Sources of Stress in Children with Asthma

Sources of Stress in Children with Asthma Michelle WaIsh, Nancy M. Ryan-Wenger

ABSTRACT: Children experience stressors related to self concept and school, family, and peer relationships. This study of children with asthma determined their perceptions of the frequency and severity of stressors they experience other than their asthma. Children with asthma are similar to peers with regard to perceptions of stressors. Teachers, health professionals, and parents should consider children with asthma as normal children who have an additional source of stress - a chronic illness. Results suggest perceptions of most stressors relate more strongly to gender-role development than to asthma. Children with asthma rated feeling left out of the group and not being good enough at sports as serious stressors. School personnel could be instrumental in encouraging management and prevention of exercise-induced asthma and promote all children’s full participation in physical activities. Further examination of the relationship between stress and asthma is needed. (J Sch Health. 1992;62( 10):459-463)

hildren experience stressors related to self-concept C and school, family, and peer relationships.’q2 Both adaptive and maladaptive patterns of coping with stressors develop early in childhood and may continue into adulthood.) Because maladjustment to normal stressors of childhood may lead to academic, behavioral, and somatic problem^,^ teachers, school nurses, and other school health professionals should be concerned about the effect of stress on children’s health and school per- formance.

Where children with chronic illness are concerned, stress has been examined primarily within the context of having an illness such as asthma, rather than within the context of an otherwise normal ~ h i l d . ~ - ~ The effect of stress on a chronically ill child’s adjustment remains a matter of contr~versy.~J In a review of the chronic illness literature, Pless and Nolan9 concluded that children who experience symptoms of chronic physical disorders are at greater risk for psychosocial maladjustment than other children their age. While some stress related to a chronic illness such as asthma can be minimized through proper symptom management, it is important also to focus on the extent to which “normal” stressors of childhood can be controlled to decrease the potential for maladj ustment .

Children with asthma were selected for this study because asthma, the most common chronic illness in childhood, accounts for more than 25% of all school absences.’oJ1 Professionals know little about the sources of stress that children with asthma experience, other than their chronic disorder, or the extent to which their stressors are similar or different from other children their age. School nurses and teachers may be instrumental in helping modify school-related and peer- related stressors.

Lazarus’ stress-coping paradigm and principles of life-span developmental psychology provided the theoretical basis for this study. Stressors are defined as “specific environmental and internal demands and con- flicts among them, which tax or exceed a person’s

Michelle Walsh, PhD. RN. Assistant Professor, Dept. of Family and Community; and Nancy M. Ryan- Wenger, PhD, RN, Associate Pro- fessor, Dept. of Life Span Process, College of Nursing, The Ohio State University, I585 Neil Ave.. Columbus, OH 43210. This article was submitted April 13. 1992, and revised and accepted for publica- tion Ju1.v 13. 1992.

resources . ” I 2 Daily hassles related to normal developmental tasks are expected, and often prove a more important source of stress than major life events.” An important aspect of the stress-coping process is primary appraisal, which requires an individual’s own evaluation of stressors, including the degree of threat (severity), frequency of occurrence, and extent to which stressors can be modified. Life-span developmental perspective emphasizes normative events and accomplish- ments anticipated during growth and development. For example, some sources of children’s stress related to normal developmental tasks of the school-age period, which include development of self-esteem and a positive self-concept, self-regulation of behavior,lJ development of an internalized reward system,I6 and ability to forego immediate gratification for long-term goals. I ’ Peer group acceptance is important to school-age children, and by fourth grade, children rely on friends as one of the most important sources of social and moral support. l o

Some studies of children’s stress are based on parents’, clinicians’, or teachers’ perceptions of what is stressful to ~ h i l d r e n . ~ ~ . ~ ~ However, evidence suggests that children’s perceptions about sources of stress differ dramatically from adults’ inferences. 2 1 Lazarus and Folkman” emphasize that stressors are only as stressful as the individual perceives them to be; thus, at a con- scious or preconscious level, cognitive appraisal of a stressor is an integral part of the stress-coping process and mediates the response. AtkinsZ2 noted more research is needed that focuses on children’s perspective of stress. The stress of having a chronic illness has been s t ~ d i e d , ~ , ~ ~ but not the extent to which children with chronic illnesses perceive the otherwise normal stressors of childhood.

METHODS This study of children with asthma determined their

perceptions of the frequency and severity of stressors they experience other than their asthma. Children’s perceptions of stressors were examined with respect to principles of life-span development.

Subjects All children (n = 103) attending the Central Ohio

Lung Association’s Camp A-OK in June 1991 were in- ~~

Journal of School Health December 1992, Vol. 62, No. 10 4 5 9

vited to participate in the study. Four parents declined to allow their children to participate, and 14 children (all male) chose not to complete the instrument. The sample (n = 84) included 48 boys and 36 girls, ages 8-13 years (x = 10.5, SD = 1.6). Distribution of subjects by age, grade, gender, ethnicity, and asthma severity based on criteria from the National Heart, Lung, and Blood Institute24 are in Table 1 . All children who participated in the study have documented allergies to environmental agents. The children’s parents were employed in a variety of occupations, representing all levels of socioeconomic status according to Duncan’s Socioeconomic Index.25 The parents of 19 children (23%), 15 of whom were biracial, Black, or Hispanic, were unemployed and received Aid to Families with Dependent Children.

Instrumentation The Feel Bad Scale (FBS) is the only instrument that

operationally defines sources of stress from the perspective of children ages 8-12.! The stressors represent daily occurrences, or “hassles.” Other available m e a s u r e ~ ’ ~ of children’s stressors focus on major life events that occur infrequently, such as the death of a parent, hospitalization, or parent’s loss of a job. The 20 FBS items were scored on a scale of 1-5 for Frequency (how often it happens) and Severity (how bad it did or would make you feel). Scores of both scales can range from 20 to 100, and higher scores indicate more frequent and severe stressors than low scores. More than 2,400 chil- ren comprised the sample for psychometric testing of the FBS. Internal consistency of the total FBS scores for the reliability sample was 0.82. Internal consistency alpha coefficients for this sample of children with asthma were 0.87 for the Severity scale and 0.78 for the Frequency scale.

Convergent validity was supported by significant differences in mean FBS scores for children’s self- ratings of four psychological states: sad, like yourself, worry, and tired (p c .001). Though the FBS items were identified by children in 1984, they are representative of categories identified by 141 children in a study pub- lished in 1989.26 The FBS was reviewed for current applicability by a panel of experts in child health and child development. The experts agreed the items repre- sented common stressors experienced by school-age children in the 1990s. Additional items recommended by the experts were similar to existing items, such as “nobody likes me” is similar to feeling left out of the group, and “doing homework” is similar to not having homework done on time. Therefore, it was determined that the FBS was suitable for the purposes of this study.

Procedures Data were collected in small groups during a quiet

period after lunch. Children’s assent to participate was obtained at the time of data collection. Instrument items were read to children ages 8-9, while older children completed the instruments at their own pace. Group scores on age, gender, ethnicity, and severity of illness were compared with t-tests and analysis of vari- ance. Stressors were rank ordered according to item mean scores for frequency and severity. Mann-Whitney

460 Journal of School Health December 1992, Vol. 62,

U tests were used to compare the frequency and severity of specific items according to gender.

RESULTS Distribution of mean Feel Bad Scale Severity and

Frequency Scale scores indicates a wide range of scores that are normally distributed, with means in the moderate range (Table 2). No significant differences occurred in Severity scale scores for age, ethnicity, or severity of illness; however, girls recorded significantly higher scores than did boys (p = 0.003). Mann-Whitney U tests indicated girls rated the following stressors significantly more severe than boys: feeling sick (p = 0.002), being overweight or bigger (p = 0.003), not being able to dress the way you want to @ = 0.041), feeling left out of the group (p = 0.008), not being good enough at sports (p = 0.049), being late for school (p = 0.012), and feeling like your body is changing (p = 0.016). Mean Frequency Scale scores did not differ according to age, gender, ethnicity, or severity of illness. However, item analysis revealed that one of the stressors (feeling left out of the group) occurred significantly more often for girls than for boys (p = 0.023).

Items from the Severity scale were rank ordered according to each item’s mean score (Table 3). Children with asthma indicated that, for them, the five most severe stressors were: being pressured to try something new that you really don’t want to try, having parents separate, feeling left out of the group, feeling sick, and having parents argue in front of you. Rank order of Fre- quency scale items revealed that the five most frequently experienced stressors were: feeling sick, not having enough money to spend, having nothing to do, having parents argue in front of you, and not being good enough at sports (Table 3).

~

DISC USSl ON Children who participated in the study were not dif-

ferent from nonparticipants with respect to demo-

Table 1 Demographic Characteristics of the Sample

Vsrlsble Glrlr Boys Total x Age

8 2 4 6 7 9 10 11 21 25

10 7 12 19 23 11 6 9 15 18 12 7 4 11 13 13 4 8 12 15

2 3 4 7 0 3 7 10 17 20 4 8 17 25 30 5 8 5 13 15 6 5 5 10 12 7 5 5 10 12 8 0 2 2 2

Black 7 14 21 25 White 25 32 57 68 Hispanic 0 1 1 1 Biracial 4 1 5 6

Grade Completed

Elhnicily

Asthma Severity Mild 7 4 11 13 Moderate 22 33 55 67 Severe 7 11 18 20

No. 10

graphic variables. The sample included a range of socioeconomic status, asthma severity, care providers, and treatment plans. Children who attend asthma camps have moderate to severe asthma and require daily medication to remain symptom free.” Most school-age children diagnosed with asthma also have allergies; exposure to allergens exacerbates their asthma.z8 There- fore, though the sample was not randomly selected, it may be considered fairly representative of the population of children with asthma.

Severity and Frequency mean scores for this sample of children with asthma were not significantly different (Severity: t=0.06, p e 0.99; Frequency: t=0.07, p e 0.99) from those of Lewis’ original sample,’ which suggests children with asthma experience similar levels of stress as their peers, and perceive severity of the stressors in much the same way. As expected, “feeling sick” was the most frequently reported stressor of children with asthma, and it also was the most frequently occur- ring stressor reported by Lewis.’ Apparently, the experience of illness of any kind is perceived as stressful to all children.

Some stressors reported by the children with asthma as most severe such as being pressured to try something new and having parents separate, were not experienced very frequently. These results are similar to those reported by Lewis,’ in which these two stressors were rated highest in severity by children who never experienced them, and next highest by children to whom the stressors happened all the time. As Lewis noted, “for intensely negative experiences, the anticipation of the event actually is worse than the event.”’

Regarding gender differences in perceptions of stressors, girls with asthma recorded significantly higher mean severity scores than boys. This result could reflect different parental expectations or societal influences, in which girls are more willing to report anxious feelings than are boys. Researchers note girls are more willing to report anxious feelings than are boys.z9

In keeping with principles of developmental psychology, school-age girls’ perceptions about not being good enough at sports are typical of their interest at this age in experimenting with activities more frequently associ- ated with boys.’O In this sample, in addition to rating the stressor of feeling left out of the group more seriously than boys, girls experienced that stressor more often than boys. Perhaps boys traditionally join groups of same-gender peers, while girls are less likely to join groups, but tend to pair off with one or more intimate friends.” Beginning in childhood, and continuing into adolescence, girls are more likely to socially ostracize each other than are boys.32 Perceptions of frequency and severity of some stressors by children with asthma are more related to gender-role development than to their illness condition.

Stressors rated more severely by girls than boys - being overweight or bigger than others your age, not being able to dress the way you want to, and feeling like your body is changing - provide indications of earlier maturity of girls than boys.32 In addition, girls’ con- cerns about appearance may relate to “modeling and re- inforcement of sex-typed responses.”32 Teachers, health professionals, and parents should consider children with

asthma as normal children with an additional source of stress - a chronic illness.

Children with asthma perceived the items feeling left out of the group and not being good enough at sports as serious stressors. Children may attribute not being able to keep up with their peers to their asthma condition. Because identification with peers is an important developmental milestone, any difference is perceived as a problem at a time when sameness is preferred. Experts note that school personnel are ill-equipped to deal with and often frightened of asthma episodes, therefore are likely to bar children with asthma from participation in

School nurses can educate teachers and coaches about management of asthma episodes and prevention of exercise-induced asthma,34 and thus decrease concern about full participation of children with asthma in physical activities.

Children with asthma reported that parents argued in front of them frequently. All families experience a certain amount of conflict, but families with a child with a chronic illness typically face an additional source of conflict, that of disagreeing about cause, treatment, and prognosis of the i l lnes~.’~ Because parents do not want their children to experience exacerbations of asthma, they may set stronger limits on the children’s behavior than they would otherwise. As a result, these children may argue with parents about house rules more frequently than other healthy children. Despite frequent absences from school due to asthma, parents and teachers should not expect less from children with asthma, since their illness does not affect their cognitive ability to accomplish appropriate grade-level work.

Table 2 Distribution of Feel Bad Scale Scores by Total Sample and Gender

Total Sample Boys Girls Subrcrle Range Mean SO Range Mean SO Range Mean SO

Frequency 25-72 43 7 10 4 25-62 42 1 10 1 28-72 4 5 8 10 6 Severity 24-87 57 5 16 7 24-59 52 9 16 2 24 63 63 8 1 5 4 ’

‘Girls had significantly higher Seventy scores fhan boys (p = 0 003)

~~

Table 3 Rank-Order of Stressors According to Perceptions of Severity

and Freauencv Strerror Being pressured to try something new, like a cigarette

Having parents separate Feeling lefl out of the group Feeling sick Having parents argue in front 01 you Not spending enough time with Mom or Dad Not getting along with your teacher Not having enough money to spend Moving from one place to another Not being good enough at sports Being overweight or bigger than others your age Not having homework done on time Changing schools Not being able to dress the way you want to Pressured to gel good grades Having nothing to do Fighting with your parents about house rules Being smaller than others your age Feeling like your body is changing Being late for school

that you really don’t want to try

Severity Frequency

t 20 2 19 3 6 4 1 5 4 6 7 7 12 8 2 9 14

10 5 11 15 12 10 13 18 14 16 15 13 16 3 17 11 18 8 19 9 20 17

Journal of School Health December 1992, Vol. 62, No. 10 461

I M PLI CAT10 N S FOR I NT E RV E NT I ON Though asthma is a physiological syndrome, evi-

dence suggests symptoms may be exacerbated by emotional stress. School nurses can assess specific stressors relevant to the individual child by interview or by using a structured instrument like the Feel Bad Scale. By attending to sources of stress identified by children, the nurse or teacher may modify or remove specific stressors. In addition, children can be encouraged to modify some of their own stressors under their control. When stressors cannot be controlled by adults or children themselves, stress-reduction techniques such as relaxation exercises, positive reappraisal, and distraction, can be introduced.

Asthma often is triggered by allergen exposure, weather changes, and physical exercise.24 Children may have medication prescriptions for bronchodilators and other pharmacological agents which prevent exacerbations if given prior to exposure or exercise. Teachers and coaches can remind children to medicate themselves at least 10 minutes prior to events known to exacerbate asthma. Written communication from parents and phy- sicians which specifies measures to be initiated when symptoms occur also are recommended.

Participation in sports and other physical activities should be encouraged for all school-age children because it is important for cardiovascular health as well as self-esteem. When children with asthma are unable to keep up with peers as players, alternate assignments that are equally important might include scorekeeper or timekeeper. Careful examination of positions within specific sports activities may reveal certain positions are better tolerated than others. For example, in hockey, the goalie remains fairly stationary; in softball or base- ball, pitcher, catcher, and first baseman positions typically require less running than other positions.

CONCLUSION Results from this study should be interpreted with

caution because the subjects came from a special camp for children with asthma and from one geographic area. Yet, little reason exists to expect their experiences and perceptions of stressors are unique. Similar studies with other samples of children with asthma are recommended, perhaps with an examination of stressors over time. Since the FBS has not been used extensively by other researchers, comparison of findings with similar popula- tions cannot be made. An empirical test of the current applicability of FBS items is recommended to further examine validity of the instrument. For example, replication of the original Lewis study’ would be appropriate to determine if new sources of stress are identified by children.

Veracity of children’s responses about stressors were not tested by other methods of measurement, such as parents’ perceptions, but research has shown that children can report accurately on questions of fact.I6 No research examines children’s reasoning regarding response selection, that is, what criteria do they use to determine that a stressor is “really bad” versus “not bad?” Though children with asthma experience stressors similar to all children, the relationship between stressors and

episodes of asthma attacks needs to be examined. For example, severity and frequency stressor scores could predict the severity and frequency of asthma attacks in children.

Parents, teachers, and school health professionals should acknowledge that children with asthma or other chronic illnesses experience the same stressors as their peers. A variety of techniques can be used to assist in normalizing their school experience. Further research is needed to determine the extent to which these otherwise normative stressors may compound the emotional adjustment difficulties that children with asthma already experience.

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Job Opportunities Intervention Specialists - The Division of Adolescent and School Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control, is seeking three inter- ventionists with broad experience in comprehensive school health programs, with specific content expertise in one of the following three areas:

reduction of tobacco use among adolescents; reduction of sedentary lifestyles among children and adoles-

cents; or reduction of dietary patterns among children and adolescents

that contribute to development of chronic diseases. Each individual will work in their area of content specialty and

wili provide technical assistance regarding appropriate and effective intervention strategies and research methods that support implementation of comprehensive school health programs to state and local education and/or health agencies, national orgnaizations, and to staff within the division. The applicant should have experience in conducting research in one of the areas listed above, and experience translating that research into effective school-based programs. Applicants should have a working knowledge of comprehensive school health education.

A doctoral degree in health education or related field is preferred.

CDC is an equal opportunity employer and provides a smoke- free environment. Applicants should submit a curriculum vitae as soon as possible to: Tom Runner (INT), Centers for Disease Control, 1600 Clifton Road, MS A13, Atlanta, GA 30333

The Division of Adolescent and School Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control, is recruiting for a Qualified individual to serve as Chief, Special Projects Branch. The Special Projects Branch develops and implements comprehensive school health projects with state and local departments of education and/or health, and collaborates with and provides technical assistance to university and other state-based comprehensive school health programs.

In the position of Chief, Special Programs Branch, assumes the leadership in developing the Division's research and pro- grammatic activities pertaining to the development of comprehensive school health programs focused on prevention of chronic disease and other health problems. As a senior member of the division's leadership team, participates in program planning, management, and policy formulation for the division. The

applicant should have the ability to utilize the research results in planning, setting priorities, and managing the implementation of state demonstration projects, and the ability to analyze and dis- seminate results of such projects. The applicant should have the ability to supervise staff and manage program resources. In addition, the applicant should have extensive experience, not only in implementing comprehensive school health programs at the national, state, and local levels, and in working with teams of health professionals providing support to program development, research, and evaluation activities. Applicant should have experience in working with national, state, and local agencies as well as voluntary health/education organizations and educational organizations. A master's degree in health education or other related field is preferred.

CDC is an equal opportunity employer and provides a smoke- free environment. Applicants should submit a curriculum vitae as soon as possible to: Tom Runner (PDSB), Centers for Disease Control, 1600 Clifton Road, MS A13, Atlanta, GA 30333.

Chief, Program Development and Services Branch: - The program development and services branch develops and implements programs that 1) address and reduce priority causes of morbid- ity, disability, and mortality for children and youth and 2) enable DASH to help schools and other youth serving organizations implement efficient and cost-effective educational interventions developed to influence behaviors in ways that reduce the risks of priority health problems. The program development and services branch collaborates with and provides technical assistance to national, state, and local education and health agencies in implementing comprehensive school health programs.

In the position of Chief, Program Development and Services Branch, assumes leadership in developing the Division's pro- grammatic activities related to the development of health programs in schools and other agencies that serve youth that focus on the prevention of Human Immunodeficiency Virus (HIV) infec- tion, sexually transmitted diseases, and other health problems. As a senior member of the Division's leadership team, participates in program planning, management, and policy formulation for the Division. The applicant should have the ability to supervise staff and manage program resources. In addition, the incumbent should have experience in implementing a comprehensive school health program at the national, state, and local levels, and in working with teams of health professional providing

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Journal of School Health December 1 9 9 2 , Vol. 62, No. 10 463

Sources of Stress in Children with Asthma

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