Wolman disease

PURPOSE. To investigate the relationship of demographic asthma, family, and child factors with self concept in children with asthma.

METHODS. Data were collected twice approximately 4 years apart from both the affected children and their mothers (N =134) via interviews and self report questionnaire.

FINDINGS. Children who demonstrated more negative attitudes toward their illness, had less satisfaction with family relationships, and used more negative coping behaviors had the poorest self concepts. Over time, the greatest improvement in self concept occurred in children whose attitudes and satisfaction with family relationships improved and whose use of negative coping behaviors decreased.

CONCLUSIONS. Results suggest that some children with asthma, especially girls with severe asthma, appear to be at risk for poor self concept

Key words: Children, asthma, self concept

Asthma is the most common chronic illness of childhood, affecting approximately 5% to 15% of children under the age of 15 years (Lemanek, 1995). A chronic illness such as asthma imposes stress on children (Eiser & Berrenberg, 1995; Walsh & Ryan-Wenger, 1992) and can negatively affect their ability to successfully complete important psychosocial developmental tasks (Miller & Wood, 1991). Studies generally indicate that children with chronic illness are at risk for adjustment problems, such as negative self-concepts (Bennett, 1994; MacLean, Perrin, Gortmaker, & Pierre, 1992; Padur et al., 1995; Rutter, Graham, & Yule, 1970; Seigel, Golden, Gough, Lashley, & Sacker,1990). Even though studies comparing self-concept in children with asthma and their healthy peers have had inconsistent results, there is empirical evidence that children with asthma have poorer selfconcepts than control groups (Bennett).

It is especially important to study self-concept in adolescence because it is strongly linked with health behaviors (McCaleb,1995), and it is during this time of life that children assume more responsibility for their health care. In children with asthma, a positive self-concept has been associated with adaptive asthma-related self-management health behaviors in pre- and early-adolescent children (Hazzard & Angert, 1986). A poor self-concept can make it difficult for children with asthma to carry out needed self-management behaviors. Moreover, the transition into adolescence can be difficult for children with asthma as they assume more responsibility for selfmanagement of their condition (Eiser & Berrenberg, 1995; Miller & Wood,1991).

Some characteristics of asthma can jeopardize the development of a positive self-concept. For example, activity restrictions may lead to feelings of being different and isolated from peers (Eiser & Berrenberg, 1995; Miller & Wood, 1991; Osman, Russell, Friend, Legge, & Douglas,1993). The inability or reduced ability to participate in sports can affect both the physical and psychosocial development of children with asthma (Annett & Bender, 1994). In addition, there is often a need to watch constantly for sudden changes in asthma symptoms so treatment can begin as soon as possible. This constant self-monitoring has been linked to lower self-esteem in young adults with asthma (Ireys, Gross, WerthamerLarsson, & Kolodner,1994).

These problems make it important for nurses to be aware of factors related to poor self-concept in children with chronic asthma. An understanding of these factors will assist nurses in identifying those at risk for self-concept problems and in helping these adolescents and their families cope more successfully with asthma. As a part of a larger longitudinal study on adaptation to childhood epilepsy and asthma, a study was conducted to identify factors related to self-concept in children with chronic asthma.

Background

What factors place children with asthma at risk for a poor self-concept? Clinical intuition suggests that severity of the asthma might be a strong factor. Although the relationship between asthma severity and adjustment in childhood asthma has been studied frequently, findings have not been consistent. In a comparison of adolescents with asthma and a group of healthy adolescents, Silverglade, Tosi, Wise, and D'Costa (1994) found that anxiety, depression, and hostility were significantly related to disease severity; however, adolescents with mild asthma were similar to those of the healthy nonasthma group. Baron, Veilleux, and Lamarre (1992) found that overanxious children, who tended to be poorly adapted to life in general and to their asthma, were overly dependent on adults for treatment and received high levels of medication. Meijer, Griffioen, Van Nierop, and Oppenheimer (1995) found significantly poorer adjustment in children with uncontrolled asthma compared to those with controlled asthma.

In contrast, other studies have shown no relationship between disease severity and self-concept (Walsh & Ryan Wenger, 1992) or between disease severity and emotional and behavioral disorders in children with asthma (Meijer et al., 1995). Perrin, MacLean, and Perrin (1989) found no relationship between severity of illness and self-concept in children with asthma, although those with greater use of medication did have poorer adjustment than did those with moderate to little use of medication.

The relationship between asthma severity and adjustment is complex, and Perrin and colleagues (1989) point out that children at all levels of severity can have adjustment problems. The complexity of this relationship strongly suggests that other variables also affect selfconcept. Because self-concept is both an important indicator of overall psychosocial adjustment and an influence on health behavior in adolescents, this literature review focuses on three groups of factors related to self concept in children with asthma: demographic, family, and child.

Demographic Factors

Demographic factors that have been investigated in the adjustment to asthma context include socioeconomic status (SES), gender, and age. Findings on the relationship between SES and child self-concept have not been consistent. In general, demographic variables such as age, gender, and SES have not predicted adjustment problems in children with chronic illness (Wamboldt, Fritz, Mansell, McQuaid, & Klein, 1998). However, SES has been significantly related to social competence in children with asthma (MacLean et al., 1992), and to adjustment (Ireys et al., 1994), with higher SES being associated with better outcomes. Conversely, in other studies SES variables were not related to adjustment in children with asthma (Hamlett, Pellegrini, & Katz, 1992; Hazzard & Angert,1986; Perrin et al.,1989).

Research studies on adjustment in children with chronic asthma have not provided definitive information to determine if adjustment differs by gender (Howe, Feinstein, Reiss, Molock, & Bergen 1993). Of the studies that did investigate gender differences in children with asthma, some found no differences (MacLean et al.,1992; Perrin et al., 1989; Silverglade et al., 1994). However, Walsh and Ryan-Wenger (1992) found girls with asthma to be more distressed than boys, and Austin (1989) found girls with asthma to be more depressed. Gender differences in self-concept also have been found in the general population, with early adolescent girls having poorer self-concepts (Simmons & Blyth, 198, and early maturing females reporting lower self-esteem (Eccles et al., 1993). Age has been investigated as an independent variable in some studies of children with asthma. Hazzard and Angert (1986) found child age was related to asthma knowledge, but no studies could be found where age was significantly related to self-concept in adolescents with asthma. In general population adolescents, how-- even research suggests that the early adolescent years are a time of developmental decline in self concepts (Eccles, Midgley, & Adler,1984).

Family Factors

The family environment is important to the development of positive self-concepts in children with a chronic illness (Miller & Wood,1991). For all children, the family serves as the primary system for mediating life events. With chronic illness, the family environment has the potential to serve either as a buffer to reduce the effects of the stressors or as a contributor to the disruption caused by the disease process. When comparing families of children with asthma to families of healthy controls, parent-child communication has been found to be lower and parent anxiety higher (Brook & Shemesh, 1991) in families of children with asthma. One study reported monthly arguments between parents and children about asthma-related issues in 34% of such families (Hazzard & Angert, 1986). Family conflict, reduced family cohesion, and lower levels of social support have been related to poorer adjustment in children with asthma (Hamlett et al., 1992). Family connectedness also has been related to child emotional well-being (Wolman, Resnick, Harris, & Blum,1994).

Parental attitudes and perceptions-important components of the family environment-have been studied less frequently. The few studies investigating parental attitudes have focused on the use of preventive medication (Osman et al., 1993) and the relationship between the mother's critical attitude and the child's asthma severity (Schobinger, Florin, Reichbau, Lindemann, & Zimmer, 1993). No studies could be found that investigated the relationship between parental attitudes and child self-concept in asthma.

Child Factors

Children's perceptions about their condition have rarely been studied, even though perceptions have been predictive of behaviors in general population children and that children's perceptions (e.g., self-concept) influence the direction, strength, and persistence of their behaviors (Schunk, 1989). The one study (Silverglade et al., 1994) that measured beliefs and emotionality in adolescents with asthma found the children with asthma had more anxiety, depression, and hostility than a healthy control group. This study, however, did not examine relationships between these factors and selfconcept. Other authors have noted the lack of research on the role that children's attitudes play in the health experience, and recommended that more studies focus on this area (Hackworth & McMahon,1991).

The review of literature suggests that further investigation is warranted to identify factors associated with self-concept in children with asthma. Selection of variables for the present study was guided both by the literature and the Double ABCX Model of Family Adjustment and Adaptation (McCubbin & Patterson, 1983), which identifies factors that influence child adaptation to a chronic stressor such as asthma in a child. Four types of factors were selected to test for relationships to selfconcept in children with asthma: demographic, asthma, family, and child variables. The model posits that demographic and asthma variables of child age, gender, age of asthma onset, and severity are existing characteristics that are not amenable to change but can affect a child's self-concept. The family variables of stressors, resources, mother's satisfaction with family functioning, and attitude, and the child variables of satisfaction with family functioning, attitude, and coping are directly related and affect self-concept. The relative contributions of each of the variables were evaluated, both cross-sectionally and over a 4-year period.

Methods

The current study employed two data collections approximately 4 years apart. Data were collected from both affected children and their mothers. Initially (Time 1), medical records were examined to identify subjects who met the four criteria: (1) ages between 8 and 13 years; (2) taking daily prescribed medication for asthma for at least 1 year; (3) no other chronic health problems; and (4) an IQ of at least 70. After subjects were identified, the study was explained to the parents and children and they were asked to participate. Most data collection took place at the healthcare facilities before and after appointments. Interviews and self report questionnaires were completed independently by both parents and children. Subjects were contacted approximately 4 years after the first data collection for the second data collection (Time 2). At that time, most interviews were conducted in the subjects' homes following the same data-collection procedures. Data presented in this paper are from the mothers and children.

Sample

One hundred thirty-four children with asthma had data at baseline. Of these,106 subjects had usable data at both Time 1 and Time 2 (37 females, 69 males). The crosssectional analyses using all available data yielded results similar to that when using just the subset of 106 who had complete data.

Descriptive statistics are presented in Tables 1 and 2. Seventeen children were African American, 85 Caucasian, and 4 other races. The mean age at Time 1 was 10.2 years and at Time 2 was 14.3 years. Age of onset of asthma ranged from immediately after birth to 10 years (mean 3.0 years). The mean SES score at Time 1 was 60.7 and at Time 2 was 60.8, which represent average scores on the scale.

Instrumentation

Demographidasthma variables. Demographic data were obtained from mothers during a structured interview. A total SES score, based on the education of the mother and occupation of the highest earner in the household, was computed using the format designed by Green (1970). Additional data were collected on child sex, age, race, age of onset of asthma, and asthma severity. A total severity score was constructed by combining scores for frequency of asthmatic episodes, side effects of medication, hospitalizations for asthma, emergency room visits for asthma, and school absences. Scores ranged from 0 to 14 in both samplings.

Family variables. To reflect the family environment, stressors and adaptive resources were measured using instruments completed by the mothers in the study. Family stressors were measured by the Family Stressors scale, which assesses the stressful changes or life events experienced by the family (McCubbin & Thompson, 198. A "yes" or "no" response yielded scores from 0 to 12. Family adaptive resources were measured by the Family Inventory of Resources for Management (FIRM) (McCubbin & Thompson), a 69-item self-report instrument to elicit information on areas of resources used to adapt to stressful events. Mothers responded to questions using a four-point response scale from "not at all" to "well," with scores ranging from 42 to 156. Mother's attitude was measured by the Semantic Differential Attitude (SDA) scale, an instrument developed for this study by author Joan K. Austin. The SDA is a six-item self-report instrument that uses a format using seven bipolar adjectives developed by Osgood for measuring attitudes (Osgood, May, & Myron, 1975). Scores ranged from 1 to 7. Mother's satisfaction with family relationships was measured by the original Family APGAR (Smilkstein, 1978). The Family APGAR is a five-item instrument measuring mother's satisfaction with five aspects of family functioning: adaptation, partnership, growth, affection, and resolve. The instrument has a fivepoint response scale of "never" to "always," with scores ranging from 4 to 20.

Child variables. The child's attitude toward the medical condition was measured by the Child Attitude Toward Illness Scale (CATIS), a 13-item self-report scale that provides information on how they feel about their health condition using a five-point response scale from "never" to "always," with scores ranging from 1 to 5 (Austin & Huberty, 1993). Child coping was measured by the Coping Health Inventory for Children (CHIC) (Austin, Patterson, & Huberty, 1991), a 49-item instrument on which mothers reported how often their child demonstrated specific coping behaviors. Using a fivepoint response scale of "never" to "always," scores ranged from 1 to 4 for negative coping and 2 to 5 for positive coping. Child self-concept was measured using the Piers-Harris Self-Concept Scale (PH), an 80-item scale measuring children's perceptions of themselves that provided a total self-concept score and subscale scores measuring behavior, intellectual and school status, physical appearance, anxiety, popularity, and happiness and satisfaction (Piers,1984). The total score was used in the analyses as a global measure of self-concept. The PH uses a "yes" or "no" response scale, yielding scores ranging from 22 to 78. Child satisfaction with family relationships was measured using the revised Family APGAR (Austin & Huberty), a scale reworded to be understandable by children as young as 8 years old. Scoring is the same as described for the parent version, with scores ranging from 3 to 20 for this sample.

Data Analyses

The independent variables included in the analysis were demographic variables (age, gender, socioeconomic status), asthma variables (age of onset, asthma severity), family variables (family stressors, family resources, mother's attitude, mother's satisfaction with family relationships), and child variables (child's attitude, child's satisfaction with family relationships, child's positive and negative coping behaviors). The effect of each of these independent variables on the Piers-Harris Total Self-Concept Score was first evaluated by univariate analysis and then adjusted for other independent variables by multiple regression. Because some of the possible predictors were strongly correlated, a combination of strategies proposed by Mosteller and Tukey (1977) was used to eliminate some variables and combine others before multiple regressions were run.

Four subscale scores from the FIRM were used to measure family resources: Family Esteem and Communication, Family Mastery and Health, Extended Family Social Support, and Financial Well-Being. These subscale scores were correlated with each other at r = >=.31 at both time points. They were combined to create a Total Family Resource score. The internal consistency for this total score was beta = .74 at initial data collection, beta = .76 at the second collection. In measuring child coping, the subscales from the CHIC of Feels Different and Withdraws and is Irritable, Moody, and Acts Out were correlated at r = >=.64 at both collection times, and therefore, these variables were combined to create a Negative Coping score. Similarly, the CHIC subscale scores of Complies with Treatment, Develops Competence and Optimism, and Seeks Support were combined to create a Positive Coping score. The internal consistency for the negative coping and positive coping score was greater than beta = .70 at both time points. Correlations were assessed to determine the need for modeling separate linear regressions to evaluate potential competing models. Multiple linear regression was performed using the following strategy First, self-concept was regressed on age, gender, age of onset, and asthma severity to determine the amount of variance explained by the demographic and illness variables. In the second step, three separate multiple regression techniques (stepwise, forward, and backward) were used to identify the family and child factors contributing significantly in explaining variation in self-concept after adjusting for age, gender, age of onset, and asthma severity. In the third step, the interaction effect of gender-by-asthma severity was included in the model after adjusting for age, gender, age of onset, and asthma severity and the family and child variables found to be significant in Step 2. The results of backward, forward, and stepwise regression were compared to evaluate the stability of the model. Residual analyses and tolerance analyses were conducted to evaluate multicollinearity, outliers, and influential points.

Separate cross-sectional analyses were conducted evaluating variables related to self-concept at initial data collection and later using the above procedure. A similar procedure was conducted to evaluate variables contributing significantly to explaining variation in selfconcept changes. Independent variables included in this analysis were gender, child's age at second collection point, age at onset, change in asthma severity, change in family variables, and change in child variables. Two separate analyses, one using simple change scores (Time 2 minus Time 1 ) and one using normalized change scores to adjust for baseline level of the variable, were conducted. Normalized scores for a given variable were computed by dividing the subjects into three strata based on the tertiles for the baseline value, and then ranking their change scores within each stratum. The percentile of the rank score then represents the normalized score. A normalized change score of 20, for example, would indicate that within that subjects stratum, the change score was at the 20th percentile.

Results

For consistency purpose, data are reported only on the subset of 106 who had data at both times. The asthma severity at Time 1 ranged from 1 to 13 (mean 6.2), and at Time 2 from 0 to 14 (mean 4.5). Of the asthma subjects, 46% were having mild asthma at Time 1 versus 72% at Time 2; 24% had severe asthma at both times. The mean for self-concept at Time 1 was 62.2 and at Time 2 was 62.8, reflecting that the sample overall had similar self-concepts to those of a general population sample (McCaleb, 1995). The mean change in self-concept was very small (M = .54). The variation, however, was large (SD = 11.66), with the change in self-concept ranging from -28.0 to 28.5.

Demographic/Asttuna Factors

Results of the cross-sectional and change score uruvariate analyses are shown in Tables 3 and 4. There were no significant differences in self-concept between males and females at either time or for the change in selfconcept. There was a trend at both Time 1 and Time 2, however, for subjects with severe asthma to have poorer self-concepts (p = .08 and p = .06, respectively) than those with mild asthma. In evaluating the gender-by-severity interaction, there were no significant relationships at Time 1. At Time 2, however, there was a significant interaction (p = .04), reflecting that the relationship between severity and self-concept differed by gender. Boys had similar self-concept scores regardless of severity, whereas girls with severe asthma were found to have lower selfconcepts than all other groups. In evaluating the change in severity, girls who had severe asthma at both times had the greatest decrease in self-concept over time, although this was not statistically significant.

Age was significantly correlated with self-concept only at Time 1, although the correlation was low (r = -.20). Moreover, older children had poorer SES scores. Age at onset of asthma was not significantly correlated with self-concept at either time, nor with the change in self-concept. Socioeconomic status was not correlated with self-concept at either time, nor was change in SES correlated with change in self-concept.

Family Factors

Total family resources and mother's attitude had correlations with self-concept ranging between .20 and .25 at both time points, but changes in these variables were not significantly correlated with the change in self-concept. Family stress was not correlated with self-concept at either time. The change in family stress, however, was weakly correlated with the change in self-concept (r = -.20).

Child Factors

Attitude, satisfaction with family relationships, and negative coping behaviors had the strongest correlations with self-concept, ranging from .34 to .56 at both times. In addition, changes in children's attitudes toward asthma and their satisfaction with their family relationships scores were highly correlated with change in selfconcept. These results led us to include in the multiple regression all family and child variables with the exception of mother's satisfaction with family relationships. Correlations using normalized scores for the change analysis were similar to those presented above.

Multiple Regression Analysis

Multiple linear regression was performed with the child's self-concept as the dependent variable. Child age, gender, SES, age of asthma onset, asthma severity, child's gender-by-asthma severity interaction, family stress, family resources, mother's attitude, child's attitude, child's satisfaction with family relationships, and child's negative coping behaviors were included as independent variables. The negative coping score and the positive coping score were highly correlated at both time points (r = -.51, r = -.46). In addition, negative coping and total family resources were highly correlated at both times (r = -.52, r = -.51 ), and positive coping was correlated with total family resources at both times (r = .38, r = .46). Evaluation of the collinearity diagnostics reflected potential collinearity among negative coping, positive coping, and total family resources. Therefore, for the cross-sectional analyses as well as the change analysis, three separate regression analyses were conducted to evaluate the potential for competing models. For each of the regression analyses, self-concept was regressed first on age, gender, age of onset, and asthma severity. In the second step, the first regression analysis excluded both positive and negative coping due to their potential collinearity with total family resources. The second regression analysis excluded positive coping and total family resources due to their potential collinearity with negative coping, and the third regression analysis excluded negative coping and total family resources due to their potential collinearity with positive coping.

In each of the cross-sectional regression analyses, after adjusting for child's age gender, age of onset, and asthma severity at the specified time point, the forward, backward, and stepwise procedures each led to the retention of child's attitude and child's satisfaction with family relationships. Negative coping was the only other significant variable retained in any of the models (Table 5). Similarly, in the analysis of the change in self-concept it was the change in child's attitude, child's satisfaction with family, and child's negative coping that were retained in the model (see Table 5). These results were consistent cross-sectionally as well as for the change in self-concept. The variables of child's age gender, age of onset, and asthma severity accounted for 13% of the variation in self-concept at Time 1 and 7% at Time 2. These variables accounted for 4% of the variation for change in self-concept. Adding scores of child's attitude toward asthma, child's satisfaction with family relationships, and child's negative coping behaviors to the model increased the amount of variation explained to R^sup 2^ = .55, R^sup 2^ = .39, and R^sup 2^ = .33 for Time 1, Time 2, and the change, respectively Adding the gender-by-severity interaction term to the cross-sectional models and the gender-bychange in severity interaction term to the change models did not increase significantly the amount of variance explained by any of the models. However, at Time 2 the amount of variance was increased by 2% (p =.10) to R^sup 2^ = .41 and over time for the change data by 3% (p =.11) to R^sup 2^ =.36, reflecting that the gender-by-severity interaction may be an important factor.

In general, the results of the regression analyses reflect that at both data collection times children who had more negative attitudes, less satisfaction with family relationships, and were withdrawn and irritable had the poorest self-concepts. Furthermore, children whose attitudes toward asthma and satisfaction with their family relationships improved and who became less withdrawn and less irritable over time, had the greatest improvement in self-concepts over time. The results for the change analyses were the same whether using normalized change scores or raw change scores, therefore, only the raw change score analysis was presented.

Discussion

The purpose of this longitudinal study was to investigate the relationship of selected demographic, asthma, family, and child factors with self-concept in children with chronic asthma. Of specific interest was whether these factors were related to child self-concept at each point in time, and if the factors were related to the change in child self-concept over a 4-year period. The main finding of the study was that of the variables tested, child variables were most closely related to child self-concept. Children who demonstrated more negative attitudes toward their asthma, had less satisfaction with family relationships, and used more negative coping behaviors had the poorest self-concepts. Over time, the greatest improvement in self-concept occurred in children whose attitudes and satisfaction with family relationships improved and whose use of negative coping behaviors decreased. This major finding is discussed following a presentation of the contributions demographic and asthma variables made in understanding self-concept.

Demographic/Asthma Factors

Older children reported poorer self-concepts than younger children at the first data collection, a finding consistent with Eccles and colleagues (1993), who found younger children's perceptions of competence more positive than older children's perceptions. No relationship was found between self-concept and SES, a result similar to those found in other studies (Hamlett et al., 1992; Hazzard & Angert,1986; Perrin et al.,1989). Age of onset of asthma also was related to self-concept, but only at the first data-collection period. Asthma severity was related to self-concept, but girls in the severe asthma group consistently had poorer self-concepts than girls with mild asthma, boys with mild asthma, and boys with severe asthma. The findings that severe asthma was associated with poorer adjustment are similar to those found by MacLean and colleagues (1992). These authors, however, did not report results from an analysis for a gender-byseverity interaction effect. Our findings exploring this interaction effect indicate that boys did not demonstrate this self-concept linkage with asthma severity

Self-concept varied by gender, with girls having lower self-concepts than boys at Time 2. This difference, however, is accounted for by girls with severe asthma having lower self-concepts than all other groups. These findings on gender are similar to those in studies of children with diabetes and cerebral palsy, where adolescent girls had more problems with psychosocial adjustment than boys (LaGreca, Swales, IQemp, Madigan, & Skyler, 1995), and in general population-early adolescent children with girls having poorer self-concepts (Simmons & Blyth, 198. It might be that girls with a severe chronic condition are experiencing more stress and, therefore, are more at risk for self-concept problems than girls with mild asthma.

Family Environment Factors

Mothers' perceptions of the family were related to child self-concept. At both time periods, children with the highest self-concepts were in families that had the most resources, the least stress, and mothers with the most positive attitudes. Killeen (1993) found that children's self-esteem reflects their perception of how their parents evaluate them, as well as how the children evaluate themselves. The finding on family resources is consistent with other findings that show low social support to be related to poor adjustment in children with asthma (Hamlett et al., 1992) and, in general population adolescents, a supportive family was associated with positive self-esteem (Allen, Hauser, Bell, & O'Connor, 1994). The relationships of mother's attitudes and family stress to child self-concept are consistent with the relationships proposed in the Double ABCX Model. It should be noted, however, that family environmental factors were not independently significant when combined with other variables in the regression models.

Child Factors

One advantage of our study was the ability to evaluate how children's perceptions about their condition and their family relationships were related to self-concept, a focus not previously addressed in the literature. It is important to emphasize that child factors contributed most to understanding self-concept. Although this study design does not permit conclusions about the direction of effects, these findings suggest that children's perceptions about their asthma, their relationships with their families, and their coping behaviors are highly related to their self-concepts. Our results support the recommendation of Hackworth and McMahon (1991) that more studies need to focus on children's attitudes toward their health. In addition, future research should explore causal directions, especially the question of whether negative attitudes and coping behaviors lead to low self-concept, or if the causal influence is in the opposite direction.

Clinical Implications

The results of the study have several clinical implications for nurses working with children with chronic asthma and their families. The findings indicate that assessing children's perceptions regarding their asthma, satisfaction with their family relationships, and their coping behaviors is important. Children's perceptions are important because they are linked to behaviors, including health behavior and management of the asthma condition. Interventions may be needed that enhance children's positive coping behaviors, enhance positive attitudes, and increase satisfaction with family relationships. Interventions that address concerns and fears about having asthma also might help them develop more positive attitudes. Nurses might need to preferentially target girls who have severe asthma for participation in programs to specifically enhance self-concept, such as support groups and counseling. Additional strategies for enhancing positive attitudes might include providing role models, such as famous athletes or people who excelled in their pursuits despite an asthma condition.

The instruments used in this study could be useful assessment tools to obtain information about the child and family Children's perceptions about their asthma and their family relationships can be assessed using the Child Attitude Toward Illness Scale and the revised Family APGAR, respectively. These two instruments generally take less than 5 minutes for children to complete. If an extensive assessment of the family is warranted, the clinician can do a more comprehensive follow-up assessment with parents using Family Stressors, Family Inventory of Resources for Management, Family APGAR, and Semantic Differential Attitude Scale. These four instruments take approximately 15 to 20 minutes for a parent to complete. A thorough assessment should help identify areas where families need nursing interventions or referrals to other services. Assessment of family and child characteristics facilitates the identification of family strengths on which to build, such as developing competence or compliance with the medical regimen. Early assessment of children and families should be conducted to implement preventive interventions before problems develop, and to promote more positive child and family adaptation. Periodic assessment of the family and child should be conducted to enable the nurse to observe changes over time.

Providing correct information about asthma, treatments, and the reasons behind different diagnostic and medical procedures should help improve children's attitudes toward their asthma by decreasing their concerns about their condition. Although there is currently no cure for asthma, it can be controlled. Interventions that enhance self-management skills may help children and parents cope more positively. These interventions include identification of asthma triggers; recognition of early warning signs and symptoms; ability to monitor objectively lung function using a peak flow meter; and understanding of, and adherence to, the asthma action plan. Helping children develop more positive attitudes and coping mechanisms should help them feel better about themselves.

Clinicians can be instrumental in soliciting feelings from children and families. For instance, clinicians can provide opportunities such as support groups, where both feelings and information can be shared. Membership in a group, where peers have similar problems, concerns, and fears, facilitates sharing of knowledge, attitudes, and coping behaviors (both successful and unsuccessful) among members. Creer and colleagues (1988) found that parents who attended an asthma program acquired positive attitudes with respect to their children's asthma and their ability to manage the disorder. An additional benefit of attending groups or camps is reduction of the child's and family's feelings of isolation through contact with other families involved in the program.

Conclusion

The results of our study suggest that child variables were highly related to self-concept. Our findings suggest that clinicians should assess children's attitudes, satisfaction with their family relationships, and coping behaviors, in addition to assessing family environment and asthma factors. This holistic approach is needed to intervene effectively with children who have asthma and their families. Our findings also indicate that interventions should be designed to address negative attitudes about having asthma.

It is very important that future intervention studies focus on enhancing positive attitudes and coping, as well as improving family relationships. Future research should explore causal directions, especially the question of whether poor attitudes and coping behaviors lead to low self-concept, or if the causal influence is in the opposite direction. A limitation of the current study, that both the independent and dependent variables come from child self report data, can be addressed in future studies by using multiple raters on the variables of interest. Finally, differences in self-concept in children with asthma appear to be related to gender and severity. Such differences warrant further exploration in future studies.

Acknowledgments. This study was supported by a grant from the National Institute of Neurological Disorders and Stroke (PHS ROl 2416) awarded to Joan K. Austin.

References

Allen, J.I'., Hauser, S.T, Bell, K.L., O'Connor, T.G. (1994). Longitudinal assessment of autonomy and relatedness in adolescent-family interactions as predictors of adolescent ego development and selfesteem. Child Development, 65,179-194.

Annett, R.D., & Bender, B.G. (1994). Neuropsychological dysfunction in asthmatic children. Neuropsychology Review, 4, 91-115.

Austin, J.K. (1989). Comparison of child adaptation to epilepsy and asthma. Journal of Child and Adolescent Psychiatric and Mental Health Nursing, 2,139-144.

Austin, J.K., & Huberty, TJ. (1993). Development of the child attitude toward illness scale. Journal of Pediatric Psychology,18, 467-480.

Austin, J.K., Patterson, JAM., & Huberty, T.J. (1991). Development of the coping health inventory for children (CHIC). Journal of Pediatric Nursing, 6,166-174.

Baron, C., Veilleux, P, & Lamarre, A. (1992). The family of the asthmatic child. Canadian Journal of Psychiatry, 37,12-16.

Bennett, D.S. (1994). Depression among children with chronic medical problems: A meta-analysis. Journal of Pediatric Psychology,19,149-169.

Brook, U., & Shemesh, A. (1991). Parental attitude and role perception in families of asthmatic children. Padiatr Grenzgeb, 30, 253-259. Creer, 1L., Bac1dal, M., Burns, K.L., Leung, R, Marion, R-J., Miklich,

D.R., Morrill, C., Taplin, P.S., & Ullman, S. (1988). Living with asthma. I. Genesis and development of a self-management program for childhood asthma. Journal of Asthma, 2S, 335 - 362.

Eccles, J.S., Midgley, C., & Adler, T. (1984). Grade-related changes in the school environment: Effects on achievement motivation. In J.G. Nicholls (Ed.), The development of achievement motivation (pp. 283-331). Greenwich, Cr. JAI Press.

Eccles, J.S., Midgley C., Wigfield, A., Buchanan, C.M., Reuman, D., Flanagan, C., & MacIver, D. (1993). Development during adolescence: The impact of stage-environment fit on young adolescents' experiences in schools and in families. American Psychologist, 48, 90-101.

Eiser, C., & Berrenberg, J.L. (1995). Assessing the impact of chronic disease on the relationship between parents and their adolescents. Journal of Psychosomafic Research, 39,109-114.

Green, L.W. (1970). Manual for scoring socioeconomic status for research on health behavior. Public Health Report, 85, 815-827.

Hackworth, S.R., & McMahon, RJ. (1991). Factors mediating children's health care attitudes. Journal of Pediatric Psychology,16, 69-85.

Hamlett, K.W, Pellegrini, D.S., & Katz, K.S. (1992). Childhood chronic illness as a family stressor. Journal of Pediatric Psychology, 27, 33-47.

Hazzard, A., & Angert L. (1986). Knowledge, attitudes, and behavior in children with asthma. Journal of Asthma, 23, 61-67.

Howe, G.W., Feinstein, C., Reiss, D., Molock, S., & Berger, K. (1993). Adolescent adjustment to chronic physical disorders-1. Comparing neurological and non-neurological conditions. Journal of Child Psychology and psychiatry, 34, 1153 - 1171.

Ireys, H.T., Gross, S.S., Werthamer-Larsson, L.A., & Kolodner, K.B. (1994). Self-esteem of young adults with chronic health conditions: Appraising the effects of perceived impact. Journal of Development fr Behavioral Pediatrics, 15, 449-415.

Killeen, M.R (1993). Parent influences on children's self-esteem in economically disadvantaged families. Issues in Mental Health Nursing, 14, 323-336.

LaGreca, A.M., Swales, T., Klemp, S., Madigan, S., & Skyler; J. (1995). Adolescents with diabetes: Gender differences in psychosocial functioning and glycemic control. Child Health Care, 24, 61-78.

Lemanek, K.L. (1995). Commentary: Childhood asthma. Journal of Pediatric Psychology, 20, 423-427.

MacLean, W.E., Perrin, J.M., Gortmaker, S., & Pierre, C.B. (1992). Psychological adjustment of children with asthma: Effects of illness severity and recent stressful life events. Journal of Pediatric Psychology,17,159-ln.

McCaleb, A. (1995). Global and multidimensional self-concept as a predictor of health practices in middle adolescents. Journal of Child and Adolescent Psychiatric Nursing, 8,18-26.

McCubbin, H.L, & Patterson, JAM. (1983). The family stress process: The double ABCX model of adjustment and adaptation. Marriage and Family Review, 6, 7-37.

McCubbin, H.L, & Thompson, A.I. (Eds). (1987). Family assessment inventories for research and practice. Madison, WI: Family Stress Coping and Health Project.

Meijer, A.M., Griffioen, R.W., van Nierop, J.C., & Oppenheimer, L. (1995). Intractable or uncontrolled asthma: Psychosocial factors. Journal of Asthma, 32, 265-274.

Miller, B.D., & Wood, B.L. (1991). Childhood asthma in interaction with family, school, and peer systems: A developmental model for primary care. Journal of Asthma, 28,405-414.

Mosteller, F, & Tukey, J.W (1977). Data analysis and regression. Reading, MA.- Addison-Wesley

Osgood, C.E., May, WH., & Myron, M.S.L. (1975). Cross-cultural universals of affective meaning. Urbana, IL: University of Illinois Press.

Osman, L.M., Russell, LT., Friend, J.A.R., Legge, J.S., & Douglas, J.G. (1993). Predicting patient attitudes to asthma medication. Thorax, 48, 827-830.

Padur, J.S., Rapoff, M.A., Houston, B.K., Barnard, M., Danovsky M., Olson, N.Y, Moore, W.V, Vats, TS., & Lieberman, B. (1995). Psychosocial adjustment and the role of functional status for children with asthma. Journal of Asthma, 32, 345-353.

Perrin, J.M., MacLean, WE., & Perrin, E.C. (1989). Parental perceptions of health status and psychologic adjustment of children with asthma. Pediatrics, 83, 26-30.

Piers, E.V. (1984). Piers-Harris Children's Self-Concept Scale (Revised Manual). Los Angeles: Western Psychological Services.

Rutter, M., Graham, P, & Yule, W. (1970). The prevalence of psychiatric disorder in neuro-epileptic children. A neuropsychiatric study in childhood. Clinics in Developmental Medicine, 35/36,175-185.

Schobinger, R, Florin, L, Reichbau, M., Lindemann, H., & Zimmer, C. (1993). Childhood asthma: Mothers' affective attitude, mother-child interaction and children's compliance with medical requirements. Journal of Psychosomatic Research, 37, 697-707.

Schunk, D.H. (1989). Self-efficacy and achievement behaviors. Educational Psychology Review, 1, 173 - 208.

Seigel, W.M., Golden, N.H., Gough, J.W, Lashley, M.S., & Sacker, LM. (1990). Depression, self-esteem, and life events in adolescents with chronic diseases. Journal of Adolescent Health Care,11, 501-504.

Silverglade, L., Tosi, D.J., Wise, I'.S., & D'Costa, A. (1994). Irrational beliefs and emotionality in adolescents with and without bronchial asthma. Journal of General Psychology,121,199-207.

Simmons, RG., & Blyth, DA. (1987). Moving into adolescence: The impact of pubertal change and school context. Hawthorne, NY Aldine De Gruyter. Smiltein, G. (1978). The family APGAR: A proposal for a family function

test and its use by physicians. Journal of Family Practice, 6,1231-1239.

Walsh, M., & Ryan-Wenger, N.M. (1992). Sources of stress in children with asthma. Journal of School Health, 62, 459-463.

Wamboldt, M.Z., Fritz, G., Mansell, A., McQuaid, E.L., & Klein, R.B. (1998). Relationship of asthma severity and psychological problems in children. Journal of the American Academy of Child and Adolescent Psychiatry, 37,943-950.

Wolman, C., Resnick, M.D., Harris, Lj., & Blum, R.W. (1994). Emotional well-being among adolescents with and without chronic conditions. Journal of Adolescent Health, 15,199-204.

Author contact: topaz@iupui.net, with a copy to the Editor. Poster@uta.edu

Angela M. McNelis, PhD(C), RN, Gertrude A. Hunter, MHS, Marti Michel, MSN, RN, Judy Hollingsworth, MSN, RN, Howard Eigen, MD, and Joan K. Austin, DNS, RN

Angela M. McNelis, PhD(C), RN, is Project Director, Indiana University School of Nursing, Indianapolis; Gertrude A. Huster, MHS, is a biostatistiean, Indiana University School of Medicine, Indianapolis; Marti Michel, MSN, RN, is a Clinical Nurse Specialist, Clarian Health Partners and Methodist Hospital of Indiana, Indianopolis; Judy Hollingsworth, MSN, RN, is a Clinical Nurse Specialist, Clarian Health Partners and Riley Hospital for Children, Indianapolis; Howard Eigen, MD, is Professor, Indiana University School of Medicine, Indianapolis; and Joan K. Austin, DNS, RN, is Distinguished Professor, Indiana University School of Nursing, Indianapolis, IN.

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