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. Author manuscript; available in PMC: 2022 Nov 28.
Published in final edited form as: Hosp Pediatr. 2021 Nov;11(11):1272–1280. doi: 10.1542/hpeds.2020-000950

Depression and Anxiety Symptoms During and After Pediatric Asthma Hospitalization

Haley Morin 1, Diana Worsley 1, Xuemei Zhang 1, Jennifer Faerber 1, Amy R Pettit 2, Chén C Kenyon 1,3, Stephanie K Doupnik 4,3
PMCID: PMC9703356  NIHMSID: NIHMS1843153  PMID: 34670757

Abstract

Objective:

Depression and anxiety are common in children with asthma, and asthma hospitalization is an underutilized opportunity to identify mental health concerns. We assessed depression and anxiety symptoms during asthma hospitalization and 1–2 months post-discharge.

Patients and Methods:

This prospective cohort study included children ages 7–17 years hospitalized for asthma exacerbation. Participants completed the self-report Patient Reported Measurement Information System (PROMIS®) Depression and Anxiety symptom scales (T score mean=50, standard deviation [SD]=10) during hospitalization and 1–2 months after discharge. Higher scores indicate more symptoms and/or greater severity. We compared patients’ scores during hospitalization and at follow-up using paired t-tests, and examined individual patients’ depression and anxiety symptom trajectories using a Sankey diagram.

Results:

Among 96 participants who completed the study, 53% had elevated symptoms of depression, anxiety, or both either during hospitalization or after discharge. During hospitalization, 38% had elevated depression symptoms and 45% had elevated anxiety symptoms. At post-discharge follow-up, 18% had elevated depression symptoms and 20% had elevated anxiety symptoms. We observed all possible symptom trajectories: symptoms during hospitalization that persisted (especially if both depression and anxiety symptoms were present), symptoms that resolved, and symptoms that were present at follow-up only.

Conclusions:

Just over half of youth hospitalized for asthma exacerbation experienced depression and/or anxiety symptoms during hospitalization or at follow-up. Patients who had both depression and anxiety symptoms during hospitalization were the most likely to have persistent symptoms at follow up. Screening at both time points may be useful to identify mental health symptoms.

Background

Asthma is one of the most common reasons for pediatric hospitalization,1 and 16% to 25% of children and adolescents with asthma also have symptoms consistent with a mood or anxiety disorder.2,3 While depression and anxiety symptoms may or may not be accompanied by a formal mental health diagnosis, these symptoms are associated with poorer control of asthma4 and higher risk of needing emergency care for asthma exacerbation.5 Given the known link between physical and mental health and the importance of early detection of mental health concerns,6 asthma hospitalization may offer an important window of opportunity to identify depression and anxiety symptoms. Prior research has shown that mental health symptoms and conditions are not reliably identified and documented during pediatric hospitalizations,7,8 and little is known about how common such symptoms are or how likely they are to persist after discharge.

In studies examining the impact of chronic illness on children’s emotional well-being, depression and anxiety symptoms have been found to vary in conjunction with intensified treatment. For example, one small study showed that children with cancer experience more depression and anxiety symptoms before and during scheduled rounds of chemotherapy than after chemotherapy is completed.9 Similarly, children with sickle cell disease were found to experience worse depression and anxiety symptoms during hospitalization for a vaso-occlusive episode than after the episode resolved.9,10 However, given the severe and complex nature of cancer and sickle cell disease and the fact that these studies were small, it is not clear whether these findings generalize to children with other pediatric conditions that may require hospitalization, such as asthma.

Understanding the degree to which depression and anxiety symptoms affect children hospitalized for asthma exacerbation can inform care during hospitalization (e.g., developing care pathways to address mental health symptoms), and understanding whether symptoms persist after hospital discharge can help guide planning for post-hospitalization follow-up care. More systematic attention to mental health may also have potential to reduce post-discharge asthma symptoms, unscheduled returns for urgent care, readmissions, and loss of time at school for children and time from work for parents. The objective of this study was to assess depression and anxiety symptoms among children and adolescents hospitalized for an asthma exacerbation at two time points (during the hospitalization and 1 to 2 months after hospital discharge) and to examine symptom trajectories.

Methods

Design, Setting, and Study Participants

We conducted a prospective cohort study in a large children’s hospital in the mid-Atlantic US that serves as a quaternary referral center and urban community hospital. Patients were eligible to participate if they were at least 7 years old and under 18 years old and had been admitted to an inpatient unit with an asthma exacerbation. Patients were ineligible to participate if they were admitted to the intensive care unit, were in custody of social services, or had intellectual disability or cognitive impairment that prevented them from completing study questionnaires. Patients were also ineligible to participate if they or their consenting caregiver did not have sufficient English proficiency to complete the informed consent process and questionnaires, as interpreter services were not available to the study team.

Study Procedures

Trained research assistants screened patients admitted for asthma exacerbation for eligibility upon transfer to an Emergency Department observation unit or medical floor. Research assistants approached eligible participants and their parent(s) or legal guardian (hereafter “caregivers”) when available during hospitalization, including during evening hours (5 to 10 pm) and on weekends. The research assistant explained the study and completed a written informed consent process with caregivers and obtained assent from all child participants. In accordance with state law, the research assistant also obtained informed consent for use of mental health information from participants aged 14 to 17 years, and from the caregiver for children younger than 14 years. The study was approved by the hospital’s Institutional Review Board.

All child participants completed standardized self-report scales (described below), and caregivers completed a self-report questionnaire and demographic form. All questionnaires were completed on a tablet using Research Electronic Data Capture (REDCap).11 Child participants were compensated $20 for completing study questionnaires in the hospital.

Starting in the 6th week following hospital discharge, a trained research assistant contacted the patient and caregiver to complete follow-up questionnaires (i.e., the same pediatric self-report scales completed at baseline) via telephone or emailed questionnaire, depending on each participant’s stated preference. The research assistant made three attempts to contact the family. No participant actively withdrew from the study, but participants who were not reached after three contact attempts and who had not completed questionnaires by 12 weeks post-discharge were considered lost to follow-up. Child participants who completed the follow-up questionnaire were compensated an additional $20.

Study Measures

Mental health symptom measures.

Child participants completed the pediatric self-report Patient-Reported Outcome Measurement Information System (PROMIS®) 8-item Depression Scale, short form version 1.0, and pediatric self-report PROMIS® 8-item Anxiety Scale, short form version 1.0, which were developed as part of a National Institutes of Health initiative.12–14 The questionnaire asks how frequently the child has experienced a given symptom in the past 7 days, with response options on a 5-point scale (never, rarely, sometimes, often, always), and scores are converted from a raw summary score to a scaled score centered around a population norm of 50 (i.e., T scores). In keeping with recommendations, depression and anxiety symptom scores at the population norm of 50 or lower were classified as normal and scores of 51–55 were classified as mildly elevated, 56–65 as moderately elevated, and > 65 as severely elevated.15 The PROMIS® Depression and Anxiety instruments measure symptom severity (as opposed to examining whether a child meets criteria for a psychiatric diagnosis), and prior research has shown that symptom scores change over time in response to changes in overall health status.9,10,16–19 For child self-reported PROMIS® depression scores, a change of 3 points in the symptom score corresponds to a clinically meaningful change.20 For anxiety, no specific cut-points have been defined; however, a general guideline for interpretation of PROMIS® measures is that a change of 0.5 SD corresponds to a clinically meaningful change.15

Additional electronic health record (EHR)-based measures.

The intensity of the child’s asthma exacerbation was categorized based on a hospital-specific asthma treatment pathway as severe (requiring continuous albuterol) or moderate (requiring intermittent albuterol) at the time of Emergency Department presentation.21 Asthma exacerbation severity was obtained from structured data fields in the hospital’s EHR. To capture asthma treatment status in the period following the hospitalization, we determined whether the patient was prescribed or directed to take an inhaled corticosteroid at hospital discharge, based on discharge prescriptions and communication with the discharging clinician. Documented mental health or psychiatric diagnoses were obtained from the patient’s diagnosis and problem lists in the EHR, which captured active diagnoses associated with the hospitalization and with prior outpatient visits that took place within the hospital’s clinical network (i.e., affiliated treatment sites).

Data Analyses

We summarized demographic and clinical characteristics using medians, frequencies, interquartile ranges, and percentages. We converted raw depression and anxiety symptom scores to scaled scores (T=50, SD=10) based on guidelines in the PROMIS® manual.22 In analyses of patient trajectories, scores were dichotomized as either normal or elevated in order to retain power due to small cell sizes among the subgroups of patients with elevated scores and to reduce multiple comparisons. Symptom scores for depression and anxiety that fell at or below a population norm of 50 were classified as normal and scores >50 were classified as elevated.

We compared in-hospital and follow-up depression and anxiety scores using paired t-tests and used the Pearson correlation coefficient to examine the relationship between depression and anxiety symptoms during hospitalization and again at follow-up. We also examined patient trajectories by capturing the number of patients falling into each mental health symptom severity category at baseline compared to follow-up, and constructed Sankey diagrams using the networkD3 package in R to visually display individual patient trajectories. All other analyses were conducted in Stata 15. P-values <0.05 were considered statistically significant.

Results

We approached 190 patients during hospitalization and enrolled 134 (71%). Of those, 38 (28%) were lost to follow-up, resulting in a final sample of 96 child-caregiver dyads. Mean time from date of discharge to completion of follow-up questionnaires was 45.9 days (SD=22.4). There were no significant differences at baseline in age, sex, race, ethnicity, Medicaid insurance status, or depression and anxiety symptoms during hospitalization for those who did and did not complete follow-up questionnaires (P>0.05 for all comparisons).

Table 1 shows demographic and clinical characteristics for the enrolled sample. The sample included a high proportion of patients (91%) who were Black, Hispanic, or other race/ethnicity (not white). The most common insurance type was Medicaid (71%), and a range of family incomes were represented. Among caregivers, 93% reported completing high school or beyond, and 32% graduated college. Among study participants, 69% were classified in the Emergency Department as having a severe asthma exacerbation requiring continuous albuterol. The median hospital length of stay was 2 days (interquartile range 1–2).

Table 1.

Characteristics of 135 Children Hospitalized for Asthma Exacerbation

Demographic characteristics N (%)
Age, Median (IQR) 10 (9–13)
  7–11 years 82 (61)
  12–17 years 53 (39)
Female 76 (56)
Race/Ethnicity
  Non-Hispanic Black 91 (67)
  Non-Hispanic white 12 (9)
  Hispanic 19 (14)
  Other 13 (10)
Medicaid Insurance 94 (70)
Parent Education
  Did not graduate high school 6 (4)
  Graduated high school 85 (63)
  Graduated college 41 (30)
  Not reported 3 (2)
Family Income
  < $25,000 47 (35)
  $25,000-$49,999 35 (26)
  $50,000-$99,999 20 (15)
  $100,000 and greater 15 (11)
  Not reported 18 (13)
Clinical characteristics N (%)
Hospitalization or ED visit for asthma in past year (at same hospital) 53 (39)
Severity of asthma exacerbation at ED presentation
  Moderate (intermittent albuterol) 42 (31)
  Severe (continuous albuterol) 93 (69)
Prescribed an inhaled corticosteroid at discharge 59 (44)
Mental health diagnosisa 19 (14)
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a

Determined from patient’s diagnosis and ICD codes in the problem list section of the electronic health record, at the time of the index hospitalization.

Note: some totals do not sum to 100% due to rounding.

During hospitalization, 37% of the 135 children who enrolled in the study had depression scores in the elevated range and 47% had anxiety scores in the elevated range. Depression and anxiety scores were positively correlated during hospitalization (r=0.74). Table 2 shows the proportion of children with scores classified in the normal, mild, moderate, and severe depression and anxiety symptom ranges at baseline.

Table 2.

Severity of Depression and Anxiety Symptoms during Pediatric Asthma Hospitalization

N Mean (SD) N (% within age group)
Normal Elevated
Mild Moderate Severe
Depression 135 46.2 (9.4) 85 (63) 23 (17) 26 (19) 1 (1)
  Age 7–11 82 48.0 (10.0) 43 (52) 17 (21) 21 (26) 1 (1)
  Age 12–17 53 43.4 (7.8) 42 (79) 6 (11) 5 (9) 0 (0)
             
Anxiety 135 48.2 (10.4) 72 (53) 24 (18) 34 (25) 5 (4)
  Age 7–11 82 50.0 (10.5) 36 (44) 19 (23) 3 (4) 4 (5)
  Age 12–17 53 45.5 (9.8) 36 (68) 5 (9) 11 (21) 1 (2)
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Note: Depression and anxiety symptoms were measured using the corresponding PROMIS® symptom scales. Scaled scores of 50 or lower were classified as normal; 51–55, mildly elevated; 56–65, moderately elevated; > 65, severely elevated, in keeping with recommended interpretation of the scales.

Table 3 shows comparisons of depression and anxiety symptoms during hospitalization and at follow-up, and the change in scores over time, for the 96 patients who completed follow-up measures. The mean within-person change in depression symptoms from hospitalization to follow-up was −5.5 points (SD=10.8, P <0.001), representing a clinically meaningful reduction in symptoms. The mean within-person change for anxiety symptoms was −8.3 points (SD=11.8, P <0.001), also representing a clinically meaningful reduction in symptoms. Depression and anxiety scores were positively correlated at post-discharge follow-up (r=0.62).

Table 3.

Depression and Anxiety Symptoms During and After Pediatric Asthma Hospitalization (N=96)

During Hospitalization At Post-Discharge Follow-Up Mean within-person difference (SD) P
Mean score (SD) Patients with elevated symptoms,
n (%)		 Mean score (SD) Patients with elevated symptoms,
n (%)
Depression 46.3 (9.7) 36 (38) 41.0 (7.4) 17 (18) −5.5 (10.8) <0.001
Anxiety 47.9 (10.9) 43 (45) 39.6 (9.2) 19 (20) −8.3 (11.8) <0.001
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Note: Depression and anxiety symptoms were measured using the corresponding pediatric self-reported PROMIS® symptom scales. Children with a T score > 50 were considered to have elevated symptoms, in keeping with recommended interpretation of the scales. Follow-up was approximately 1–2 months after discharge.

The Supplement table shows the number of patients with an elevated (>50) depression or anxiety symptom score at each time period, and Figure 1 illustrates these data with patient symptom trajectories for the 96 patients who completed follow-up measures. All possible trajectories were present: no elevated symptoms at hospitalization or follow-up, persistent elevated symptoms, elevated symptoms that resolved over time, and new symptoms that emerged over time. Overall, 27% of patients had elevated depression or anxiety symptoms during hospitalization but no longer had elevated symptoms at post-discharge follow-up, whereas 9% of patients had no significant symptoms during hospitalization but reported elevated symptoms at follow-up.

Figure 1. Depression and Anxiety Symptom Trajectories, Asthma Hospitalization to Post-Discharge Follow-Up.

Figure 1.

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Boxes on the left side reflect symptoms during hospitalization. Categories indicate normal range (T < 50) or elevated (T > 50) scores on pediatric self-reported PROMIS® symptom scales. Boxes on the right side reflect scores at 1 to 2 months after discharge. Lines between boxes represent trajectories for individual participants.

We also examined findings among subgroups based on their reporting of depression or anxiety symptoms during hospitalization. Among the subgroup of 28 patients initially reporting both depression and anxiety during hospitalization, 18% continued to report both depression and anxiety symptoms 1 to 2 months after discharge; 18% reported either depression or anxiety; and 64% reported no symptoms at follow-up. Among the subgroup of 45 patients with no reported depression or anxiety symptoms during hospitalization, 20% had elevated symptoms after discharge.

Discussion

We found that more than half (53%) of the children and adolescents hospitalized for an asthma exacerbation in our study reported elevated depression or anxiety symptoms during hospitalization, despite the fact that only 11% had a documented mental health condition. At 1 to 2 month follow-up, 26% of patients reported elevated depression or anxiety symptoms, indicating that some symptoms had resolved by that time. Patients reporting elevated symptoms of both depression and anxiety during hospitalization were most likely to report persistent depression and anxiety symptoms at follow-up.

Our findings are consistent with previous studies showing that depression and anxiety symptoms are common among children with asthma2,7,23 and expand our understanding of mental health symptom burden in children hospitalized for asthma exacerbation. Most prior research has focused on documentation of diagnoses of mood and anxiety disorders rather than measuring symptom burden. Our findings demonstrate that many children and adolescents experience mental health symptoms during hospitalization, and most of them had no formal mental health diagnoses. Our study sample was predominantly composed of Black and Hispanic patients insured by Medicaid, who are at higher risk of asthma and asthma hospitalization24,25 and may also be at risk for mental health disparities.26 Thus, our results help extend findings from prior research to priority populations that have been historically under-represented in clinical trials and other research.27–29 Further, the finding that acute mental health symptoms were common may be of particular interest for the general pediatric hospitalist, since children requiring hospitalization for other issues, particularly those with an acute on chronic presentation such as irritable bowel syndrome or diabetic ketoacidosis, may experience similar distress.

Regulatory bodies increasingly require mental health screenings during medical encounters30 and hospitals are beginning to compare performance on mental health measures. Our findings suggest that hospital-based screening initiatives are likely to detect acute symptoms and reactions to acute general medical illness. As with physical pain, young people are likely to benefit from assistance managing their anxiety and mood symptoms as part of their hospital care, regardless of whether those symptoms persist beyond their stay or are part of a more chronic mood or anxiety disorder. Several hospital-based coping toolkits exist for children and parents,31–34 and future research could investigate whether implementing these tools more broadly could benefit children with elevated depression and anxiety symptoms during hospitalization for asthma or other conditions. Prior work shows that when mental health consultation is needed, involving mental health consultants earlier reduces hospital length of stay.35 When mental health specialists are not available, a prior qualitative study with hospitalized young people experiencing mental health symptoms found that they valued compassionate clinicians, staying occupied with activities, physical comforts like warm blankets, and knowing what to expect, suggesting that general patient-centered care can reduce distress.36 Future research to investigate what depression and anxiety symptom thresholds warrant specific interventions or mental health consultation could help ensure that patients with elevated symptoms receive the right support at the right time.

It is also important to note that not all children who struggle with mental health symptoms during an acute hospitalization will have persistent symptoms over time. Our finding that a substantial portion of children no longer had elevated symptoms at post-discharge follow-up is consistent with prior research showing that depression and anxiety symptom burden are responsive to changes in a child’s physical asthma symptoms.19 Yet 20% of the children in our sample who did not report elevated depression and anxiety symptoms during hospitalization did report elevated symptoms 1 to 2 months after discharge, which could suggest that some children had a delayed response to the stress of acute illness exacerbation and hospitalization (i.e., medical post-traumatic stress37,38) or that they experienced a new stressor. Given that we observed various trajectories, a process to monitor symptoms post-hospitalization is likely to be important, both to avoid overtreatment and because new or persistent depression and anxiety symptoms influence overall well-being and can affect adherence to asthma therapies.3,39 This highlights the importance of educating families about when to seek follow-up mental health care (e.g., if symptoms persist or new or serious symptoms such as suicidal thoughts emerge) and also points to the value of incorporating mental health specialists into hospital-based and outpatient medical care teams. When this is not possible, families are likely to benefit from messaging that acknowledges that coping with a chronic health condition can be challenging, and that anxiety and depression symptoms are common and treatable.

Future research to understand the reasons for elevated depression and anxiety symptom during and after asthma hospitalization can inform clinical care to help address these symptoms. Questions of particular importance for future research will include: understanding risk factors for elevated depression and anxiety symptoms, whether hospital-based interventions can improve depression and anxiety symptoms, how ongoing asthma symptoms post-hospitalization correlate with asthma self-management and overall well-being, and what constitutes optimal post-discharge outpatient care for mental health symptoms.

This study has several limitations. First, in keeping with routine hospital practice, we relied on EHR-documented history of psychiatric conditions rather than formal psychiatric evaluations to identify children with a history of a mental health diagnosis, and the accuracy of this information may vary due to variations in clinical practice.7 In addition, whereas the EHR captured diagnostic information for children receiving primary care or specialty mental healthcare within the hospital’s care network, we did not have access to information from outside providers. Second, we did not have information on whether patients received mental health treatment after discharge. As a result, we are unable to determine whether symptoms that resolved did so due to treatment or did so without treatment. Third, we offered participants the option to complete follow-up rating scales by telephone or email. This was to maximize convenience for families, but it introduces a possibility of measurement bias if mode of completion influenced disclosure of symptoms. A study of mode effects in self-report vs. telephone-administered PROMIS® pediatric scales found high correlations between scores obtained with the two modes, with small differences that would not be expected to affect overall interpretation of results.40 Fourth, we were not able to include families who preferred a language other than English because trained interpreters were not available to the study team. Fifth, a high proportion of families were lost to follow-up. The most common reason for failed telephone follow up was that the phone numbers provided to the study team were for pre-paid no-contract cellular phones, and the phone numbers were no longer in service at follow-up. Future studies may benefit from anticipating and troubleshooting potential contact difficulties in advance, such as acquiring contact info from multiple caregivers.

Conclusion

Anxiety and depression symptoms are common during hospitalization for acute asthma exacerbation and persist after discharge in many patients. Our findings suggest that efforts to assess symptom burden during hospitalization could be most effective at helping patients if they are accompanied with a process to monitor symptoms post-hospitalization.

References

  • 1.Leyenaar JK, Ralston SL, Shieh M-S, Pekow PS, Mangione-Smith R, Lindenauer PK. Epidemiology of pediatric hospitalizations at general hospitals and freestanding children’s hospitals in the United States. J Hosp Med 2016;11(11):743–749. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Goodwin RD, Messineo K, Bregante A, Hoven CW, Kairam R. Prevalence of probable mental disorders among pediatric asthma patients in an inner-city clinic. J Asthma 2005;42(8):643–647. [DOI] [PubMed] [Google Scholar]
  • 3.Richardson LP, Lozano P, Russo J, McCauley E, Bush T, Katon W. Asthma symptom burden: relationship to asthma severity and anxiety and depression symptoms. Pediatrics 2006;118(3):1042–1051. [DOI] [PubMed] [Google Scholar]
  • 4.Ciprandi G, Schiavetti I, Rindone E, Ricciardolo FL. The impact of anxiety and depression on outpatients with asthma. Ann Allergy Asthma Immunol 2015;115(5):408–414. [DOI] [PubMed] [Google Scholar]
  • 5.Bardach NS, Neel C, Kleinman LC, et al. Depression, anxiety, and emergency department use for asthma. Pediatrics 2019;144(4):e20190856. [DOI] [PubMed] [Google Scholar]
  • 6.American Psychological Association. Child and Adolescent Mental and Behavioral Health Resolution 2019. Available at: https://www.apa.org/about/policy/child-adolescent-mental-behavioral-health. Accessed March 18, 2021.
  • 7.Doupnik SK, Henry MK, Bae H, et al. Mental health conditions and symptoms in pediatric hospitalizations: a single-center point prevalence study. Acad Pediatr 2017;17(2):184–190. [DOI] [PubMed] [Google Scholar]
  • 8.Doupnik SK, Feudtner C, Marcus SC. Family report compared to clinician-documented diagnoses for psychiatric conditions among hospitalized children. J Hosp Med 2017;12. [DOI] [PubMed] [Google Scholar]
  • 9.Reeve BB, Edwards LJ, Jaeger BC, et al. Assessing responsiveness over time of the PROMIS(®) pediatric symptom and function measures in cancer, nephrotic syndrome, and sickle cell disease. Qual Life Res 2018;27(1):249–257. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Dampier C, Jaeger B, Gross HE, et al. Responsiveness of PROMIS® Pediatric Measures to hospitalizations for sickle pain and subsequent recovery. Pediatr Blood Cancer 2016;63(6):1038–1045. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11.Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009;42(2):377–381. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.DeWalt DA, Gross HE, Gipson DS, et al. PROMIS(®) pediatric self-report scales distinguish subgroups of children within and across six common pediatric chronic health conditions. Qual Life Res 2015;24(9):2195–2208. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13.Varni JW, Magnus B, Stucky BD, et al. Psychometric properties of the PROMIS ® pediatric scales: precision, stability, and comparison of different scoring and administration options. Qual Life Res 2014;23(4):1233–1243. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14.Irwin DE, Stucky B, Langer MM, et al. An item response analysis of the pediatric PROMIS anxiety and depressive symptoms scales. Qual Life Res 2010;19(4):595–607. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15.PROMIS® Score Cut Points. Available at: https://www.healthmeasures.net/score-and-interpret/interpret-scores/promis/promis-score-cut-points. Accessed March 18, 2021.
  • 16.Reeve BB, McFatrich M, Mack JW, et al. Expanding construct validity of established and new PROMIS Pediatric measures for children and adolescents receiving cancer treatment. Pediatr Blood Cancer 2020;67(4):e28160. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17.Curtis S, Brandow AM. Responsiveness of Patient-Reported Outcome Measurement Information System (PROMIS) pain domains and disease-specific patient-reported outcome measures in children and adults with sickle cell disease. Hematology Am Soc Hematol Educ Program 2017;2017(1):542–545. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18.Brenner EJ, Long MD, Mann CM, et al. Responsiveness of the Patient-reported Outcomes Measurement Information System (PROMIS) Pediatric Measures to changes in disease status and quality of life among children and adolescents with Crohn’s disease. Inflamm Bowel Dis 2021;27(3):344–351. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19.Howell CR, Thompson LA, Gross HE, Reeve BB, DeWalt DA, Huang IC. Responsiveness to change in PROMIS(®) Measures among children with asthma: a report from the PROMIS(®) pediatric asthma study. Value Health 2016;19(2):192–201. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.Thissen D, Liu Y, Magnus B, et al. Estimating minimally important difference (MID) in PROMIS pediatric measures using the scale-judgment method. Qual Life Res 2016;25(1):13–23. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 21.Kenyon CC, Fieldston ES, Luan X, Keren R, Zorc JJ. Safety and effectiveness of continuous aerosolized albuterol in the non-intensive care setting. Pediatrics 2014;134(4):e976–982. [DOI] [PubMed] [Google Scholar]
  • 22.PROMIS® Scoring Manuals Health Measures, Northwestern University. https://www.healthmeasures.net/index.php?option=com_content&view=article&id=180&Itemid=994. Accessed May 5, 2020. [Google Scholar]
  • 23.Richardson LP, Russo JE, Lozano P, McCauley E, Katon W. The effect of comorbid anxiety and depressive disorders on health care utilization and costs among adolescents with asthma. Gen Hosp Psychiatry 2008;30(5):398–406. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 24.Akinbami LJ, Moorman JE, Simon AE, Schoendorf KC. Trends in racial disparities for asthma outcomes among children 0 to 17 years, 2001–2010. J Allergy Clin Immunol 2014;134(3):547–553.e545. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 25.Sullivan K, Thakur N. Structural and social determinants of health in asthma in developed economies: a scoping review of literature published between 2014 and 2019. Curr Allergy Asthma Rep 2020;20(2):5. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 26.Alegria M, Vallas M, Pumariega AJ. Racial and ethnic disparities in pediatric mental health. Child Adolesc Psychiatr Clin N Am 2010;19(4):759–774. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 27.Wechsler ME, Szefler SJ, Ortega VE, et al. Step-up therapy in black children and adults with poorly controlled asthma. N Engl J Med 2019;381(13):1227–1239. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 28.Mak ACY, White MJ, Eckalbar WL, et al. Whole-genome sequencing of pharmacogenetic drug response in racially diverse children with asthma. Am J Respir Crit Care Med 2018;197(12):1552–1564. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 29.White MJ, Risse-Adams O, Goddard P, et al. Novel genetic risk factors for asthma in African American children: precision medicine and the SAGE II Study. Immunogenetics 2016;68(6):391–400. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 30.Wissow LS, Brown J, Fothergill KE, et al. Universal mental health screening in pediatric primary care: a systematic review. J Am Acad Child Adolesc Psychiatry 2013;52(11):1134–1147.e1123. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 31.Marsac ML, Weiss D, Kohser KL, et al. The Cellie Coping Kit for Children with injury: initial feasibility, acceptability, and outcomes. Child Care Health Dev 2018;44(4):599–606. [DOI] [PubMed] [Google Scholar]
  • 32.Marsac ML, Klingbeil OG, Hildenbrand AK, et al. The Cellie Coping Kit for sickle cell disease: initial acceptability and feasibility. Clin Pract Pediatr Psychol 2014;2(4):389–399. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 33.Hill DL, Carroll KW, Snyder KJG, et al. Development and pilot testing of a coping kit for parents of hospitalized children. Acad Pediatr 2019;19(4):454–463. [DOI] [PubMed] [Google Scholar]
  • 34.Doupnik SK, Hill D, Palakshappa D, et al. Parent coping support interventions during acute pediatric hospitalizations: a meta-analysis. Pediatrics 2017;140(3). [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 35.Bujoreanu S, White MT, Gerber B, Ibeziako P. Effect of timing of psychiatry consultation on length of pediatric hospitalization and hospital charges. Hosp Pediatr 2015;5(5):269–275. [DOI] [PubMed] [Google Scholar]
  • 36.Worsley D, Barrios E, Shuter M, Pettit AR, Doupnik SK. Adolescents’ experiences during “boarding” hospitalization while awaiting inpatient psychiatric treatment following suicidal ideation or suicide attempt. Hosp Pediatr 2019;9(11):827–833. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 37.Brosbe MS, Faust J, Gold SN. Complex traumatic stress in the pediatric medical setting. J Trauma Dissociation 2013;14(1):97–112. [DOI] [PubMed] [Google Scholar]
  • 38.Kassam-Adams N, Butler L. What do clinicians caring for children need to know about pediatric medical traumatic stress and the ethics of trauma-informed approaches? AMA J Ethics 2017;19(8):793–801. [DOI] [PubMed] [Google Scholar]
  • 39.Di Marco F, Verga M, Santus P, et al. Close correlation between anxiety, depression, and asthma control. Respir Med 2010;104(1):22–28. [DOI] [PubMed] [Google Scholar]
  • 40.Magnus BE, Liu Y, He J, et al. Mode effects between computer self-administration and telephone interviewer-administration of the PROMIS(®) pediatric measures, self- and proxy report. Qual Life Res 2016;25(7):1655–1665. [DOI] [PMC free article] [PubMed] [Google Scholar]

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