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. Author manuscript; available in PMC: 2020 Nov 30.
Published in final edited form as: J Pediatr. 2019 Jul 15;214:178–186. doi: 10.1016/j.jpeds.2019.06.003

The Adaptive Effect of Illness-Specific Panic-Fear on Asthma Outcomes in Mexican and Puerto Rican Children

Jonathan M Feldman a,b, Karenjot Kaur a, Denise Serebrisky c, Deepa Rastogi b, Flavio F Marsiglia d, Kimberly J Arcoleo e
PMCID: PMC7703716  NIHMSID: NIHMS1648790  PMID: 31320144

Abstract

Objective:

To examine baseline measures of illness-specific panic-fear (the level of anxiety experienced specifically during asthma exacerbations) as a protective factor in pediatric asthma outcomes over 1 year.

Study design:

The sample included 267 children (Mexican=188, Puerto Rican=79; ages 5–12 years) from a longitudinal, observational study in Phoenix, AZ and the Bronx, NY. Assessments occurred at baseline, 3, 6, 9, and 12 months. The Childhood Asthma Symptom Checklist was administered at baseline to children and caregivers to assess children’s illness-specific panic-fear. Asthma outcome variables quantified longitudinally included pulmonary function, the Asthma Control Test, acute healthcare utilization, and medication adherence measured by devices attached to inhaled corticosteroids.

Results:

Child report of illness-specific panic-fear at baseline predicted higher FEV1 % across 1-year follow-up in Mexican children (β= .17, P = .02), better asthma control in Puerto Rican children (β= .45, p=.007), and less acute healthcare utilization for asthma in both groups: Mexicans (β= −.39, p=.03) and Puerto Ricans (β= −.47, p=.02). Caregiver report of child panic-fear predicted higher FEV1 in Mexican (β= .30, p=.02) and Puerto Rican (β= .19, p=.05) children. Panic-fear was not related to medication adherence.

Conclusions:

Illness-specific panic-fear had beneficial effects on asthma outcomes in both groups of Latino children. The heightened vigilance associated with illness-specific panic-fear may lead children to be more aware of their asthma symptoms and lead to better strategies for asthma management.

The largest ethnic disparity in asthma prevalence and control exists between two Latino subgroups: Puerto Rican and Mexican children. Puerto Rican children exhibit the highest rates of asthma prevalence and morbidity, whereas Mexican children have the lowest rates.1, 2 Poor adherence to inhaled corticosteroids is common3, 4, especially in Puerto Rican and Dominican children5–7. Fewer than 50% of prescribed doses are taken8, 9 and ICS adherence rates as low as 28% were found in a sample primarily consisting of Puerto Rican children with electronic monitoring devices10. A sample of primarily Mexican children with asthma had high controller medication adherence rates (87%), although these data were only based on self-report11. Identifying predictors of positive asthma management behaviors (eg, attention to asthma symptoms, ICS adherence, avoidance of asthma triggers) may play a key role in reducing these ethnic disparities in asthma outcomes.

Illness-specific panic-fear is the level of anxiety experienced specifically during asthma exacerbations. This construct is different from general anxiety or anxiety disorders, as illness-specific panic-fear may be adaptive for asthma. At 6 months after discharge, adult inpatients with asthma and high illness-specific panic-fear were re-hospitalized for asthma 50% less frequently than patients with low panic-fear12. Low illness-specific panic-fear in a community sample of adults predicted future asthma attacks and emergency health care use in patients who recently suffered an asthma attack13. The adaptive nature of panic-fear for asthma may be due to increased vigilance of asthma symptoms and adherence to self-management plans14. Two recent pediatric studies15, 16 examined anxiety about asthma over the past 2 weeks. This construct is similar to illness-specific panic-fear although it does not specifically focus on anxiety symptoms during asthma attacks. Higher asthma-related anxiety in adolescents was associated with self-reports of taking breathing problems more seriously, visiting a provider for the presence of asthma symptoms15, and taking steps to prevent and manage asthma symptoms16. Therefore, asthma-related anxiety may be protective in children.

Theoretical models for the perception of asthma symptoms highlight the importance of recognizing a physical sensation as threatening and then mobilizing attentional resources toward this threat17. Social and contextual factors also play a role in models of asthma disparities that examine asthma symptom interpretation and treatment decisions for asthma18. One key input affecting the interpretation of asthma symptoms is the emotional component, such as anxiety, which can heighten the perceived threat level (Figure). Anxiety elicited specifically within the context of asthma attacks may lead to appropriate, preventative asthma management behaviors including trigger avoidance, medication adherence, and following asthma action plans. We hypothesized that illness-specific panic-fear would prospectively have an adaptive effect on longitudinal asthma outcomes (i.e., better asthma control assessed by pulmonary function and symptom report, less acute healthcare utilization, better ICS adherence) in both Puerto Rican and Mexican children over 1 year.

Figure 1.

Figure 1.

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Conceptual Model

Methods

The overarching aim of the larger study was to understand the existing pediatric asthma disparities between Puerto Ricans and Mexicans using a longitudinal, observational design19. The focus is on the illness-specific panic-fear measure. This multisite study recruited participants from asthma/allergy clinics from two inner-city hospitals in the Bronx, NY (n= 110) and two school-based health clinics in Phoenix, AZ and Phoenix Children’s Hospital Breathmobile (n= 157) from June 2010 to October 2013. Data collection was completed by August 2014. A total of 267 Latino children ages 5–12 years old with a diagnosis of asthma and their caregivers participated in the study. Electronic medical records were used to identify and confirm asthma diagnoses. Recruitment strategies included mailings from providers, phone calls, and in-person enrollment at clinics.

The children and caregivers were required to speak either English or Spanish, have no learning/cognitive disabilities that would impact study participation, and have no other significant pulmonary conditions in the child. The caregiver was chosen based on self-identification as being a primary caregiver of the child who had either primary or at least equal responsibility for the child’s day-to-day asthma management. Only Puerto Rican (n = 79) and Mexican (n = 188) families were enrolled, and ethnicity was determined by caregiver self-report.

Caregivers and children provided consent/assent for their participation in the study. The Albert Einstein College of Medicine, Arizona State University, Ohio State University, Phoenix Children’s Hospital, and Scottsdale Healthcare Institutional Review Boards approved the study. Children and caregivers completed study measures at a baseline session and 3, 6, 9, and 12-month follow-up sessions, which allowed for seasonal variations in asthma symptoms across the year. The measures were completed in English or Spanish based on each participant’s preference. Children completed spirometry testing to assess pulmonary function at all sessions. Families were financially compensated for their participation and travel to the study sites.

Measures

Exogenous Variables

Illness Specific Panic-Fear

The Childhood Asthma Symptom Checklist Subscales (CASCL) is a 47-item self-report measure of symptoms20 modified from the adult version21 of this scale with similar factor structure, and modest correlations between child and caregiver report of items. The panic-fear subscale has 15-items assessing the frequency that children experience anxiety symptoms (e.g., scared, worried about the attack, frightened) during asthma attacks. The CASCL also consists of subscales measuring irritability (e.g., cranky, very angry/mad, unhappy with things) and general physical symptoms (e.g., hard to breathe, heavy feelings in chest, worn out). The Spanish version of the Asthma Symptom Checklist has good internal consistency and construct validity22. Caregivers also completed the CASCL with respect to how often they perceived their children experienced these symptoms during asthma exacerbations. The panic-fear subscales were analyzed as the main predictors for this study.

Social/Contextual factors

Demographic measures were collected from the caregivers including self-reported poverty status23. Caregivers also completed the Center for Epidemiological Studies Depression Scale24 to assess caregiver depressive symptoms; the Asthma Illness Representation Scale25, 26 to assess health beliefs about asthma; the Stephenson Multigroup Acculturation Scale to assess degree of immersion to the ethnic and dominant society culture27; the Caregiver-Healthcare Provider Relationship Scale25, 26, and the Family and Friend Support measure28. Asthma severity was rated by study clinicians and categorized as intermittent, mild persistent, moderate persistent, or severe persistent based on national guidelines29.

Endogenous Variables

Pulmonary Function

Spirometry testing was performed at the end of each session using a spirometer (nSpire Health, Longmont, CO) to assess multiple measures of pulmonary function. The testing was done as per the guidelines set by the American Thoracic Society30. The measure of pulmonary function analyzed for this study was the percent predicted forced expiratory volume in one second (FEV1 % predicted), which is the volume of air that is exhaled during the first second of a forced vital capacity maneuver.

Asthma Control

The Childhood Asthma Control Test (C-ACT)31 is a combination of child (4 items) and caregiver responses (3 items) to measure asthma control over the past month. Children who were 12 years old completed the Asthma Control Test (ACT)32, which consists of 5 items. Both versions assess interference with activities, asthma symptoms, and nighttime awakenings, and are reliable and valid in English31–33 and Spanish34. Higher scores indicate better asthma control.

Acute Health Care Utilization

The total number of acute asthma-related sick visits to clinics, ED visits, and hospitalizations was added together based on a combination of medical chart review and caregiver report at every study visit across the 12 months of the study. At each visit, the higher number of visits obtained by self-report versus chart review was used in order to account for visits that were outside the study sites’ medical records.

Adherence Monitoring

Adherence to ICS medications was objectively measured by Doser devices (Meditrack, Massachusetts, USA), which were attached to the top of metered dose inhalers at the baseline session. Dosers record the daily frequency of a child’s use of the medication for a 30-day period. These devices are more reliable for tracking medication use than self-report or pharmacy records35. Data from these devices were downloaded at all follow-up visits to assess longitudinal adherence across 12 months. Adherence data across the follow-up periods were available for 123 children (89 Mexican, 34 Puerto Rican) out of 192 children who were currently prescribed ICS medications compatible with Doser devices (e.g., non-combination ICS). Other reasons for missing adherence data included failure to bring medication to the visit, battery failure, or loss of the device. Overall percent adherence was calculated as the number of total doses taken by a child per day, divided by the number of prescribed doses for that day across the monitoring period. Data reduction steps truncated adherence to a maximum of 100% per day if the number of doses recorded was greater than the prescribed doses on any particular day due to accidental recordings or “dumping” of doses to catch up for prior missed doses.

Statistical Analyses

Descriptive statistics assessed the distributional characteristics of the data; means and standard deviations for continuous variables and proportions for categorical variables. Effect sizes were computed for continuous variables (Cohen d) and odds ratios for categorical variables to examine baseline differences between Mexicans and Puerto Ricans. To examine whether sample bias was present, eligible participants who declined to participate were compared with those enrolled on demographic characteristics. A 2-group (Mexican and Puerto Rican) latent variable structural equation growth model was used to test the hypotheses and examine model fit statistics. Structural equation modeling (SEM) is a powerful multivariate approach that has several advantages over multiple regression. SEM allows for testing the hypothesized theoretical relationships by not only obtaining parameter estimates, but by also examining the fit of the data to the hypothesized model. SEM allows for specification of more complex models with multiple intervening and dependent variables and examination of direct and indirect effects on the outcomes of interest. Instead of adjusting or controlling for variables in the model as in multiple regression, SEM allows the variables to correlate and model estimation is based on the covariance matrix – not correlations. Covariance structure models also allow us to test whether a set of variables have equal variances across two or more groups.

Baseline measures of the exogenous variables were used to model longitudinal changes in each endogenous variable over the 12-month period. Seasonality was examined as part of model trimming analyses we conducted and determined not to be a significant variable in the models. Thus, for parsimony, this variable was not included in the final models. The analyses conducted by Bruzzese et al revealed a curvilinear relationship between adolescent asthma-related anxiety and symptom prevention.16 Because of this, we ran linear and quadratic models for all outcomes. Our results revealed no curvilinear relationships between children’s illness-specific panic-fear and the specified outcomes in this study.

A p < .10 was considered statistically significant, which is the convention for SEM analyses36. Version 9.4 of the SAS System for Windows (copyright 2017, SAS Institute Inc) was used for the descriptive analyses and MPlus version 8.137 was used for the SEM analyses. In SEM, several fit statistics (e.g., root mean square error of approximation, comparative fit index, Tucker-Lewis Index, and standardized root mean square residual) are used to ascertain how well the sample data fit the hypothesized model. All models met or exceeded the thresholds for determining acceptable fit. To test model effect sizes and equivalence between Puerto Ricans and Mexicans, the chi-square difference test was conducted on the two models37. If the difference in chi-squares is statistically significant then the models differ. Missing data patterns were explored and determined to be missing completely at random. Multiple imputation was done when exogenous variables were missing.

Results

A total of 267 caregiver-child dyads (ages 5–12, mean = 9.5) were enrolled in the study. Retention was computed as the number of participants who completed 3 or more of the 5 assessments. Overall retention was 82% across 12 months. As expected, the Arizona sites consisted of mostly Mexican families (99.4%) and the Bronx had mainly Puerto Rican families (70.9%) with a smaller number of Mexican families (29.1%). Mexican caregivers were younger and more likely to be poor, married, and complete the interview in Spanish (Table I). Puerto Rican caregivers had a higher educational level and more depressive symptoms. Mexican children had greater illness-specific panic-fear, lower asthma severity, better asthma control, and shorter duration of asthma versus Puerto Rican children. Adherence to ICS medications was better in Mexican children than Puerto Rican children at 6, 9, and 12-month follow-up. Diagnostic analyses revealed that children with missing adherence data were more likely to have mild or severe persistent asthma and had caregivers who were older and high school graduates.

Table 1.

Sample Characteristics at Baseline (n=267)

Variable Mexican (N=188) Puerto Rican (N=79) Effect size Odds Ratio Cohen’s d P
N (%) N (%)
Child Sex (% Female) 62 (33.0) 32 (40.5) .72 .24
Caregiver Sex (% Female) 180 (95.7) 74 (93.7) 1.52 .52
Married (% Yes) 104 (55.3) 24 (30.4) 2.84 .0002
Poor (% Yes) 126 (67.0) 25 (31.7) 4.39 <.0001
High School Graduate (% Yes) 85 (45.5) 48 (60.8) .54 .02
Language of caregiver interview (% Spanish) 170 (90.4) 15 (19.0) 40.0 <.0001
Any Controller Medication Use Past Month (% Yes) 130 (69.1) 62 (78.5) .61 .12
Asthma Severity (Clinician-rated) .02
  Intermittent (reference group) 32 (17.2) 11 (14.7)
  Mild Persistent 63 (33.9) 16 (21.3) .74
  Moderate Persistent 74 (39.8) 31 (41.3) 1.22
  Severe Persistent 17 (9.1) 17 (22.7) 2.91
Asthma Control Test (% Well controlled) 106 (56.4) 12 (15.2) 7.22 <.0001
Mean (SD) Mean (SD) P
Child’s Age (Years) 9.67 (2.15) 9.23 (2.23) .20 .13
Caregiver’s Age 35.47 (6.31) 38.42 (10.47) .34 .02
Asthma Duration (Months) 67.94 (39.54) 88.46 (31.77) .57 <.0001
# Family Members w/Asthma 1.24 (.73) 0.91 (1.09) .36 .02
Caregiver Depression (CES-D) 10.95 (10.15) 16.03 (12.30) .46 .002
Asthma Symptom Checklist (C-CASCL): Panic-Fear (Child) 35.12 (12.69) 31.10 (12.32) .32 .02
Asthma Symptom Checklist (P-CASCL): Panic-Fear (Caregiver) 30.89 (11.88) 30.58 (12.24) .03 .85
FEV1 % Predicted 101.23 15.34) 92.51 (13.98) 1.30 .001
% ICS Adherence : 3 months 45.30 (30.45) 35.65 (28.91) .33 .28
% ICS Adherence : 6 months 51.70 (32.38) 35.44 (37.86) .46 .08
% ICS Adherence : 9 months 48.36 (29.52) 29.94 (27.57) .64 .03
% ICS Adherence : 12 months 49.13 (31.79) 26.41 (28.98) .75 .02
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Note: N=123 for inhaled corticosteroid (ICS) adherence data

Child report of illness-specific panic-fear

Child self-report of illness-specific panic-fear at baseline predicted higher FEV1 (Table 2) across 1-year follow-up in Mexican children and a similar trend was observed in Puerto Rican children. The two-group model explained more variance in Mexicans than Puerto Ricans, p < .0001. Child-reported illness-specific panic-fear predicted better asthma control (ACT) in Puerto Rican children, but not Mexican children. The Puerto Rican model had higher explained variance than the Mexican model on the ACT, p < .0001. Child panic-fear predicted less acute asthma-related healthcare utilization in both Puerto Rican and Mexican children. There was no difference in explained variance for the Puerto Rican model compared with the Mexican model. Child illness-specific panic-fear did not predict ICS adherence in Mexicans or Puerto Ricans. The other emotional CASCL subscale of irritability during asthma attacks predicted the opposite direction from panic-fear: worse asthma control and lower FEV1 in Mexican children.

Table 2.

Child-reported illness-specific panic-fear as a longitudinal predictor of FEV1, asthma control, acute healthcare utilization, and controller medication adherence

Variable FEV1 % Predicted Asthma Control Acute Healthcare Utilization Controller Medication Adherence
Mexican Puerto Rican Mexican Puerto Rican Mexican Puerto Rican Mexican Puerto Rican
Model R2 67% 62% 38% 53% 12% 41% 43% 48%
β (SE) p-Value β (SE) p-Value β (SE) p-Value β (SE) p-Value β (SE) p-Value β (SE) p-Value β (SE) p-Value β (SE) p-Value
Child sex −.05 (.08) .04 −.08 (.13) .17 −.02 (.09) .86 −.13 (.12) .21 −.09 (.12) .49 .13 (.14) .36 −.46 (.13) <.0001 .28 (.23) .23
Marital status −.06 (.08) .02 −.05 (.15) .04 −.19 (.09) .04 .09 (.13) .52 .29 (.13) .03 −.32 (.15) .03 −.04 (.15) .78 .003 (.26) .99
Poverty .08 (.08) .05 .12 (.15) .20 .04 (.09) .64 .44 (.13) .001 −.22 (.13) .09 −.52 (.15) .001 .15 (.14) .28 −.26 (.27) .34
Caregiver Education −.01 (.08) .02 −.21 (.12) .03 −.11 (.09) .21 .14 (.12) .26 −.06 (.13) .65 .31 (.14) .03 −.006 (.13) .96 .21 (.22) .36
Child age −.31 (.08) .01 −.38 (.16) .14 .004 (.10) .97 .09 (.12) .45 −.44 (.15) .003 −.72 (.21) .001 −.08 (.16) .63 −.16 (.29) .59
Caregiver age −.12 (.08) .008 .03 (.15) .30 −.03 (.11) .79 .71 (.18) <.0001 −.09 (.13) .51 .35 (.14) . 01 .10 (.13) .44 .17 (.29) .55
Asthma duration −.19 (.08) .01 .16 (.13) .03 −.09 (.10) .38 −.28 (.15) .06 .001 (.14) .99 .39 (.18) .04 −.006 (.17) .97 −.24 (.27) .37
# Family members with asthma −.03 (.08) .01 −.42 (.14) .17 −.05 (.10) .62 −.38 (.13) .005 .13 (.14) .33 .40 (.16) .01 −.03 (.15) .84 −.31 (.29) .28
Asthma severity .05 (.08) .05 .24 (.14) .06 .04 (.09) .70 .10 (.13) .47 −.12 (.13) .35 .22 (.17) .19 −.20 (.14) .16 .14 (.36) .70
Illness representations .02 (.10) .03 .06 (.14) .09 .20 (.11) .07 .14 (.13) .27 −.34 (.16) .03 .04 (.15) .79 .15 (.18) .40 −.31 (.26) .23
Social support .05 (.09) .02 −.11 (.13) .01 .05 (.10) .65 .14 (.13) .28 −.24 (.14) .08 −.06 (.16) .71 .26 (.14) .07 −.44 (.26) .08
Healthcare provider relationship .03 (.09) .05 −.19 (.13) .11 .01 (.11) .93 −.02 (.12) .90 −.12 (.15) .44 .17 (.15) .25 .04 (.16) .82 −.18 (.27) .50
Ethnic society immersion −.10 (.10) .04 −.38 (.16) .03 −.01 (.11) .92 .09 (.16) .56 −.18 (.15) .24 .06 (.19) .77 −.24 (.16) .12 .05 (.32) .87
Dominant society immersion .07 (.10) .03 .55 (.16) .09 .001 (.11) .99 .04 (.15) .81 .22 (.15) .15 −.14 (.18) .44 −.09 (.16) .60 −.08 (.42) .85
Caregiver depression .05 (.08) .03 −.17 (.13) .08 −.07 (.10) .48 .26 (.15) .08 −.15 (.13) .25 −.34 (.18) .06 .19 (.13) .15 −.21 (.26) .41
Illness-specific physical symptoms (child) −.08 (.10) .03 −.04 (.17) .03 −.16 (.11) .15 −.86 (.16) <.0001 .11 (.15) .49 .44 (.20) .03 .02 (.16) .92 .41 (.36) .25
Illness-specific irritability (child) −.01 (.11) .04 −.08 (.15) .11 −.25 (.12) .04 −.18 (.14) .20 .20 (.17) .25 .24 (.16) .15 .10 (.18) .57 −.07 (.26) .78
Illness-specific panic-fear (child) .17 (.11) .02 .47 (.18) .10 .08 (.13) .55 .45 (.17) .007 −.39 (.18) .03 −.47 (.20) .02 −.04 (.17) .81 −.58 (.36) .11
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Caregiver report of illness-specific panic-fear

Child panic-fear reported by caregivers also predicted higher FEV1 (Table 3) in both groups of children. The model for Mexican children explained more variance than Puerto Rican children, p < .0001. Caregiver report of panic-fear did not predict asthma control, acute healthcare utilization for asthma, or controller medication adherence. Caregiver-reported child irritability predicted lower FEV1 in Mexican children. However, caregiver report of child irritability predicted less acute healthcare utilization for asthma in Puerto Ricans and better ICS adherence in both groups.

Table 3.

Caregiver-reported child illness-specific panic-fear as a longitudinal predictor of FEV1, asthma control, acute healthcare utilization, and controller medication adherence

Variable FEV1 % Predicted Asthma Control Acute Healthcare Utilization Controller Medication Adherence
Mexican Puerto Rican Mexican Puerto Rican Mexican Puerto Rican Mexican Puerto Rican
Model R2 67% 64% 38% 12% 38% 38% 43% 46%
β (SE) p-Value β (SE) p-Value β (SE) p-Value β (SE) p-Value β (SE) p-Value β (SE) p-Value β (SE) p-Value β (SE) p-Value
Child sex −.06 (.08) .02 −.003 (.14) .11 −.03 (.09) .79 −.23 (.13) .09 −.07 (.14) .60 −.03 (.24) .90 −.47 (.13) <.0001 .35 (.25) .16
Marital status −.06 (.08) .02 −.004 (.15) .02 −.14 (.10) .14 −.07 (.14) .62 .39 (.14) .006 .08 (.23) .72 −.05 (.15) .73 .12 (.24) .61
Poverty .05 (.08) .03 .18 (.15) .06 .04 (.10) .66 .33 (.14) .02 .19 (.14) .20 −.07(.19) .72 .21 (.14) .13 −.38 (.27) .16
Caregiver Education −.01 (.08) .03 −.20 (.13) .05 −.13 (.09) .18 .24 (.13) .06 −.12 (.14) .41 .11 (.19) .57 −.05 (.13) .72 −.13 (.21) .54
Child age −.33 (.08) .01 −.25 (.15) .22 −.03 (.11) .81 .18 (.17) .31 −.57 (.17) .001 −1.21 (.33) <.0001 −.10 (.16) .53 −.28 (.31) .37
Caregiver age −.13 (.08) .06 −.08 (.14) .09 .008 (.10) .94 .18 (.14) .17 −.21 (.14) . 13 .39 (.20) .05 −18 (.13) .18 −.49 (.25) .05
Asthma duration −.20 (.08) .03 .13 (.13) .03 −.10 (.10) .33 −.24 (.17) .17 −.03 (.16) .87 1.25 (.36) <.0001 −.007 (.16) .97 .30 (.26) .25
# Family members with asthma −.03 (.08) .02 −.43 (.14) .09 −.03 (.10) .73 −.45 (.14) .001 .02 (.14) .89 .27 (.17) .11 −.04 (.14) .79 −.18 (.29) .53
Asthma severity .03 (.08) .08 .09 (.14) .14 −.02 (.10) .84 .10 (.15) .49 −.11 (.15) .45 .74 (.26) .004 −.21 (.14) .13 .95 (.36) .0009
Illness representations .03 (.09) .006 .09 (.14) .04 .24 (.12) .04 −.008 (.14) .95 −.51 (.20) .009 .02 (.16) .91 .25 (.19) .18 −.41 (.27) .12
Social support .05 (.09) .008 −.20 (.15) .007 .05 (.10) .61 .08 (.15) .60 −.09 (.15) .53 −.44 (.19) .02 .29 (.15) .05 −.65 (.31) .04
Healthcare provider relationship −.02 (.09) .02 −.23 (.15) .13 −.05 (.11) .65 .18 (.15) .25 .09 (.18) .63 −.47 (.26) .07 .03 (.16) .84 .22 (.25) .39
Ethnic society immersion −.09 (.10) .02 −.37 (.16) .02 −.005 (.11) .96 −.03 (.18) .87 −.17 (.17) .32 −.28 (.30) .34 −.22 (.15) .14 .44 (.30) .14
Dominant society immersion .07 (.10) .06 .50 (.17) .09 .001 (.11) .99 .15 (.16) .37 .16 (.17) .35 −.04 (.15) .80 −.09 (.16) .59 −.71 (.38) .06
Caregiver depression .04 (.08) .007 −.20 (.15) .21 −.08 (.10) .41 .02 (.16) .90 −.22 (.16) .16 −.60 (.20) .003 .13 (.13) .33 −.32 (.25) .21
Illness-specific physical symptoms (caregiver) −.03 (.09) .01 .10 (.18) .04 .14 (.11) .22 −.57 (.17) .001 .05 (.16) .76 .83 (.25) .001 .09 (.17) .60 −.29 (.28) .30
Illness-specific irritability ( caregiver ) −.15 (.10) .03 −.08 (.20) .22 −.02 (.12) .84 −.004 (.19) .98 .21 (.18) .24 −.77 (.36) .03 .38 (.17) .02 .75 (.32) .02
Illness-specific panic-fear ( caregiver ) .30 (.11) .02 .19 (.18) .05 −.10 (.14) .45 .23 (.18) .21 −.15 (.20) .44 −.19 (.25) .44 −.13 (.19) .51 −.19 (.35) .59
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Discussion

Child illness-specific panic-fear prospectively predicted better pulmonary function and asthma control, and less acute healthcare utilization for asthma across a 1-year follow-up. Mexican children reported higher levels of illness-specific panic-fear and better asthma control than Puerto Rican children. Given the adaptive nature of illness-specific panic-fear, these findings highlight one potential mechanism to explore further to reduce disparities in asthma outcomes. Child self-report of panic-fear was a stronger predictor across several positive asthma outcomes than caregiver report of the child’s panic-fear, which predicted one measure (FEV1). Children are likely more aware of their internal state of how much anxiety they experience during asthma attacks and thus, asking the child directly may be the best assessment of the panic-fear construct. Support was not found for the hypothesis of panic-fear and ICS medication adherence. This suggests that other potential pathways besides medication adherence might explain the adaptive nature of panic-fear, such as avoidance of asthma triggers, perception of asthma symptoms, and timely management of asthma exacerbations.

The heightened vigilance associated with illness-specific panic-fear may lead children to be more aware of their asthma symptoms and lead to better strategies for asthma management. In contrast, low illness-specific panic-fear might lead to disregard of asthma symptoms and lapses in asthma management. Children who are more focused on their asthma during attacks might also be more motivated to pay closer attention in between asthma flare-ups. Children’s attention skills are a strong predictor of the ability to perceive asthma symptoms38. Illness-specific panic-fear and irritability in adults with asthma have been shown to influence provider decision making in the direction of stronger controller medications39, 40. Given the problem of under-prescription of ICS medications in ethnic minority children41, greater child illness-specific panic-fear might lead providers to prescribe a more optimal medication regimen in Latino children who appear more anxious about their asthma attacks. Our finding of greater child illness-specific panic-fear predicting less acute healthcare utilization for asthma is consistent with the prior findings that adolescents with asthma-related anxiety report being more likely to seek routine visits for asthma care15 and take steps to prevent and manage asthma symptoms16. The picture emerging across studies suggests that anxiety specifically about asthma elicits a more active and vigilant approach to asthma management.

These findings yield important clinical implications for providers. Children who have low anxiety during asthma attacks might be at risk for disregarding symptoms and having poor asthma control. Providers should pay close attention to children who have little or no fear of their asthma and high rates of acute healthcare utilization for asthma. Illness-specific panic-fear and its adaptive focus on disease management is a different construct from general measures of anxiety and anxiety disorders. In contrast, children with high general anxiety may have excessive restriction of activities, such as not participating in gym class despite provider encouragement of exercise. Providers should assess whether avoidance of triggers is asthma-related or anxiety-based.

Higher trait anxiety in children with asthma is associated with poor asthma control42. Panic disorder in adults is associated with worse asthma control and greater rescue medication use43, 44. Children with asthma have a higher prevalence rate of anxiety disorders than children without asthma45. Trait anxiety in children and adults with asthma is associated with over-perception of asthma symptoms, greater rescue medication use, and greater restriction of activities due to asthma46, 47. Anxiety can become maladaptive when there is persistent worry between asthma attacks that is excessive compared with objective measures of asthma control. A key distinguishing feature of illness-specific panic-fear is that the anxiety occurs specifically during asthma exacerbations. Interventions for anxious children with asthma should attempt to reduce trait anxiety while maintaining illness-specific panic-fear.

It is also important to distinguish between illness-specific panic-fear and the construct of illness-related distress, which refers to emotional distress that is a consequence of illness-related stressors48. Illness-related distress has been studied in chronic diseases besides asthma. For example, diabetes-related distress measures depressive symptoms linked with the burden of living with diabetes and it is associated with poor glycemic control49, 50. Illness-related distress and its focus on maladaptive depressive symptoms is in contrast to the adaptive anxiety that characterizes illness-specific panic-fear in asthma. Future research should examine illness-specific panic-fear in other pediatric chronic conditions to assess whether these findings are replicated.

In Latinos there are culturally sanctioned ways of expressing distress and anxiety, which can be part of the context of asthma attacks51, 52. An ataque de nervios is a cultural idiom of distress characterized by intense emotional reactions in connection to stressful events53. Ataques can provide Latino patients with a normalized venue to express anxiety and panic and in some cases, they might help children and adults cope with the source of trauma or stress such as an asthma attack51, 54, 55. A recent cultural adaptation of a behavioral treatment for anxiety in Latinos emphasized encouraging patients to discuss intense emotional reactions to asthma56. In the present study, the beneficial effects of illness-specific panic-fear in Mexican and Puerto Rican children might represent an adaptive expression of anxiety that is a culturally normative source for channeling panic and stress associated with asthma attacks.

The irritability subscale of the CASCL had mixed effects on asthma outcomes, and no a priori hypotheses were formulated for this subscale. Greater child-reported irritability during asthma attacks predicted lower FEV1 and worse asthma control in Mexican children. Given that irritability is a symptom of depression, this finding might reflect airway constriction via cholinergic pathways57, 58, which has been reported in children with asthma during depressive mood states and symptoms. However, greater caregiver-reported irritability in the child predicted better ICS medication adherence in both groups and less acute healthcare utilization for asthma in Puerto Rican children. Caregivers who perceive their children as more irritable and upset during asthma exacerbations may be more motivated to ensure their children are adherent to controller medications to prevent additional attacks. Better ICS adherence might not be protective specifically for cholinergically-mediated asthma exacerbations triggered by depressive or irritability symptoms. This might explain why illness-specific irritability was linked with worse pulmonary function despite better ICS adherence, as well as the difference between informants (caregiver versus self-report). Illness-specific irritability has received even less attention in the literature than panic-fear and these findings should be explored further.

The main limitation of this study was the large amount of missing adherence data due to families losing or forgetting to bring the Doser devices. Adherence data were analyzed for 64% of the families who were assigned a device. The low adherence rates in this study might actually underestimate the problem of medication adherence in asthma, as the families who failed to bring back or lost their devices might have the lowest rates of adherence. The lack of support for the ICS adherence hypothesis might be due to these missing data. Mexican caregivers primarily spoke Spanish and most Puerto Rican caregivers spoke English, which prevented teasing apart the role of language versus ethnicity in regards to illness-specific panic-fear.

This study highlights that illness-specific panic-fear in children with asthma has an adaptive role in asthma management across Latino subgroups. These findings replicate the adult literature and suggest that this construct of illness-specific panic-fear is highly relevant to children. Baseline measures of illness-specific panic-fear longitudinally predicted objective (FEV1) and subjective (ACT) measures of asthma control over the next year. This demonstrates the importance of asking children directly about their emotional experiences with asthma. Providers should be aware of distinctions between adaptive anxiety focused on asthma and general anxiety. It is important to continue identifying these behavioral pathways and develop interventions to reduce asthma disparities in ethnic minority, high-risk children.

Acknowledgments

Supported by the National Center for Complementary & Alternative Medicine (1R01AT005216 [to K.A.) and the National Institutes of Health Clinical and Translational Science Award (1UL1 TR001073).

Abbreviations:

ACT

Asthma Control Test

CASCL

Childhood Asthma Symptom Checklist

FEV1

forced expiratory volume in one second

SEM

structural equation model

Footnotes

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The authors declare no conflicts of interest.

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