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 Anxiety disorders occur in 28% to 49% of asthmatic children, but the type of disorder reported differs by study (1). The relation of anxiety disorder with asthma is not found in other psychiatric disorders, nor do anxious children have increased rates of chronic illnesses other than asthma (1), suggesting a highly specific relation. Possible explanations include that anxiety disorders are a secondary complication of asthma or that internalizing asthma burden leads to psychiatric illness. Another explanation may be a common genetic vulnerability to anxiety and asthma or a common environmental risk factor, such as lower socioeconomic status. Asthmatic children with anxiety or depression have lower self-esteem, social competence, and educational level than do asthmatic children without psychiatric disorders (1). Psychiatric disorder in asthmatics also predicts increased severity, length of stay in hospital, and use of steroid medication (2). Treatment of anxiety by CBT can reduce asthma presentations and hospital admissions if children present with more severe asthma than is evidenced on their lung function tests (3). Thus understanding comorbid anxiety and asthma has important treatment implications. This exploratory study compared asthmatic children with anxiety with a matched group with anxiety only on life stresses, depression, parental psychopathology, family history of psychiatric disorders, and perinatal factors. All have been linked to both anxiety and asthma, potentially representing common genetic and (or) environmental risks. We also investigated possible group differences in CBT response. We hypothesized that children with both anxiety and asthma can be distinguished from those with anxiety only on the basis of these characteristics and may respond differentially to CBT. MethodSubjects Subjects comprised 170 consecutively referred children aged 8 to 12 years and their parents in an anxiety disorders clinic of a large urban children’s hospital. All met criteria for at least one DSM-IV anxiety disorder. Children participated in 2 randomized controlled trials of CBT with the same protocol, examining the role of a concurrent parent group (4) and the role of group, compared with individual, administration (5). No significant differences in treatment outcome were found for the measures of interest (4,5), so results were not analyzed separately for parental involvement or modality of therapy. All participants provided permission for further study of the data, and we obtained study approval from the hospital research ethics board. Childhood asthma requiring treatment was reported for 36 children matched for age, sex, and specific anxiety diagnosis with 36 anxious children from the same data set but with no history of asthma. In cases of an exact match (2 occurred), we selected the nonasthmatic child by coin toss. Measures Psychiatrists administered a semistructured diagnostic interview based on the DICA-R separately to children and their parents. Consenting subjects meeting inclusion criteria completed the following: the RCMAS, the child report and parent’s report about the child, the CDI, the BSI for parent symptoms, and the Family and Household Form (derived from the Ontario Child Health Study) (4,5). We chose questionnaires with high internal consistency and test–retest reliability. Anxiety and depression measures were repeated posttreatment. Clinicians blind to treatment assignment completed the CGIS and the DSM-IV Multiaxial Evaluation Report Form for problems on Axis IV relevant to children. Analysis We used independent sample t tests to examine group differences on all measures. We applied the Bonferroni correction to control for type I error. We used repeated measures design to analyze group differences in treatment effects. If there was a significant interaction for group x time, we performed ANCOVA (with pretest score as the covariant) on the post-CBT scores. ResultsAge, sex, diagnostic distribution, treatment assignment, and socioeconomic status did not differ significantly by group. Children had significantly more perinatal complications (P = 0.001), especially problems at delivery (P = 0.008), with a trend toward more maternal substance abuse (P = 0.07), premature birth (P = 0.10), and low birth weight (P = 0.08); significantly higher total (P = 0.000) and psychological stressors (P = 0.02, although this was ns after Bonferroni correction), especially parent–child problems (P = 0.01); and significantly more hostile (P = 0.05), depressive (P = 0.04), and psychotic (P = 0.04) symptoms in their fathers (though ns after the Bonferroni correction), compared with children with anxiety only. Children with comorbid anxiety and asthma reported lower levels of depression (P = 0.03) and anxiety (P = 0.05) with a trend toward lower worry or oversensitivity (P = 0.07) and social concerns and (or) concentration (P = 0.09), compared with those with anxiety only. Children with comorbid anxiety and asthma had higher physiological anxiety by mothers’ reports (P = 0.034) and fathers’ reports (P = 0.084 for fathers’ reports, ns after the Bonferroni correction). There were no significant group differences on other measures. Both groups reported fewer symptoms of anxiety (P = 0.001) and depression (P = 0.000) posttreatment, with a trend toward higher CGIS scores (that is, less improvement) in those with comorbid anxiety and asthma (P = 0.09). There was a significant interaction for group ´ time for child-reported RCMAS total (P = 0.012) and physiological anxiety (P = 0.035) scores. ANCOVA on post-CBT total and physiological anxiety scores (keeping pre-CBT total and physiological anxiety scores, respectively, as covariates) revealed a trend toward less improvement in total (P = 0.075) and physiological anxiety (P = 0.102) in children with both asthma and anxiety, compared with those with anxiety only (See Figure 1 and Figure 2). There was no significant group x time interaction for mother-reported or father-reported RCMAS or depression scores.
_83.jpg) DiscussionIn this exploratory study, children with both anxiety and asthma were distinguished from their nonasthmatic peers with anxiety by levels of psychosocial stressors (especially parent– child problems), anxiety, depression, perinatal complications, and CBT outcomes. Consistent with previous adult studies (6), chi-square analysis showed that asthma is significantly more prevalent (c2 = 19.53, P < 0.001) among the study population (point prevalence 21%), compared with the general population (10.7% in individuals aged 0 to 19 years). Referral bias could also contribute to this finding. Child-reported anxiety and depression scores were significantly lower in children with anxiety and asthma, compared with anxiety only, pretreatment. Possible reasons include variation in genetic vulnerability (although no differences in family history of anxiety, depression, or other psychiatric illnesses was found), in environmental stresses (with illness-related family disruption being a larger contributor than anxiety symptoms in the comorbid group, compared with subjective feelings of anxiety in children with anxiety only), and in child characteristics (cognitive abilities and coping mechanisms were not examined). It is difficult to assess whether anxiety and depression is really lower in asthmatic children with comorbid anxiety or is merely underreported. Parents of children with comorbid anxiety and asthma reported more child physiological anxiety than did parents of children with anxiety only. It is unclear whether these symptoms are manifestation of their anxiety disorder, of asthma (with variability in asthma control), or of sympathomimetic asthma medications. Diagnosis and management of this comorbidity is difficult, since psychiatric and respiratory symptoms may be interrelated or overlapping (3). Consistent with previous studies implicating perinatal factors in the pathogenesis of asthma (7), higher perinatal issues were reported in anxious children with asthma than in children with anxiety only. There was a trend toward less improvement with CBT in children with anxiety and asthma on 2 independent measures (the CGIS and the child-reported RCMAS). Higher family dysfunction reported in children with anxiety and asthma could account for less favourable CBT outcomes. Parents of asthmatic children are reportedly more controlling and promote less independence in early childhood (8), possibly limiting treatment response. The occurrence of perinatal complications in comorbid children (often associated with lower cognitive performance) (7) may also limit CBT response. Despite the study’s limitations, it highlights the unique needs of children with both anxiety and asthma and the importance of tailoring CBT to those needs. Replication with larger, more culturally diverse samples is advocated. Funding and SupportThis work was supported by a Summer Scholarship to Ms Papneja by the Faculty of Medicine, University of Toronto. Data were collected during 2 larger treatment outcome studies: one supported by the Ontario Mental Health Foundation (Type A Grant) and the other unfunded. References1. Vila G, Nollet-Clemencon C, de Blic J, Mouren-Simeoni MC, Scheinmann P. Prevalence of DSM-IV anxiety and affective disorders in a pediatric population of asthmatic children and adolescents. J Affect Disord 2000;58:223–31. 2. Weil C, Wade S, Bauman L, Lynn H, Mitchell H, Lavigne J. The relationship between psychosocial factors and asthma morbidity in inner-city children with asthma. Pediatrics 1999;104:1274–80. 3. Park SJ, Sawyer SM, Glaun De. Childhood asthma complicated by anxiety: An application of cognitive behavioral therapy. J Pediatr Child Health 1996;32:183–7. 4. Mendlowitz S, Manassis K, Bradley S, Scapillato D, Miezitis S, Shaw B. Cognitive behavioral group treatments in childhood anxiety disorders: The role of parental involvement. J Am Acad Child Adolesc Psychiatry 1999; 38:1223–9. 5. Manassis K, Mendlowitz S, Scapillato D, Avery D, Fiksenbaum L, Freire M, and others. Group and individual cognitive behavior therapy for childhood anxiety disorders: A randomized trial. J Am Acad Child Adolesc Psychiatry 2002;41:1423–30. 6. Spinhoven P, Ros M, Westgeest A, van der Does AJW. The prevalence of respiratory disorders in panic disorder, major depressive disorder, and V-code patients. Behav Res Ther 1994;32:647–9. 7. Bracken MB, Belanger K, Cookson WO, Triche E, Christiani DC, Leaderer BP. Genetic and perinatal risk factors for asthma onset and severity: a review and theoretical analysis. Epidemiol Rev 2002;24:176–89. 8. Duff A. Psychological interventions in cystic fibrosis and asthma. Pediatr Respir Rev 2001;2:350–7. AuthorsManuscript received June 2005, revised, and accepted January 2006. 1. Senior Medical Student, University of Toronto, Toronto, Ontario. 2. Staff Psychiatrist, Hospital for Sick Children, Toronto, Ontario; Associate Professor, Department of Psychiatry, University of Toronto, Toronto, Ontario. Address for correspondence: Dr K Manassis, Department of Psychiatry, Hospital for Sick Children, 555 University Avenue, Toronto, ON. M5G 1X8 e-mail: katharina.manassis@sickkids.ca
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