likelihood estimates) accounting for children being nested within site and ethnic group assessed the contribution of social context, family, and parent variables to medication adherence.
RESULTS:
Medication adherence differed by ethnic group (F2, 271 = 7.46, P < .01), with NLW families demonstrating the highest levels of adherence. Multilevel models indicated that parental beliefs about medication necessity and family organization regarding medication use were significant predictors of adherence, even for families below the poverty threshold. With family factors in the model, a substantial improvement in model fit occurred (Akaike Information Criterion change of 103.45).
CONCLUSIONS:
Adherence to controller medications was lower among Latino children in our sample. Targeted interventions that capitalize on existing family resources, emphasize structure, and address parental beliefs about the importance of medications may be of benefit to families from different cultural backgrounds.
doi:10.1542/peds.2011-1391
PMCID: PMC3362901  PMID: 22566417
asthma; patient nonadherence; disparities
6.  Identifying Individual, Cultural and Asthma-Related Risk and Protective Factors Associated With Resilient Asthma Outcomes in Urban Children and Families 
Journal of Pediatric Psychology  2012;37(4):424-437.
Objective The goal of this study is to identify individual, family/cultural, and illness-related protective factors that may minimize asthma morbidity in the context of multiple urban risks in a sample of inner-city children and families. Methods Participating families are from African-American (33), Latino (51) and non-Latino white (47) backgrounds. A total of 131 children with asthma (56% male), ages 6–13 years and their primary caregivers were included. Results Analyses supported the relationship between cumulative risks and asthma morbidity across children of the sample. Protective processes functioned differently by ethnic group. For example, Latino families exhibited higher levels of family connectedness, and this was associated with lower levels of functional limitation due to asthma, in the context of risks. Conclusions This study demonstrates the utility of examining multilevel protective processes that may guard against urban risks factors to decrease morbidity. Intervention programs for families from specific ethnic groups can be tailored to consider individual, family-based/cultural and illness-related supports that decrease stress and enhance aspects of asthma treatment.
doi:10.1093/jpepsy/jss002
PMCID: PMC3415979  PMID: 22408053
asthma outcomes; cultural factors; inner city; pediatric asthma; protective factors
7.  Addressing Asthma Health Disparities: A Multilevel Challenge 
Substantial research has documented pervasive disparities in the prevalence, severity, and morbidity of asthma among minority populations compared to non-Latino whites. The underlying causes of these disparities are not well understood, and as a result, the leverage points to address them remain unclear. A multilevel framework for integrating research in asthma health disparities is proposed in order to advance both future research and clinical practice. The components of the proposed model include health care policies and regulations, operation of the health care system, provider/clinician-level factors, social/environmental factors, and individual/family attitudes and behaviors. The body of research suggests that asthma disparities have multiple, complex and inter-related sources. Disparities occur when individual, environmental, health system, and provider factors interact with one another over time. Given that the causes of asthma disparities are complex and multilevel, clinical strategies to address these disparities must therefore be comparably multilevel and target many aspects of asthma care. Clinical Implications: Several strategies that could be applied in clinical settings to reduce asthma disparities are described including the need for routine assessment of the patient’s beliefs, financial barriers to disease management, and health literacy, and the provision of cultural competence training and communication skills to health care provider groups.
doi:10.1016/j.jaci.2009.02.043
PMCID: PMC2693441  PMID: 19447484
Asthma disparities; multi-level model of asthma disparities; clinical recommendations
9.  Immigration and Acculturation-Related Factors and Asthma Morbidity in Latino Children* 
Journal of Pediatric Psychology  2011;36(10):1130-1143.
Objective This article presents a summary of findings from asthma studies focusing on immigration and acculturation-related factors. A study examining associations between these processes, family cohesion and social support networks, and asthma morbidity in a sample of Dominican and Puerto Rican caregivers residing in the mainland U.S., is also described. Methods Latino children with asthma (n = 232), ages 7–16 (49% female) and their caregivers completed interview-based questionnaires on immigration and acculturation-related processes, family characteristics, and asthma morbidity. Results The frequency of ED use due to asthma may be higher for children of caregivers born in Puerto Rico. Acculturative stress levels were higher for Puerto Rican born caregivers residing in the mainland U.S. Conclusion Asthma-related educational and intervention programs for Latino children and families should be tailored to consider the effects that the immigration and acculturation experience can have on asthma management. Specific family-based supports focused on decreasing stress related to the acculturation process, and increasing social and family support around the asthma treatment process may help to reduce asthma morbidity in Latino children.
doi:10.1093/jpepsy/jsr041
PMCID: PMC3247793  PMID: 21745811
acculturation; asthma morbidity; immigration
10.  Conundrums in childhood asthma severity, control, and health care use: Puerto Rico versus Rhode Island 
Background
The lifetime prevalence of self-reported asthma among Puerto Ricans is very high, with increased asthma hospitalizations, emergency department visits, and mortality rates. Differences in asthma severity between the mainland and island, however, remain largely unknown.
Objective
We sought to characterize differences in asthma severity and control among 4 groups: (1) Island Puerto Ricans, (2) Rhode Island (RI) Puerto Ricans, (3) RI Dominicans, and (4) RI whites.
Methods
Eight hundred five children aged 7 to 15 years completed a diagnostic clinic session, including a formal interview, physical examination, spirometry, and allergy testing. Using a visual grid adapted from the Global Initiative for Asthma, asthma specialists practicing in each site determined an asthma severity rating. A corresponding level of asthma control was determined by using a computer algorithm.
Results
Island Puerto Ricans had significantly milder asthma severity compared with RI Puerto Ricans, Dominicans, and whites (P < .001). Island Puerto Ricans were not significantly different from RI whites in asthma control. RI Puerto Ricans showed a trend toward less control compared with island Puerto Ricans (P = .061). RI Dominicans had the lowest rate of controlled asthma. Paradoxically, island Puerto Ricans had more emergency department visits in the past 12 months (P < .001) compared with the 3 RI groups.
Conclusions
Potential explanations for the paradoxic finding of milder asthma in island Puerto Ricans in the face of high health care use are discussed. Difficulties in determining guideline-based composite ratings for severity versus control are explored in the context of disparate groups.
doi:10.1016/j.jaci.2009.05.014
PMCID: PMC3380616  PMID: 19615729
Asthma; severity; control; clinical guidelines; Global Initiative for Asthma; Latino; Puerto Rican; Dominican; Rhode Island; health care use
11.  Validity of the Family Asthma Management System Scale with an Urban African-American Sample 
Journal of Pediatric Psychology  2009;36(5):576-585.
Objective To examine the reliability and validity of the Family Asthma Management System Scale for low-income African-American children with poor asthma control and caregivers under stress. The FAMSS assesses eight aspects of asthma management from a family systems perspective. Methods Forty-three children, ages 8–13, and caregivers were interviewed with the FAMSS; caregivers completed measures of primary care quality, family functioning, parenting stress, and psychological distress. Children rated their relatedness with the caregiver, and demonstrated inhaler technique. Medical records were reviewed for dates of outpatient visits for asthma. Results The FAMSS demonstrated good internal consistency. Higher scores were associated with adequate inhaler technique, recent outpatient care, less parenting stress and better family functioning. Higher scores on the Collaborative Relationship with Provider subscale were associated with greater perceived primary care quality. Conclusions The FAMSS demonstrated relevant associations with asthma management criteria and family functioning for a low-income, African-American sample.
doi:10.1093/jpepsy/jsp083
PMCID: PMC3131702  PMID: 19776230
adherence; asthma; family functioning; parent stress.
12.  The role of caregiver major depression in the relationship between anxiety disorders and asthma attacks in island Puerto Rican youth and young adults 
The goal of this study was to assess whether the association between asthma attacks and anxiety disorders in youth/young adults is reduced after adjusting for caregivers’ psychiatric disorders. An island-wide probability sample of 641 households in Puerto Rico with youth/young adults between 10 and 25 years old participated along with their caregivers. The Diagnostic Interview Schedule for Children and the Composite International Diagnostic Interview were conducted to assess anxiety and depressive disorders. Youth/young adults with an anxiety disorder were more likely to have a lifetime history of asthma attacks versus youth/young adults without an anxiety disorder. Caregivers of participants with asthma attacks were more likely to have major depression than caregivers of participants without asthma attacks. The association between asthma attacks and anxiety disorders in youth was no longer significant after adjustment for caregiver major depression. It is important to consider the role of caregiver depression in asthma-anxiety comorbidity in youth/young adults.
doi:10.1097/NMD.0b013e3182174e84
PMCID: PMC3090724  PMID: 21543950
anxiety; asthma; depression; mental health; Puerto Rican
13.  Asthma symptom perception and obesity in children☆ 
Biological Psychology  2009;84(1):135-141.
This study examined the relationship between obesity and asthma symptom perception in 200 youth with asthma. Repeated subjective and objective peak flow measurements were summarized using the Asthma Risk Grid (Klein et al., 2004), resulting in Accurate, Symptom Magnification and Danger Zone scores. Analyses were stratified by age and included ethnicity.
For younger children, obesity was not significantly related to perception scores. For older children, a significant obesity-by-ethnicity interaction for Accurate Symptom Perception scores indicated that obese white children had lower accuracy than white nonobese children, while there was no difference for obese versus nonobese minority children. Obesity was also related to higher Symptom Magnification scores regardless of ethnicity for older children.
These findings suggest that obesity may complicate asthma management by interfering with the ability to accurately perceive symptoms for some patients. More remains to be learned about the role of sociodemographic factors underlying this relationship.
doi:10.1016/j.biopsycho.2009.11.007
PMCID: PMC3278964  PMID: 19941934
Asthma; Body mass index; Obesity; Symptom perception; Children
14.  Multiple Urban and Asthma-Related Risks and Their Association with Asthma Morbidity in Children 
Journal of Pediatric Psychology  2007;32(5):582-595.
Objective
To determine whether a multi-dimensional cumulative risk index (CRI) is a stronger predictor of asthma morbidity in urban, school-aged children with asthma, than poverty or severity alone.
Methods
A total of 163 children with asthma, ages 7–15 years (42% female; 69% ethnic minority) and their primary caregivers completed interview-based questionnaires, focusing on potential cultural, contextual, and asthma-specific risks that can impact asthma morbidity.
Results
Higher levels of cumulative risks were associated with more asthma morbidity, after controlling for poverty level or asthma severity. Analyses by ethnic group and subgroup also supported the relationship between the CRI and specific indices of asthma morbidity.
Conclusions
This study demonstrates the utility of multiple-dimensional risk models for predicting variations in asthma morbidity in urban children. Research efforts with urban families who have children with asthma need to consider the context of urban poverty as it relates to children’s cultural backgrounds and specific asthma outcomes.
doi:10.1093/jpepsy/jsl050
PMCID: PMC3274817  PMID: 17218338
asthma risks; urban
15.  Cultural-Related, Contextual, and Asthma-Specific Risks Associated with Asthma Morbidity in Urban Children 
The objective of this study was to examine associations between specific dimensions of the multidimensional cumulative risk index (CRI) and asthma morbidity in urban, school-aged children from African American, Latino and Non-Latino White backgrounds. An additional goal of the study was to identify the proportion of families that qualify for high-risk status on each dimension of the CRI by ethnic group. A total of 264 children with asthma, ages 7–15 (40% female; 76% ethnic minority) and their primary caregivers completed interview-based questionnaires assessing cultural, contextual, and asthma-specific risks that can impact asthma morbidity. Higher levels of asthma-related risks were associated with more functional morbidity for all groups of children, despite ethnic group background. Contextual and cultural risk dimensions contributed to more morbidity for African-American and Latino children. Analyses by Latino ethnic subgroup revealed that contextual and cultural risks are significantly related to more functional morbidity for Puerto Rican children compared to Dominican children. Findings suggest which type of risks may more meaningfully contribute to variations in asthma morbidity for children from specific ethnic groups. These results can inform culturally sensitive clinical interventions for urban children with asthma whose health outcomes lag far behind their non-Latino White counterparts.
doi:10.1007/s10880-009-9178-3
PMCID: PMC3266227  PMID: 20157798
Pediatric asthma; Cumulative risks; Ethnic minority; Urban
16.  Access to and Use of Asthma Health Services Among Latino Children: The Rhode Island-Puerto Rico Asthma Center Study 
Medical Care Research and Review  2011;68(6):683-698.
This study determines asthma-related health care access and utilization patterns for Latino children of Puerto Rican and Dominican origin residing in Rhode Island (RI) and Latino children residing in Puerto Rico (Island). Data included 804 families of children with persistent asthma recruited from clinics. Island children were less likely to receive regular asthma care and care from a consistent provider and more likely to have been to the emergency department and hospitalized for asthma than RI children. Island children were 2.33 times more likely to have used the emergency department for asthma compared with RI non-Latino White (NLW) children. Latino children residing in both Island and RI were less likely to have used specialty care and more likely to have had a physician visit for asthma in the past year than RI NLW children. The differences might reflect the effects of the different delivery systems on pediatric health care utilization and asthma management.
doi:10.1177/1077558711404434
PMCID: PMC3266228  PMID: 21536604
asthma; Hispanic Americans; Latino; children; health service accessibility; health care utilization; Puerto Rico
17.  Beliefs and Barriers to Medication Use in Parents of Latino Children With Asthma 
Pediatric Pulmonology  2009;44(9):892-898.
Summary
Objective
Disparities in asthma outcomes exist between Latino and non-Latino white (NLW) children. We examined rates of medication use, medication beliefs, and perceived barriers to obtaining medication in US and island Puerto Rican parents of children with asthma
Hypotheses
Island PR parents would report the lowest rates of controller medication use, followed by RI Latino and RI NLW parents; Latino parents would report more medication concerns than NLW parents; and Island PR parents would report the most barriers to medication use.
Study Design
Five hundred thirty families of children with persistent asthma participated, including 231 Island PR, 111 RI NLW, and 188 RI Latino. Parents completed survey measures.
Results
Group differences were found on reported use of ICS (X2 = 50.96, P <0.001), any controller medication (X2 = 56.49, P <0.001), and oral steroids (X2 = 10.87, P <0.01). Island PR parents reported a greater frequency of barriers to medication use than the other two groups (X2 = 61.13, P <0.001). Latino parents in both sites expressed more medication concerns than NLW parents (F = 20.18, P <0.001). Medication necessity was associated with ICS use in all three groups (all P’s <0.01). Medication concerns were positively associated with ICS use in PR only (OR = 1.64, P <0.05).
Conclusions
Differences in medication beliefs and the ability to obtain medications may explain the reported disparity in controller medication use. Further studies are needed to evaluate these obstacles to medication use.
doi:10.1002/ppul.21074
PMCID: PMC3266229  PMID: 19672958
disparities; adherence; asthma; ethnicity; childhood; medication use
18.  Issues and Methods in Disparities Research 
Pediatric Pulmonology  2009;44(9):899-908.
Summary
Background
Epidemiologic studies have documented higher rates of asthma prevalence and morbidity in minority children compared to non-Latino white (NLW) children. Few studies focus on the mechanisms involved in explaining this disparity, and fewer still on the methodological challenges involved in rigorous disparities research.
Objectives and Methods
This article provides an overview of challenges and potential solutions to research design for studies of health disparities. The methodological issues described in this article were framed on an empirical model of asthma health disparities that views disparities as resulting from several factors related to the healthcare system and the individual/community system. The methods used in the Rhode Island–Puerto Rico Asthma Center are provided as examples, illustrating the challenges in executing disparities research.
Results
Several methods are described: distinguishing ethnic/racial differences from methodological artifacts, identifying and adapting culturally sensitive measures to explain disparities, and addressing the challenges involved in determining asthma and its severity in Latino and other minority children. The measures employed are framed within each of the components of the conceptual model presented.
Conclusions
Understanding ethnic and/or cultural disparities in asthma morbidity is a complicated process. Methodologic approaches to studying the problem must reflect this complexity, allowing us to move from documenting disparities to understanding them, and ultimately to reducing them.
doi:10.1002/ppul.21075
PMCID: PMC3266230  PMID: 19658111
asthma; health disparities; Latino; Puerto Rican; children; research methods
19.  Differences in Environmental Control and Asthma Outcomes Among Urban Latino, African American, and Non–Latino White Families 
Latino and African American children with asthma are at increased risk for asthma morbidity compared with non–Latino White children. Environmental control (ie, environmental exposures and family strategies to control them) may contribute to greater asthma morbidity for ethnic minority children living in urban environments. This study examined ethnic differences in a semi-structured assessment of environmental control, associations between environmental control and asthma outcomes (asthma control, functional limitation, and emergency department [ED] use), and ethnic differences in environmental triggers in a sample of urban Latino, African American, and non–Latino White families. One hundred thirty-three children (6–13 years of age) and their caregivers completed demographic questionnaires, measures of asthma control and morbidity, and a semi-structured interview assessing environmental control. Reported environmental control differed significantly by ethnicity (P<0.05), with Latino families reporting higher levels of environmental control. Reported environmental control was significantly associated with asthma control (P<0.017) and functional limitation (P<0.017). Reported environmental control and ED use were significantly associated in Latino families (P<0.05). Non–Latino White and African American families reported more secondhand smoke exposure than Latino families (P<0.001). Latino families reported more optimal home environmental control than other ethnic groups. Substantial ethnic differences in asthma triggers suggest that observed ethnic disparities in asthma may be due, at least in part, to differences in the home environment.
doi:10.1089/ped.2011.0081
PMCID: PMC3255502  PMID: 22276226
20.  Ethnic Differences in Perception of Lung Function 
Rationale: Disparities in pediatric asthma exist in that Latino children have higher prevalence and greater morbidity from asthma than non–Latino white children. The factors behind these disparities are poorly understood, but ethnic-related variations in children's ability to accurately recognize and report their pulmonary functioning may be a contributing process.
Objectives: To determine (1) if differences exist between Latino and non–Latino white children's perceptual accuracy and (2) whether these differences are related to asthma outcomes.
Methods: Five hundred and twelve children, aged 7–16 years (290 island Puerto Ricans, 115 Rhode Island Latinos, and 107 Rhode Island non-Latino white children) participated in a 5-week home-based protocol in which twice daily they entered subjective estimates of their peak expiratory flow rate into a hand-held, programmable spirometer and then performed spirometry. Their accuracy was summarized as three perceptual accuracy scores. Demographic data, asthma severity, intelligence, emotional expression, and general symptom-reporting tendencies were assessed and covaried in analyses of the relationship of perceptual accuracy to asthma morbidity and health care use.
Measurements and Main Results: Younger age, female sex, lower intelligence, and poverty were associated with lower pulmonary function perception scores. Island Puerto Rican children had the lowest accuracy and highest magnification scores, followed by Rhode Island Latinos; both differed significantly from non–Latino white children. Perceptual accuracy scores were associated with most indices of asthma morbidity.
Conclusions: Controlling for other predictive variables, ethnicity was related to pulmonary function perception ability, as Latino children were less accurate than non–Latino white children. This difference in perceptual ability may contribute to recognized asthma disparities.
doi:10.1164/rccm.200906-0836OC
PMCID: PMC2902755  PMID: 20299534
childhood asthma; symptom recognition; disparities
21.  Comorbidity Between Asthma Attacks and Internalizing Disorders Among Puerto Rican Children at One-Year Follow-Up 
Psychosomatics  2006;47(4):333-339.
Authors examined the association between internalizing disorders and asthma attacks at 1-year follow-up among a community sample of 1,789 children and adolescents ages 5–18 years living on the island of Puerto Rico. The Diagnostic Interview Schedule for Children was administered to assess DSM-IV internalizing disorders during the past year. Children with a lifetime history of asthma attacks at baseline had greater odds of having an internalizing disorder at 1-year follow-up, independent of socio-demographic measures. However, an association was not found between asthma attacks and persistence of internalizing disorders. These findings show that the association between internalizing disorders and asthma attacks was replicated 1 year later in the same sample.
doi:10.1176/appi.psy.47.4.333
PMCID: PMC2966278  PMID: 16844893
22.  Symptom Perception and Functional Morbidity Across a 1-Year Follow-up in Pediatric Asthma 
Pediatric pulmonology  2007;42(4):339-347.
Summary
The purpose of this study was to examine the association between asthma symptom perception measured during a 5–6 week baseline and functional morbidity measured prospectively across a 1-year follow-up. Symptom perception was measured by comparing subjective ratings with peak expiratory flow rate (PEFR) and forced expiratory volume in one second (FEV1). We hypothesized that accurate symptom perception (ASP) would be associated with less functional morbidity. Participants consisted of 198 children with asthma ages 7–17 recruited from three sites. The children used a programmable electronic spirometer in the home setting to guess their PEFR prior to exhalation. Each “subjective” guess was classified as being in an ASP, dangerous symptom perception (DSP; underestimation of symptoms), or symptom magnification (SM; overestimation) zone based upon the corresponding measurement of PEFR or FEV1. An index of functional morbidity was collected by parent report at baseline and across 1-year follow-up. A greater proportion of ASP blows and a lower proportion of DSP blows based on PEFR predicted less functional morbidity reported at baseline, independent of asthma severity and race/ethnicity. A greater proportion of ASP blows (using PEFR and FEV1) and a lower proportion of SM blows (using FEV1) predicted less functional morbidity across 1-year follow-up. Symptom perception was not associated with emergency department visits for asthma at baseline or across follow-up. In comparison to PEFR, FEV1 more frequently detected a decline in pulmonary function that children did not report. Symptom perception measured in naturalistic settings was associated with functional morbidity at baseline and prospectively across 1-year follow-up. Support was found for including multiple measures of pulmonary function in the assessment of asthma symptom perception.
doi:10.1002/ppul.20584
PMCID: PMC2966282  PMID: 17358038
asthma; forced expiratory volume; morbidity; peak expiratory flow rate; perception
23.  Symptom Perception in Children with Asthma: Cognitive and Psychological Factors 
Objective:
This study tested the differential effects of several cognitive and psychological variables on children's perception of asthma symptoms by use of an Asthma Risk Grid. Children's subjective and objective assessments of PEFR (peak expiratory flow rate) were characterized as representing perceptual accuracy, symptom magnification, and/or underestimation of asthma symptoms.
Design:
Two hundred and seventy children with asthma (ages 7-17) and their primary caregivers completed measures assessing cognitive and psychological factors and a 5-6 week symptom perception assessment.
Main Outcome Measures:
Children's symptom perception scores by use of the Asthma Risk Grid.
Results:
Children's attentional abilities had more of a bearing on their symptom monitoring abilities than their IQ estimates and psychological symptoms. The more time children took on Trails and Cancellation Tasks and the fewer errors they made on these tasks, the more likely they were to perceive their asthma symptoms accurately. More time on these tasks were associated with more symptom magnification scores, and fewer errors were related with fewer symptom magnification scores. More errors and higher total scores on the Continuous Performance Task were associated with a greater proportion of scores in the danger zone.
Conclusion:
Statistical support was provided for the utility of attentional-based instruments for identifying children who may have problems with perceptual accuracy, and who are at risk for asthma morbidity.
doi:10.1037/a0013169
PMCID: PMC2658619  PMID: 19290715
Asthma; symptom perception; cognitive and psychological factors
24.  Pediatric Asthma and Problems in Attention, Concentration, and Impulsivity 
Rationale
This study assesses the relationships between ADHD symptoms, specific family asthma management domains, and pediatric asthma morbidity.
Methods
Participants were 110 children with asthma and a respective parent (ages 7-17, X = 11.6 years, 25% ethnic/racial minority). Parents completed measures of asthma morbidity and report of child ADHD symptoms. Children completed measures of attention, concentration, and impulsivity. Families participated in the Family Asthma Management System Scale (FAMSS) interview to assess the effectiveness of eight features of asthma management.
Results
Parent report of ADHD symptoms and poor child performance on a computerized task of sustained visual attention were associated with asthma morbidity. Paper and pencil tasks of visual attention, and an index of auditory attention, were not related to asthma morbidity. Modest associations were found between parent report of ADHD symptoms, child performance-based indicators of attention and concentration, and features of family asthma management, although not across all measures. The family response to asthma partially mediated the relationship between ADHD symptoms and morbidity.
Conclusions
ADHD symptoms are modestly associated with difficulties in family asthma management.
doi:10.1037/1091-7527.26.1.16
PMCID: PMC2636964  PMID: 19198669
25.  Latino Caregivers' Beliefs about Asthma: Causes, Symptoms, and Practices 
Background and Objective:
This study examined belief systems of Latino caregivers who have children with asthma from Puerto Rican and Dominican backgrounds who resided on the Island of PR and the Mainland. The goal of this study was to document similarities and differences in beliefs about the causes, symptoms and treatments of asthma across two sites and two Latino ethnic sub-groups of children who remain the most at risk for asthma morbidity.
Methods:
Participants included 100 primary caregivers of a child with asthma. Fifty caregivers from Island PR and fifty caregivers from mainland RI were interviewed (at each site, 25 caregivers were from Puerto Rican backgrounds and 25 caregivers were from Dominican backgrounds). The interview included an assessment of demographic information and beliefs about the causes and symptoms of asthma, and asthma practices.
Results:
Results indicated more similarities in beliefs about the causes and symptoms of asthma across site and ethnic group. The majority of differences were among beliefs about asthma practices by site and ethnic group. For example, a higher proportion of caregivers from Island PR, particularly those of Dominican descent, endorsed that a range of home and botanical remedies are effective for treating asthma.
Conclusions:
Results from this study point to several interesting directions for future research including larger samples of Latino caregivers with children who have asthma. A discussion of the importance of understanding cultural beliefs about asthma and asthma practices is also reviewed.
doi:10.1080/02770900801890422
PMCID: PMC2590764  PMID: 18415827
Asthma; Latino Caregiver's Beliefs

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