The Journal of School Nursing2023, Vol. 39(1) 37–50© The Author(s) 2021Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405211061508journals.sagepub.com/home/jsn
Asthma is one of the most common pediatric chronic physical conditions. Youth with comorbid asthma and anxiety/depressive symptoms tend to have less controlled asthma and an increased use of health services in schools. The purpose of this integrative review was to examine the literature on educational and behavioral/ cognitive behavioral skills interventions for children with asthma and anxiety/depressive symptoms. Five electronic databases and forward/backward citations were searched. Eleven peer reviewed articles were retained for review. Main findings of the limited evidence suggest that educational and behavioral/cognitive behavioral skills programs may increase asthma knowledge and asthma-related self-efficacy while reducing anxiety/depressive symptoms. One study showed a decrease in use of quick relief inhalers and another had increased adherence to asthma controller medication. The literature indicates that educational and cognitive behavioral skills programs can have a positive impact on children with asthma and symptoms of anxiety/depression. School-based skills programs had better retention than outpatient programs.
Keywordsasthma, mental health, elementary, integrative reviews, school based intervention
Chronic disease management is a common priority for school nurses and asthma is in the forefront. A recent study of school nurses in North Carolina indicated that students received asthma related care more than 100,000 times annually (Best et al., 2021). Intervening with this student population to improve asthma knowledge and selfmanagement behaviors could reduce the burden of nurse time spent on administering care to the student with asthma, decrease lost instructional time, and improve academic and health outcomes (Harris et al., 2019).
Current data suggest that asthma affects 5.1 million children in the United States (US) and that up to 50% of this group has uncontrolled asthma (Centers for Disease Control and Prevention, 2019a, 2019b, 2021). Missed school instructional time and absenteeism due to asthma is associated with a negative effect on academic outcomes (Fleming et al., 2019). Finally, the subsequent financial and psychosocial burden for parents and primary caregivers can increase the morbidity of children with asthma (Foronda et al., 2020). Since some children are managing their asthma medications as early as six years of age (Bellin et al., 2017), children need to learn about their condition and become adept at managing their asthma.
Further, children and adolescents with asthma are up to three times more likely to experience anxiety or depressive symptoms than those without asthma (Dudeney et al., 2017; Goodwin et al., 2013). Previous studies have indicated that the comorbidity tends to occur more in children with less controlled asthma, while not as frequently in children with mild, intermittent asthma (Goodwin et al., 2013). The comorbidity of pediatric asthma and anxiety or depression can lead to a lower quality of life, less controlled asthma (Adams et al., 2017; Goodwin et al., 2013; Saragondlu Lakshminarasappa et al., 2021), more asthma-related emergency department visits (Bardach et al., 2019), and a higher incidence of death due to asthma (Strunk et al., 1985). We also know that childhood anxiety can lead to adolescent depression (Cohen et al., 2018) and that adolescent depression can continue into adulthood (Korhonen et al., 2018; Richter et al., 2021). Asthma and depression are associated with inflammation (Jiang et al., 2014), which can give rise to cardiovascular risk during adulthood (Shanahan et al., 2013). Therefore, ameliorating the effects of comorbid asthma and anxiety or depressive symptoms during childhood is imperative to potentially prevent long-term consequences.
Behavioral and cognitive behavioral skills interventions have been identified as a potentially beneficial modality to improve the physical outcomes of children with asthma. A 2019 Cochrane review for youth with asthma found that school-based self-management interventions may reduce hospitalizations and emergency department visits, particularly if the intervention is theory-based (Harris et al., 2019). The purpose of this review was to evaluate the body of literature related to interventions that specifically target children with comorbid asthma and anxiety/depressive symptoms. Therefore, the question guiding our review was: How does an educational and behavioral/cognitive behavioral skills-building intervention affect anxiety/depression and asthma outcomes for children ages 6 to 18 years with asthma?
We chose an integrative review approach due to the limited number of studies, small sample sizes, and varied study designs in addition to further exploring theoretically-based interventions (Toronto & Remington, 2020; Whittemore & Knafl, 2005) for the population of interest. The concepts for this review were chosen prior to the search and included behavioral/cognitive behavioral skills interventions, anxiety/depressive symptoms (operationalized by measures assessing symptoms), and asthma education. We wanted to examine the literature related to interventions for children with asthma and anxiety or depressive symptoms, specifically looking at behavioral and cognitive behavioral skills building interventions coupled with asthma education.
Quality assessment for studies in an integrative review poses challenges due to the diverse methodologies (Whittemore & Knafl, 2005). Therefore, quality assessment was completed using the Effective Public Health Practice Project’s (EPHPP) Quality Assessment Tool for Quantitative Studies (Armijo-Olivo et al., 2012; Thomas et al., 2004), which can be used to evaluate various types of study designs. While the Cochrane tool is considered the “gold standard,” it would have been too limiting given the nature of the included studies and state of the literature for this topic. Likewise, the Jadad scale evaluates randomized controlled trials only. A study comparing the EPHPP and the Cochrane tool revealed the EPHPP tool had better inter-rater reliability than Cochrane’s (Armijo-Olivo et al., 2012). The first two authors reviewed and independently rated each study. A plan was in place for resolving discrepancies in assessment, but none occurred.
The state of the science for interventions that address children with asthma and anxiety/depressive symptoms revealed that only pilot studies have been published. As such, all studies found in our search were included regardless publication date. The EPHPP quality assessment tool provides a global finding, which does not recognize relative strengths among each study. Therefore, we also included the mean score of the ratings in each category. We wanted to provide a more balanced rating for each study in the limited body of evidence. Viewing both scores (e.g., the EPHPP global scores alongside the average scores; see Table 1) allows readers to recognize that most studies were stronger than what they may appear.
With the assistance of a research librarian, we conducted the search between June and October 2021. We searched PubMed, CINAHL, ERIC, PsychINFO, and SocINDEX electronic databases and forward/backward citations. No year limitations were applied since so few studies were completed targeting comorbid asthma and anxiety/depression and to detail the relative strengths and challenges of various approaches with community-based interventions. The following search terms were applied in various combinations: (Children OR school age OR elementary AND/OR adolescent) AND (chronic condition OR asthma) AND (mental health OR anxiety OR depression) AND (intervention OR cognitive behavior AND educational intervention).
Studies were included if (a) the design was a randomized controlled trial, quasi-experimental, or case series (b) intervention population included children 6 to 18 years of age, (c) the intervention had an asthma education component, (d) anxiety/depression was a measured outcome pre/posttest or more (e) the intervention included behavioral component(s) and/or relaxation training targeting anxiety/depression, and (f) the study was published in a peer-reviewed journal in English. Exclusion criteria were: hospital-based studies, interventions targeting parents, and interventions targeting other chronic health conditions (e.g., anaphylaxis, cystic fibrosis, or diabetes).
Figure 1 illustrates the PRISMA flow diagram. Data were extracted by the first two authors using a template (see Table 2). The template included the following information points: authors, year of publication, country where conducted, purpose, design/sample, intervention format (e.g., individual vs. group, frequency, and timing where reported), delivery and setting, sample size with attrition, age range, measures used, outcomes and findings, strengths, and limitations.
Our search yielded 971 articles. Another three were identified through forward/backward searches of citations (See Figure 1). After the initial screening to exclude studies unrelated to asthma, children, or targeted parents, 153 abstracts were scanned, followed by full text assessment of 18 articles. Articles were eliminated if there was a lack of behavioral intervention (e.g., acupuncture, art therapy, hypnosis) or if articles reported different aspects of the same study (Bignall et al., 2015).
Eleven articles were retained for the review with study characteristics described in Table 2. All were pilot studies and published between 1990–2019, with 50% being randomized controlled trials (Bignall et al., 2015; Chiang et al., 2009; Colland, 1993; Dahl et al., 1990; Marsland et al., 2019; Perrin et al., 1992), 30% cohort design (Long et al., 2011; Marriage & Henderson, 2012; McGovern et al., 2019), and 20% case series (Peck et al., 2003; Sicouri et al., 2017). Sample sizes varied from 4–112 participants, ranging in age from 6–16 years of age, though one study (Dahl et al., 1990) only provided the mean age. The studies were conducted in the US (Bignall et al., 2015; Long et al., 2011; Marsland et al., 2019; McGovern et al., 2019; Peck et al., 2003; Perrin et al., 1992), Australia (Sicouri et al., 2017), the Netherlands (Colland, 1993), Sweden (Dahl et al., 1990), Taiwan, ROC (Chiang et al., 2009), and the UK (Marriage & Henderson, 2012).
Intervention sessions and durations ranged from 30 min, once a month for two months (Bignall et al., 2015) to one hour per week for ten weeks in groups (Colland, 1993). Chiang et al. (2009) implemented an intervention with case management phone calls to families three times per week for 12 weeks; contact time related to the case management was not specified. All but one of the studies (Perrin et al., 1992) specifically used behavioral or cognitive behavioral skills. Perrin et al. (1992) reported using a developmental approach to understanding illness. Table 2 provides further details of the data extracted.
All included studies reported at least a partial reduction (i.e., either statistically or clinically significant or, for case series or smaller pilot studies - several participants reported a reduction in symptoms) in anxiety or depressive symptoms at post-intervention.
Table 3 illustrates the behavioral/cognitive skillsbuilding techniques implemented in the studies. All studies included a form of relaxation technique (e.g., imagery, deep breathing/diaphragmatic breathing, or progressive muscle relaxation). Nine studies reported incorporating psychoeducation (Bignall et al., 2015; Chiang et al., 2009; Colland, 1993; Dahl et al., 1990; Long et al., 2011; McGovern et al., 2019; Peck et al., 2003; Perrin et al., 1992; Sicouri et al., 2017) and six integrated cognitive restructuring or changing negative thoughts to positive thoughts (Colland, 1993; Dahl et al., 1990; Long et al., 2011; Marriage & Henderson, 2012; McGovern et al., 2019; Sicouri et al., 2017). Four included problem-solving (Chiang et al., 2009; Colland, 1993; McGovern et al., 2019; Sicouri et al., 2017), Colland (1993) incorporated roleplaying, and all but two studies (Colland, 1993; Perrin et al., 1992) reported the assignment of practice or homework outside of the sessions or groups
All of the studies included some form of asthma education but did not necessarily include details. Four specifically addressed the relationship between asthma and anxiety (Dahl et al., 1990; McGovern et al., 2019; Perrin et al., 1992; Sicouri et al., 2017). Participants in all studies improved (either statistically significant and/or via clinically meaningful effect sizes) their asthma-related self-efficacy. Of the studies containing an objective measure of lung function, three (Chiang et al., 2009; Long et al., 2011; Peck et al., 2003) reported improvement post-intervention. Studies that measured quality of life and/or subjective asthma symptoms all reported improvements. Dahl et al. (1990) reported a decrease in use of the quick relief medication, while McGovern et al. (2019) reported fewer missed doses of asthma controller medication (See Table 2).
Attrition tended to be lower for school-based programs implemented during the school day. Studies with the highest attrition rates (e.g., 41%) were delivered individually and outside of the school day/setting (Marriage & Henderson, 2012). Table 2 provides further details.
Table 1 describes the assessment of study quality. Use of the average scores for the studies allowed for a more balanced rating and accounted for strengths within the studies. However, the global ratings were lower as expected. Six of the studies were rated weak (Colland, 1993; Dahl et al., 1990; Marriage & Henderson, 2012; McGovern et al., 2019; Peck et al., 2003; Sicouri et al., 2017), four were assessed as moderate (Bignall et al., 2015; Chiang et al., 2009; Long et al., 2011; Perrin et al., 1992) and one was strong (Marsland et al., 2019). Studies evaluated as moderate to weak quality with the EPHPP tool were less than optimal mainly due to design, sample size, or other methodological flaws increasing the threat to internal validity.
The question we sought to answer for this review was “How does an educational and behavioral/cognitive behavioral skills-building intervention affect anxiety/depression and asthma outcomes for children ages 6 to 18 years with asthma?” Our review shed light on several key findings in the body of literature related to interventions for children with comorbid asthma and anxiety/depressive symptoms. First, the time and location of intervention implementation is important to consider. School-based programs (Bignall et al., 2015; Dahl et al., 1990; Long et al., 2011; McGovern et al., 2019; Peck et al., 2003) tended to have lower attrition rates than programs that occurred in outpatient clinics (Chiang et al., 2009; Long et al., 2011; Marriage & Henderson, 2012; Sicouri et al., 2017). The lower attrition could be related to children already being in school and no transportation is needed to receive the intervention. Second, creating protected time in the nurse’s schedule and utilizing a convenient time in the student’s school schedule can provide the needed structure for implementing a schoolbased intervention.
Another important factor with school-based interventions is session duration and frequency. In our review, programs implemented by psychologists or psychology interns tended to have longer sessions and did not necessarily have better outcomes than programs with shorter sessions (Colland, 1993; Long et al., 2011; Marsland et al., 2019; Peck et al., 2003). For example, the intervention by Peck et al. (2003) was 20 min, four times per week for four weeks. This could be difficult to implement on a large scale. Shorter sessions on a weekly basis may be easier to integrate into the school day, such as groups that meet during the scheduled lunch time (McGovern et al., 2019).
To reduce missed instruction time, interventions should target lunch time, such as “lunch bunch groups,” or implement the program before or after school. Additionally, the intervention would preferably be in a group-based format to reach more children and potentially strengthen peer support. The most frequently used behavioral/cognitive behavioral skills building interventions and recommendations for an asthma educational and behavioral program are illustrated in Table 3. Asthma educational components should conform to national guidelines (Mammen & McGovern, 2021; National Heart Lung and Blood Institute, 2021, February 4).
The EPHPP global quality assessment findings in this study were mostly low to moderate, while the mean scores for each study were relatively higher (See Table 1). The EPHPP ratings do not recognize subtle strengths of the pilot studies in this review. A study is automatically rated moderate or weak with only one or two weak scores, respectfully. For example, Bignall et al. (2015) was a pilot randomized controlled trial, and only 10% attrition, but the EPHPP rating was 2 (moderate) while the mean score was 1.67 (between strong and moderate; see Table 1). However, only 56% of individuals agreed to participate and the authors did not mention whether researchers knew who was assigned to the control or experimental groups, which brought the global score down to a 2, or moderate. Including the mean score/average provides a more balanced assessment.
There were several notable strengths among the studies. All studies included asthma education resulting in increased asthma-related self-efficacy or management. Most of the studies’ interventions were specified by manuals that prescribed the content, frequency, and intervals and were theoretically-based (Bignall et al., 2015; Colland, 1993; Dahl et al., 1990; Long et al., 2011; Marriage & Henderson, 2012; Marsland et al., 2019; McGovern et al., 2019; Sicouri et al., 2017).
All the studies reported a reduction in anxiety or depressive symptoms. Other beneficial outcomes were found among the studies. Several reported a reduction in asthma symptoms (Dahl et al., 1990; Long et al., 2011; Marriage & Henderson, 2012; Marsland et al., 2019; McGovern et al., 2019; Peck et al., 2003; Sicouri et al., 2017), in the use of quick relief inhalers (Dahl et al., 1990), or fewer missed doses of asthma controller medication (McGovern et al., 2019). Interventions have the potential for improved long-term asthma control and mental health (e.g., anxiety/depression), particularly if a program results in all the above improved outcomes. The challenge is to make the intervention scalable and easy for practitioners to adopt.
The limitations of the studies were primarily due to sample size, one group design, and a lack of anonymous assignment of the control and experimental group participants during data collection. Providing effect sizes, such as the case with McGovern et al. (2019) and Marsland et al. (2019), reveals the clinical impact of the intervention particularly if statistical significance is not reached with small sample sizes. Rigorous studies with a scalable intervention for children with asthma and anxiety/depressive symptoms are needed, which is consistent with previous reviews (Pateraki & Morris, 2018).
Our review included peer reviewed published articles in English and could have missed programs published in other languages. Outcomes measured and method of measurement were heterogeneous among the studies, which added to the challenge of comparing results. Additionally, some of the studies cited were completed more than ten years ago; however, it was important to include them to demonstrate the gaps in research and highlight important findings from those studies. Finally, several studies did not provide details about setting, statistical methods, or results; thus, we could not report these findings.
A strength of this review is that it was guided by the recommendations of Toronto and Remington (2020) and Whittemore and Knafl (2005). This is also the first known review specifically targeting educational and behavioral interventions for children with comorbid asthma and anxiety or depressive symptoms.
Children experiencing symptoms of asthma frequently visit school nurses (Best et al., 2021). We know that children with asthma are at higher risk of anxiety/depression and that this comorbidity leads to less controlled asthma and increased healthcare use (Bardach et al., 2019). The school nurse may be the only consistent healthcare provider that this pediatric population sees on a regular basis. The nurse is in a position to recognize students who frequent the health office due to asthma symptoms. Further evaluation is warranted, given the rates of youth with comorbid asthma and anxiety/depressive symptoms and paucity of data on this subset of children with asthma (Dudeney et al., 2017; Goodwin et al., 2013).
The U.S. Preventive Services Task Force (2016) recommends depression screening in children 12–18 years of age and younger if resources are available. For this reason, it is even urgent to develop a scalable intervention for youth with asthma and anxiety/depression because what benefit is there to screening if no effective treatment options are available? The screening tool recommended for adolescents is the Patient Health Questionnaire for Adolescents or the Child Depression Inventory (U.S. Preventive Services Task Force, 2016). Children younger than 12 years of age could be screened with other validated measures for anxiety/depressive symptoms (e.g., SCARED for anxiety and the PROMIS-SF-Pediatric Depression). These youth with comorbid asthma and anxiety/depressive symptoms could benefit from targeted educational and behavioral/cognitive skills-building interventions. School-level protocols should be in place if a child scores particularly high on a depression screening, such as immediate follow up with school staff for risk assessment, referral to community resources, and notification to the parent or guardian.
This review provides several recommendations and insights for implementing interventions. First, participant retention was higher for educational and behavioral programs held during the school day. School nurses have competing priorities during the school day. However, implementing an asthma education and behavioral skills program could reduce the time children spend out of class and in the nurse’s office over the course of the school year. In doing so, disruptions to the school nurse’s day could be lessened.
School health services can include licensed providers and unlicensed staff and attend to the needs of student populations (Spring, 2020) with the goal of supporting children and families.
Children with poorly or moderately controlled asthma may also have anxiety or depressive symptoms. The development of a program that could be integrated into the school day could fill the present gap. Figure 2 offers a list of proposed basic components for a school-based intervention. School health services providers are in a position to influence policy. Given the ongoing financial challenges of school districts nationwide, consideration should be given to programs that may qualify for reimbursement (Melnyk, 2020). School-based health clinics can bill for mental health and asthma-related services (Medicaid and CHIP Payment and Access Commission, 2018). Additionally, mental health-related emergency department visits have increased among youth since the Covid-19 pandemic (Leeb et al., 2020). Programs addressing children with asthma and anxiety/depressive symptoms may be billable when implemented by licensed members of the student support team (e.g., nurse, psychologist, social worker, or guidance counselor).
There are currently no scalable interventions specifically targeting children with comorbid asthma and anxiety/depressive symptoms. Our review sheds light on the need for such a program, particularly because it could benefit children while decreasing visits to the school nurse. Such a program may improve the mental and physical health outcomes of these children long-term and into adulthood.
The content is based solely on the perspectives of the authors and do not necessarily represent the official views of the sponsors.
The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Sigma Theta Tau Alpha Alpha.
Colleen McGovern https://orcid.org/0000-0002-4616-5121
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Colleen M. McGovern, PhD, MPH, RN, is an Assistant Professor in the Family & Community Nursing Division, University of North Carolina - Greensboro.
Renee Harrison, APRN-CNP, PMHNP-BC, is a PhD student at the University of North Carolina - Greensboro, School of Nursing, and Department Chair, Associate Degree Nursing at Forsyth Technical College.
Kimberly Arcoleo, PhD, MPH, Research Professor, Director of Nursing Research, College of Nursing, University of Rhode Island.
1 School of Nursing, University of North Carolina at Greensboro, Greensboro, NC, USA
2 Forsyth Technical Community College, Winston-Salem, NC, USA
3 College of Nursing, University of Rhode Island, South Kingstown, RI, USA
Corresponding Author:Colleen M. McGovern, School of Nursing, University of North Carolina at Greensboro, UNCG School of Nursing, Nursing and Instructional Building, 1007 Walker Avenue, Office #366P; Greensboro, NC, 27412, USA.Email: cmmcgovern@uncg.edu
