PEDIATRICS Vol. 122 No. 6 December 2008, pp. e1186-e1192 (doi:10.1542/peds.2008-0292)
ARTICLE |
At What Age Do Children Start Taking Daily Asthma Medicines on Their Own?
Departments of a Pediatrics
b Psychiatry
d Epidemiology and Biostatistics
e Philip Lee Institute of Health Policy Studies, University of California, San Francisco, California
c Department of Human Development, Washington State University, Seattle, Washington
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONREFERENCES |
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OBJECTIVE. Use of daily controller medications is a critical task in management of persistent asthma. Study aims were to examine (1) the association between child age and extent of daily controller-medication responsibility in a sample aged 4 to 19 years, (2) parent, child, and disease predictors of child daily controller-medication responsibility and overall daily controller-medication adherence, and (3) the association between child daily controller-medication responsibility and overall daily controller-medication adherence.
METHODS. We conducted a cross-sectional telephone survey of 351 parents of children who were prescribed daily controller medication. Children's mean age was 10.4 years; 61.5% were male, and 88.1% were white. Parents provided all data, including an estimate of the percentage of child and parent daily controller-medication responsibility. Daily controller-medication adherence was measured as parents' report of percentage of daily doses taken per doses prescribed in a typical week. We used multivariate linear regression to determine associations between parent race/ethnicity, education, income, number of dependents, child age, gender, years since diagnosis, parent perception of symptom severity and control, and dependent variables (child daily controller-medication responsibility and daily controller-medication adherence). We also examined associations between child daily controller-medication responsibility and daily controller-medication adherence.
RESULTS. Child daily controller-medication responsibility increased with age. By age 7, children had assumed, on average, almost 20% of daily controller-medication responsibility; by age 11, 
50%; by age 15, 75%; and by age 19, 100%. In multivariate models, child age and male gender remained significantly associated with child daily controller-medication responsibility, and child's age and parents' race/ethnicity remained significantly associated with daily controller-medication adherence.
CONCLUSIONS. Clinicians may need to screen for child daily controller-medication management and include even young children when educating families on the use of asthma medications and other key asthma-management tasks.
Key Words: daily asthma medications • asthma self-management • children • parents • adherence
Abbreviations: DCM—daily controller medication
Asthma is 1 of the most common childhood chronic diseases; an estimated 6.8 million youth younger than 18 years reported symptoms in 2006.1 Effective asthma management entails a variety of tasks that range from avoiding allergens to taking medicines on a schedule.2–5 Whereas a parent assumes primary responsibility for management of a young child's asthma, children necessarily take on increased responsibility over time. As with other developmental tasks (eg, personal hygiene, household chores),6 parents must decide the extent of responsibility that their child will assume for each of the tasks of asthma management.
One of the most critical tasks in the management of persistent asthma, irrespective of age, is the daily use of controller medications (eg, inhaled corticosteroids) for symptom control.2 For children with asthma, daily controller medications (DCMs) must be used not just in the short-term but also daily and continually over the lifetime course of asthma. It is important in terms of defining and addressing modifiable risk factors, therefore, to identify the factors that predict the extent to which parents delegate responsibility for DCM self-management to children. It is also important to examine the association between extent of child DCM responsibility and adherence to the DCM regimen.
We know very little about the factors that influence parents' decisions about how much responsibility a child will have for illness self-management. Factors likely include child characteristics (eg, age), parent characteristics (eg, education), and disease characteristics (eg, disease duration).
Several studies have examined the influence of child characteristics on extent of child responsibility for aspects of illness management. Although designed primarily to identify component tasks in the management of asthma,3–5 diabetes,7,8 and cystic fibrosis,8 these studies have suggested that child age is a key factor in increased child responsibility. The samples in these studies, however, were limited in size and/or age range; consequently, we lack even a cursory understanding of the developmental trajectory of illness self-management. The upshot is that we know surprisingly little about what to expect normatively as a child matures or at which age/developmental stage clinicians should begin to educate children about each of the tasks of illness management. In this study, we used a sample that was larger in size and broader in age range than has been previously studied in this regard to cross-sectionally examine the association between age and DCM responsibility from early childhood to young adulthood.
Child gender, also a likely influence on extent of children's illness self-management, has been examined in only 1 published study.7 This study found that girls were given more responsibility than boys for "social" aspects of their diabetes management, such as telling friends and teachers. In this study, we hypothesized that girls would have greater DCM responsibility than boys.
We know of no research on how parents' demographic characteristics may affect extent of child chronic illness self-management; however, given the greater challenges encountered by parents of racial/ethnic minority groups, lower socioeconomic status, and larger families,9 we hypothesized that these demographic characteristics would predict greater child DCM responsibility. Research has demonstrated that parents underestimate the severity of their children's asthma symptoms and overestimate symptom control relative to expert criteria.2,10,11 We hypothesized that, although lacking in construct validity, parents' judgment of severity and control, not expert severity and control categorizations,2 would influence parents' decision-making regarding child DCM responsibility. Specifically, we hypothesized an inverse relation between parent perception of symptom severity and child DCM responsibility and a positive association between parent perception of control and child DCM responsibility.
Disease characteristics likely also influence parents' decisions about children's responsibility for illness self-management. The diabetes literature suggests that whereas disease duration is associated with increased child responsibility,7 it accounts for no unique variance in extent of child diabetes responsibility beyond that accounted for by age. We expected similar findings for children with asthma. In sum, the goals of this study were to (1) cross-sectionally examine the age-responsibility trajectory for children's DCM self-management in a sample aged 4 to 19, (2) identify child, parent, and disease characteristics that predict child DCM responsibility, and (3) examine the association between child DCM responsibility and overall DCM adherence.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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We analyzed a subset of data from a randomized clinical trial designed to evaluate the effect of asthma education on provider adherence to National Heart, Lung, and Blood Institute guidelines2 for the prescription of daily corticosteroids. Of note, baseline data from this patient population have been used to identify and classify parents' specific concerns about children's daily asthma medications12 and to assess the impact of parents' positive and negative medication beliefs on medication adherence.13
Details of the baseline sample can be found in these published studies.12,13 The institutional review boards of the University of Michigan and the University of California, San Francisco, approved the study protocol.
Patient Population
We recruited a volunteer sample of 40 general pediatricians from a variety of practice settings (rural, urban, suburban) within Michigan and developed a registry of 4145 patients with asthma from pediatricians' patient panels. Project staff successfully contacted by telephone the parent/guardian "usually responsible for the child's health-related care and who takes him/her to the doctor" of 3263 patients to invite study participation, obtain informed consent, and screen for eligibility. Of these 3263 patients, 1858 met eligibility criteria.
Eligibility criteria included being the patient of a study physician, having a diagnosis of asthma and having used health care services in the preceding 2 years, being between ages 2 and 16 years, and having no other diseases associated with pulmonary complications. We included only 1 child per family. We excluded children when they had a parent who worked for a study physician or when children were younger than 2 years because the diagnosis of asthma can be difficult to establish before age 2.
Parents/guardians of 1322 of the 1858 eligible patients (71.2% response rate) agreed to participate. Baseline telephone interviews were conducted with these 1322 parents between July 2003 and April 2004. Follow-up interviews were conducted 1 and 2 years later, between March and August 2006 for wave 1 (n = 973) and March and August 2007 for wave 2 (n = 819). DCM responsibility was assessed only at wave 2 and when parents indicated that their child had been prescribed a DCM (n = 351); therefore, we used only this subset of data in this study.
Variables
Independent variables included characteristics of the child (age, gender); parent (race/ethnicity, education level, income, number of dependents, perception of symptom severity and control), and disease (years since diagnosis). Parent education was categorized as <12 years/less than high school, 12 years/high school graduate, 13 to 14 years/some college/trade school, 16 years/college graduate, or >16 years/graduate or professional school. We used the definition of poverty published by the US Department of Health and Human Services in 200614 to determine whether annual household income was above or below the federal poverty level, adjusting for the number of dependents.
Symptom control was assessed as parents' ratings on a 5-point scale (1 = not at all; 5 = very) of how controlled their child's symptoms had been in the previous month. Parents were then asked the frequency of their child's daytime and nighttime symptoms in the previous month, to recall their child's most recent asthma episode in the past year, and to report the duration of symptoms (eg, wheezing, chest tightness) during this episode in number of days. Symptom severity was then assessed as parents' judgment regarding whether their child's symptoms were mild, moderate, or severe.
Extent of child DCM responsibility was defined as parents' perception of the percentage of time (0% to 100%) that their child had responsibility for "taking their DCM as prescribed." We similarly assessed extent of parent DCM responsibility. DCM adherence was measured as a percentage by calculating parents' report of the number of daily DCM doses that their child had taken in an average week, irrespective of who had responsibility for the task, divided by the number of prescribed doses.
Data Analyses
β coefficients and P values were calculated by using linear regression to determine associations between child, parent, and disease characteristics and continuous dependent variables. Specifically, we examined the bivariate association between (1) child DCM responsibility and (2) parent perception of DCM adherence with the following independent variables: child age, gender, parent race, ethnicity, education, income, number of dependents, perceived symptom severity, perceived symptom control, and disease duration. Parameters with P < .20 in the bivariate analysis were included in multivariate linear regressions. We also used multivariate models to examine whether increased child DCM responsibility was associated with decreased medication adherence, controlling for demographic and disease characteristics. Predictive value was assessed using the R2 statistic. SAS 9.1 (SAS Institute, Inc, Cary, NC) was used for data analyses.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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Participants
Participants were parents of children who were prescribed DCM at the time of the wave 2 interview (n = 351 of 819). Children's average age was 10.4 years (SD: 3.7; range: 4 to 19 years); 61.5% were male. The sample was predominantly white (88.1%) and college-educated (60.5%); therefore, race categories were reclassified as white and nonwhite and parent education categories as
15 years of education, 16 years (college graduate), and >16 years. Approximately 12% had an annual household income less than or equal to twice the federal poverty level (Table 1).
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Extent of Child DCM Responsibility Averaged According to Child Age
Our sample size and age range allowed a cross-sectional assessment of the percentage of child DCM responsibility stratified according to child age and the corollary percentage of parent DCM responsibility. Figure 1 presents the developmental trajectory from early childhood (4 years old) to young adulthood (19 years old) as the average child DCM responsibility (and average parent DCM responsibility) for each age group, according to year of age.
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There was a strong overall linear increase in child DCM responsibility with age and a corresponding decrease in parent DCM responsibility. By age 7, children on average had assumed almost 20% of DCM responsibility; by age 11, on average
50%; by age 15, 75%; and by age 19, 100%. Decrements in the degree of child DCM responsibility were observed in this sample at 8, 12, and 16 years of age, with compensatory increments in parents' DCM responsibility when children were aged 12 and 16.
Child, Parent, and Disease Factors Associated With Child DCM Responsibility
In unadjusted bivariate analyses, older age and greater number of years since asthma diagnosis were highly predictive of greater child DCM responsibility (β = 6.71 [SE: 0.48] and β = 4.51 [SE: 0.65], respectively; P < .001). Parents with >16 years of education reported significantly less child DCM responsibility than parents with 15 years of education (β = –16.0 [SE: 5.79]; P = .01). Parents of male children also reported less child DCM responsibility (β = –21.0 [SE: 4.42]; P < .001). In a multivariate model that included child age, child gender, parent education, and years since diagnosis, only child age (β = 6.85 [SE: 0.61]; P < .001) and male gender (β = –14.5 [SE: 3.59]; P < .001) remained significant (Table 2). This multivariate model accounted for 41% of the variance in extent of child DCM responsibility (F = 47.2, P < .001).
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Child, Parent, and Disease Factors Associated With DCM Adherence
In unadjusted bivariate analyses, younger child age (β = –1.16 [SE: 0.30]; P < .001), parents' race (β = 11.6 for white race versus nonwhite [SE: 3.58]; P = .001), and less child DCM responsibility (β = –0.05 [SE: 0.03]; P = .05) were significantly associated with parent report of higher adherence to the prescribed dosing schedule in an average week (Table 3). In preliminary multivariate models, a multicollinearity effect was observed between child age and years since diagnosis. Because child age was more strongly and obviously related to adherence to prescribed dosing, years since diagnosis was excluded from the final model. After adjustment, only younger age (β = –1.40 [SE: 0.42]; P = .001) and parents' race (β = 10.4 [SE: 3.77]; P = .01) were associated with increased adherence, accounting for 10% of variance (F = 4.34, P < .001). In the multivariate model, child DCM responsibility was not associated with increased adherence.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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Consistent with other studies,3–5,7,8 we found that child responsibility for DCM self-management increased with age. In this study, the sample size and age range (4–19 years) allowed a more detailed overview of this association than has been previously available. Indeed, this study offers a first look at the likely developmental trajectory of long-term medication self-management from early childhood to young adulthood. A striking finding is that parents delegate a substantial degree of DCM responsibility to children at a relatively early age.
Although there was a strong linear increase in child DCM responsibility with age, temporary decrements were observed at ages 8, 12, and 16 years. These decrements are likely a function of this specific sample. Notably, however, these ages represent key transitional years when children must accommodate to new and challenging developmental demands and when parents may recognize the need to increase temporarily their DCM responsibility to compensate (see Fig 1). At approximately age 8 (grade 3), for example, the child is entering the concrete operational stage of cognitive development,15 when children begin to reason logically and when they transition from "learning to read" to "reading to learn."16 Twelve years of age (grade 7) marks the start of middle school, when young adolescents must adjust to major changes in physiologic, cognitive, and socioemotional development.17 At age 16 (grade 11), adolescents gain increased autonomy as they learn to drive, hold part-time jobs, and develop romantic attachments.18,19 Whether the decrements are a function of this specific sample or this particular asthma-management task or are more broadly representative remains an empirical issue that can be clarified only with longitudinal research to describe the developmental trajectory of child responsibility for each of the various tasks of asthma management.
The only published study7 on gender differences in children's illness self-management found that girls assume more responsibility than boys for their diabetes self-management specifically as it pertains to tasks of social presentation. We found similar gender differences in child DCM responsibility, reflecting previous research on health care responsibility (eg, contraception) more generally.20
We also examined child, parent, and disease predictors of parent-reported DCM adherence, irrespective of who held responsibility. Parents with younger children reported greater overall DCM adherence. This is unsurprising given that these parents had greater DCM responsibility and logically could better monitor adherence than when children had proportionally greater responsibility; however, studies21 have shown self-reported adherence to be inflated.
Parent race/ethnicity was also related to adherence. Nonwhite parents reported significantly lower DCM adherence than white parents. This finding conforms to other research showing that asthma management can be compromised in ethnic minority populations,22 perhaps as a result of competing family priorities.23
We found no relation between child DCM responsibility and overall (not child only) adherence. McQuaid et al24 also found no association between child-reported responsibility and adherence, measured as electronic asthma medication monitoring. In this case, child responsibility was assessed globally (mean score across 10 asthma-management tasks) and mapped to adherence to inhaled medications, a single, discrete task. Neither study mapped child responsibility for a specific task to child adherence to that task. Future research must examine this issue more systematically.
Limitations
This study was cross-sectional in design, and each age cohort could have experienced unique events that alternatively explain outcomes. In addition, parents assessed DCM responsibility using a 0 to 100% scale; research has shown that individuals can vary in their interpretation of probability terms.25 Research is warranted to address more definitively the assessment of responsibility.
These data do not allow judgment concerning the appropriateness of the age at which parents allowed child DCM responsibility. Additional research is needed to identify factors that can be used as markers to determine when it is appropriate to delegate long-term medication management to a developing child. Inappropriate delegation of DCM management to children who are unprepared to undertake such tasks increases risk for adverse outcomes.26
Parents served as sole informants on all variables, including their own and their child's DCM responsibility and adherence. In addition to the limitations of self-report data, the validity of parents' report of child adherence is likely compromised when the child is at least partly responsible for his or her medication management. Parents may simply be unable to monitor children's symptoms or medication adherence. Of note, studies4,5 that examined shared parent–child responsibility for asthma management showed that parents may perceive children as having less responsibility than children perceive themselves to have. Thus, levels of child DCM responsibility reported in this study may be, if anything, an underestimation, making our findings all the more notable.
This was a predominantly white, college-educated sample of parents. Furthermore, this sample of children, by definition, had been prescribed DCM, partly explaining the lack of variability in symptom control. As such, results may not generalize more broadly. Given known racial and socioeconomic disparities in asthma management and health outcomes,22,23 the question of sociodemographic differences remains at issue.
Finally, we examined only 1, albeit key, task in the range of tasks that comprise asthma management.2–5 Furthermore, because responsibility was defined in general terms, these data do not illuminate the particular aspects of DCM responsibility for which children were responsible. Child responsibility and adherence may vary not only with the task but also with particular aspects of the task.3
Implications
Notwithstanding these limitations, this study has important clinical implications. A considerable number of children may assume significant DCM responsibility at an early age. Consequently, clinicians should carefully query families about who assumes the day-to-day responsibility for children's daily asthma medications. If children are being delegated DCM responsibility, then an assessment of a child's readiness to assume such an important responsibility may be prudent, because inconsistent DCM use is a risk factor for poor asthma outcomes.26 This study emphasizes the need to include children when families are educated in the use of asthma medications and in the delivery of key asthma self-management messages.
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ACKNOWLEDGMENTS |
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This study was supported by National Institutes of Health grant HL70771.
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FOOTNOTES |
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Accepted Sep 2, 2008.
Address correspondence to Joan K. Orrell-Valente, PhD, University of California, Division of Adolescent Medicine, 3333 California St, LH 245, Box 0503, San Francisco, CA 94143-0503. E-mail: joan.valente{at}ucsf.edu
The authors have indicated they have no financial relationships relevant to this article to disclose.
| What's Known on This Subject We know little about the characteristics that predict the extent to which parents delegate asthma responsibility to children, only that child age may be positively associated with child asthma responsibility.
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| What This Study Adds This work demonstrates the likely developmental trajectory of long-term medication self-management from early childhood to young adulthood. Older age and male gender were significantly associated with child responsibility for daily asthma medications; parents' demographic and child's disease characteristics were not significantly associated.
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PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics
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