Pediatric Stress Pediatric Stress Management InterventionsManagement Interventions

Anna Marsland, Ph.D., RNAnna Marsland, Ph.D., RN

OverviewOverview ““Connections to Coping”– for children newly Connections to Coping”– for children newly

diagnosed with cancer and their familiesdiagnosed with cancer and their families• Need for interventionNeed for intervention• Initial Phase: Developing the interventionInitial Phase: Developing the intervention• Feasibility Phase – Initial pilot dataFeasibility Phase – Initial pilot data• Randomized clinical trial: Current funded interventionRandomized clinical trial: Current funded intervention

““I Can Cope” - for children with moderate, I Can Cope” - for children with moderate, persistent asthmapersistent asthma• Need for interventionNeed for intervention• Initial phase: Developing the interventionInitial phase: Developing the intervention• Feasibility Phase – Initial pilot dataFeasibility Phase – Initial pilot data• Where next? Where next?

The The Connections Connections

to Coping to Coping StudyStudy

Lin Ewing, Ph.D., RN, Anna Marsland, Ph.D., RN, Lin Ewing, Ph.D., RN, Anna Marsland, Ph.D., RN, Armando Rotondi, Ph.D, Andrew Baum, Ph.D., Armando Rotondi, Ph.D, Andrew Baum, Ph.D.,

Jean Tersak, M.D , A. Kim Ritchey, M.D Jean Tersak, M.D , A. Kim Ritchey, M.D

12,400 under 19 12,400 under 19 diagnosed with diagnosed with cancer in USA/yearcancer in USA/year

Dramatic Dramatic improvements in improvements in prognosis over the prognosis over the past 4 decadespast 4 decades

Children’s Oncology Children’s Oncology Group estimate that Group estimate that survival rates have survival rates have improved since the improved since the 1950s from less than 1950s from less than 10 percent to about 10 percent to about 77 percent overall.77 percent overall.

Leukemia and Lymphoma – 5 Year Leukemia and Lymphoma – 5 Year Survival RatesSurvival Rates

28

4

52

18

70

78

92

69

0 20 40 60 80 100

All Types

ALL

Hodgkin's

Lymphoma

Percentage Surviving 5 years

1997

1960

NCI: SEER statistics

Coping with a Chronic DiseaseCoping with a Chronic Disease

Current estimates - 1 in Current estimates - 1 in 1000 under 20 years is a 1000 under 20 years is a survivor of childhood survivor of childhood cancer. cancer.

Shift in psychological Shift in psychological emphasis from coping with emphasis from coping with imminent death, to coping imminent death, to coping with a chronic disease with with a chronic disease with uncertain outcomeuncertain outcome

Treatment ProtocolsTreatment Protocols

Vary, but generally include 4 phasesVary, but generally include 4 phases1. Induction of remission1. Induction of remission

Intense chemotherapy regimens until disease-free Intense chemotherapy regimens until disease-free state is achieved state is achieved

2. Central nervous system prophylaxis2. Central nervous system prophylaxis

3. Consolidation of treatment3. Consolidation of treatment Intensifying treatment to reduce chance of resistance Intensifying treatment to reduce chance of resistance

to chemotherapyto chemotherapy

4. Maintenance of treatment4. Maintenance of treatment Ongoing chemotherapy for 2-3 years after remission Ongoing chemotherapy for 2-3 years after remission

is achieved to prevent relapse. is achieved to prevent relapse.

Side Effects of TreatmentSide Effects of Treatment1.1. Alopecia (hair regrowth starts 1-3 Alopecia (hair regrowth starts 1-3

months into maintenance)months into maintenance)

2.2. Moon face – Cushing’s syndromeMoon face – Cushing’s syndrome

3.3. Nausea and vomitingNausea and vomiting

4.4. Diarrhea/constipationDiarrhea/constipation

5.5. Low blood counts – susceptibility to Low blood counts – susceptibility to infection, need for transfusionsinfection, need for transfusions

6.6. Fatigue and weaknessFatigue and weakness

7.7. Mouth and throat soresMouth and throat sores

Late Effects of Cancer Late Effects of Cancer

Growth, endocrine function, Growth, endocrine function, reproductionreproduction

Brain development and functionBrain development and function Risk of secondary malignancyRisk of secondary malignancy Late effects on organ functionLate effects on organ function

?? Psychological development and ?? Psychological development and functionfunction

Impact of Childhood Cancer on Impact of Childhood Cancer on Psychosocial FunctioningPsychosocial Functioning

Unusually stressful Unusually stressful life circumstances life circumstances that can impact that can impact quality of life. quality of life.

Uncontrollable and Uncontrollable and unpredictable unpredictable nature of disease -- nature of disease -- extreme chronic extreme chronic stressorstressor

Are Children with Cancer at Are Children with Cancer at Psychosocial Risk?Psychosocial Risk?

Longitudinal studiesLongitudinal studies – Overall risk for – Overall risk for emotional and behavioral problems no emotional and behavioral problems no greater than community norms (e.g., greater than community norms (e.g., Sawyer et al., 1997)Sawyer et al., 1997)

But, psychological adjustment varies But, psychological adjustment varies across individualsacross individuals

Subgroup at increased risk of psychological Subgroup at increased risk of psychological and social adjustment problems, including and social adjustment problems, including depression, anxiety and social withdrawal. depression, anxiety and social withdrawal.

Are Caregivers at Risk?Are Caregivers at Risk? High levels of distress usually decline over the first High levels of distress usually decline over the first

year after diagnosis (e.g., Sawyer et al., 1997).year after diagnosis (e.g., Sawyer et al., 1997).

BUTBUT

25-30% experience ongoing problems -- marital 25-30% experience ongoing problems -- marital distress, loneliness, anxiety and depression distress, loneliness, anxiety and depression (Dahlquist et al., 1996; Kupst et al., 1995; Van (Dahlquist et al., 1996; Kupst et al., 1995; Van Dongen-Melman et al., 1995). Dongen-Melman et al., 1995).

35 -37% endorse moderate-severe symptoms of 35 -37% endorse moderate-severe symptoms of posttraumatic stress at least one year following posttraumatic stress at least one year following treatment (Barakat et al., 1997, Manne et al., treatment (Barakat et al., 1997, Manne et al., 1998). 1998).

Are Siblings at Risk?Are Siblings at Risk? Siblings may be at greater risk than the Siblings may be at greater risk than the

child with cancer (Cairns et al., 1979)child with cancer (Cairns et al., 1979) Symptoms includeSymptoms include

• GuiltGuilt• withdrawal, withdrawal, • AnxietyAnxiety• jealousy jealousy • aggressiveness, aggressiveness, • feelings of abandonment/rejection by parents feelings of abandonment/rejection by parents • poor academic achievementpoor academic achievement• social isolation social isolation

(Carr-Gregg &White, 1987). (Carr-Gregg &White, 1987).

Predictors of Better Psychological Predictors of Better Psychological Adjustment among PatientsAdjustment among Patients

Lower perceived stress (disease-specific Lower perceived stress (disease-specific and non-disease related)and non-disease related)

Higher social support (family, classmate Higher social support (family, classmate and teacher)and teacher)

Family functioning – higher cohesion and Family functioning – higher cohesion and expressivenessexpressiveness

Higher perceived physical appearanceHigher perceived physical appearance Lower parental distressLower parental distress

Role of Parental AdjustmentRole of Parental Adjustment Reviews:Reviews: Child’s adjustment positively Child’s adjustment positively

associated withassociated with• Maternal adjustmentMaternal adjustment• Marital/family adjustmentMarital/family adjustment• Family support/cohesionFamily support/cohesion

(Lavigne & Faier-Routman (1993). J Dev. Behav. Pediatr. 14:117 123; (Lavigne & Faier-Routman (1993). J Dev. Behav. Pediatr. 14:117 123;

Drotar (1997) J. Pediatr Psychol, 22:149-165)Drotar (1997) J. Pediatr Psychol, 22:149-165)

Prospective study:Prospective study: Maternal distress Maternal distress following diagnosis positively associated following diagnosis positively associated with child’s psychological adjustment 2 with child’s psychological adjustment 2 years later. years later.

(Sawyer et al., (1998). J. Am. Acad. Child Adolesc. Psychiatry, 37:815-822.)(Sawyer et al., (1998). J. Am. Acad. Child Adolesc. Psychiatry, 37:815-822.)

Intervention StudiesIntervention Studies

Possible to identify Possible to identify modifiable vulnerability modifiable vulnerability factors and target them factors and target them for intervention.for intervention.• Parental distressParental distress• Family functionFamily function

Intervention Studies - FewIntervention Studies - Few Kupst & Schulman, 1988:Kupst & Schulman, 1988: Outreach Outreach

support associated with improved support associated with improved maternal coping in early treatment, but no maternal coping in early treatment, but no differences from controls at 1, 2, or 6-8 differences from controls at 1, 2, or 6-8 year follow-up year follow-up (J. Pediat. Psychol. 13:7-22).(J. Pediat. Psychol. 13:7-22).

Hoekstra-Weebers et al., 1998.Hoekstra-Weebers et al., 1998. Psychoeducational intervention in first 6 Psychoeducational intervention in first 6 months after diagnosis found to be months after diagnosis found to be supportive, but no differences from supportive, but no differences from standard care controls on psychological standard care controls on psychological functioning or negative affect functioning or negative affect (J. Pediatr. Psychol. 23:207-214)(J. Pediatr. Psychol. 23:207-214)

Objective of Pilot StudyObjective of Pilot Study

To develop an intervention for To develop an intervention for children newly diagnosed with cancer children newly diagnosed with cancer and their families designed to and their families designed to address modifiable risk factors, address modifiable risk factors, includingincluding• Patient, sibling and parental stressPatient, sibling and parental stress• Social supportSocial support• Family Functioning Family Functioning • Coping strategies/ problem-solvingCoping strategies/ problem-solving

Design of the InterventionDesign of the Intervention

Information used to develop the Information used to develop the intervention was gathered from:intervention was gathered from:

1.1. The literatureThe literature

2.2. The Parent Advisory Group at CHPThe Parent Advisory Group at CHP

3.3. Clinical experience at CHPClinical experience at CHP

4.4. Similar interventions designed for Similar interventions designed for adult patientsadult patients

Initial InterventionInitial Intervention

6 sessions lasting from 60-90 6 sessions lasting from 60-90 minutes scheduled within the first 3 minutes scheduled within the first 3 months following diagnosismonths following diagnosis

Children seen separately from Children seen separately from parents for 45 minutes of this period. parents for 45 minutes of this period.

Flexible timing of sessions to fit in Flexible timing of sessions to fit in with medical treatment with medical treatment

Order of sessions fixed Order of sessions fixed

The InterventionThe Intervention

Session 1Session 1 Building rapport/telling storyBuilding rapport/telling story

Stress and coping assessmentStress and coping assessment

Introduction to relaxationIntroduction to relaxation

Session 2Session 2 CBT: thoughts, feelings, CBT: thoughts, feelings, expectations about illnessexpectations about illness

Impact on whole familyImpact on whole family

Session 3Session 3 Stress management and Stress management and coping skills trainingcoping skills training

Session 4Session 4 Coping skills: emotion versus Coping skills: emotion versus problem focusedproblem focused

Active behavioral and cognitive Active behavioral and cognitive techniquestechniques

Normalization of family routineNormalization of family routine

Session 5Session 5 Parenting ill child and his/her Parenting ill child and his/her siblings siblings

Communication in the familyCommunication in the family

Social skills trainingSocial skills training

Session 6Session 6 Review and application of skillsReview and application of skills

Health BehaviorsHealth Behaviors

Feasibility Study Feasibility Study SubjectsSubjects

• 28 patients, 6-18 years and their 28 patients, 6-18 years and their primary caregiver(s) and any siblings primary caregiver(s) and any siblings within the study age range living at within the study age range living at homehome

• Within one month of a new diagnosis of Within one month of a new diagnosis of acute lymphoblastic leukemia or acute lymphoblastic leukemia or lymphomalymphoma

RecruitmentRecruitment

Eligible Patients Eligible Patients N = 28N = 28

Consented to hear about Consented to hear about projectproject

N = 25 (89%)N = 25 (89%)

Consented to be randomizedConsented to be randomized N = 20 (80%)N = 20 (80%)

Dropped out after Dropped out after consent/prior to consent/prior to randomizationrandomization

N = 1N = 1

Intervention groupIntervention group

Drop outsDrop outsN = 13/20 (65%)N = 13/20 (65%)

N = 5/13 (38%)N = 5/13 (38%)

Standard care controlsStandard care controls

Drop outsDrop outsN = 6/20 (30%)N = 6/20 (30%)

N = 2/6 (33%)N = 2/6 (33%)

Completed interventionCompleted intervention N = 8 (intervention)N = 8 (intervention)

N = 4 (controls)N = 4 (controls)

Barriers to ParticipationBarriers to Participation

Large catchment area – separate Large catchment area – separate intervention visits not feasibleintervention visits not feasible

Difficulty accessing family members Difficulty accessing family members who do not attend clinic visitswho do not attend clinic visits

Problem findings time with flexibilityProblem findings time with flexibility Changes in treatment protocolChanges in treatment protocol

Outcome MeasuresOutcome Measures

Patient and Sibling Quality of LifePatient and Sibling Quality of Life• The Pediatric Cancer Quality of Life Inventory The Pediatric Cancer Quality of Life Inventory

(Varni et al., 1998) (Varni et al., 1998) • TThe Child Health Questionnaire (Landgraff et he Child Health Questionnaire (Landgraff et

al.,1996) al.,1996) (Patient, siblings)(Patient, siblings) Parental DistressParental Distress

• The SP36 (Ware et al., 1994) The SP36 (Ware et al., 1994) • Perceived Stress Scale (Cohen et al., 1983)Perceived Stress Scale (Cohen et al., 1983)• SCL-90-R (Derogatis, 1983) SCL-90-R (Derogatis, 1983) • Parenting Stress Index (Abidin, 1983Parenting Stress Index (Abidin, 1983))

Outcome Measures, ContOutcome Measures, Cont

Child DistressChild Distress• CDI (Kovacs, 1992)CDI (Kovacs, 1992)• State/Trait Anxiety Inventory for State/Trait Anxiety Inventory for

Children (STAIC; Spielberger, 1973) Children (STAIC; Spielberger, 1973) • Children’s Hassles Scale (CHS; Kanner, Children’s Hassles Scale (CHS; Kanner,

Harrison & Wertlieb,1985)Harrison & Wertlieb,1985)

Moderator VariablesModerator Variables

Social Support (Child, sibling and Social Support (Child, sibling and parent)parent)

Coping Coping Family EnvironmentFamily Environment

Control VariablesControl Variables

Demographics – age, SESDemographics – age, SES

Disease factors (stage, treatment)Disease factors (stage, treatment)

Mean group differences post-Mean group differences post-interventionintervention

ControlControl InterventionIntervention ANOVA ANOVA

(p)(p)

Depressive Depressive Symptoms Symptoms (CES-D)(CES-D)

22.4022.40 14.1714.17 .04.04

AnxietyAnxiety 29.0529.05 23.4223.42 .009.009

Social supportSocial support 4.224.22 5.605.60 .05.05

SF36- mental SF36- mental wellbeingwellbeing

39.7239.72 46.8346.83 .09.09

““Connections to Coping”Connections to Coping”NCI Funded RCT NCI Funded RCT

Intervention was modified based on Intervention was modified based on barriers to participation identified in barriers to participation identified in feasibility studyfeasibility study

• Multimodal: Multimodal: web site- bulletin boardsweb site- bulletin boards Telephone contactTelephone contact

• Shorter sessions in clinic – 30 minutesShorter sessions in clinic – 30 minutes• 2 in-home visits2 in-home visits• Full time clinician in clinicFull time clinician in clinic

A Stress Management A Stress Management Intervention for Children with Intervention for Children with Moderate, Persistent AsthmaModerate, Persistent Asthma

Anna Marsland, Ph.D., R.N.; David P. Skoner, M.D.; Lin Ewing, Anna Marsland, Ph.D., R.N.; David P. Skoner, M.D.; Lin Ewing, Ph.D., R.N.; Rhonda Rosen, M.S.W.; Amanda Thompson, Ph.D.; Ph.D., R.N.; Rhonda Rosen, M.S.W.; Amanda Thompson, Ph.D.;

Kristin Long; Megan Ganley; & Sheldon Cohen, Ph.D.Kristin Long; Megan Ganley; & Sheldon Cohen, Ph.D.

Why Pediatric Asthma?Why Pediatric Asthma?

Etiology multifactorial – precipitants Etiology multifactorial – precipitants • Environmental – allergensEnvironmental – allergens• Physiological – predisposition to allergies Physiological – predisposition to allergies

and upper respiratory infection (80-85% and upper respiratory infection (80-85% of pediatric exacerbations involve URI)of pediatric exacerbations involve URI)

• Psychological – psychological stress, Psychological – psychological stress, negative emotional states/excitementnegative emotional states/excitement

Stress can trigger or exacerbate Stress can trigger or exacerbate acute and chronic asthma in children acute and chronic asthma in children (Sandberg et al., 2000) (Sandberg et al., 2000)

Theoretical Model: Potential Theoretical Model: Potential Pathways linking stress to asthma Pathways linking stress to asthma

1.1. Behavioral:Behavioral: e.g., adherence to e.g., adherence to prophylactic meds, changes in sleep, prophylactic meds, changes in sleep, diet, activitydiet, activity

2.2. Physiological –Physiological – Stress is associated Stress is associated with activation of innate with activation of innate inflammatory paths likely to be inflammatory paths likely to be involved in asthma exacerbation involved in asthma exacerbation

3.3. Physiological –Physiological – stress is associated stress is associated with increased susceptibility to URI with increased susceptibility to URI in childrenin children

Psychosocial Interventions in Psychosocial Interventions in Childhood Asthma Childhood Asthma (McQuaid et al., 2000)(McQuaid et al., 2000)

6 studies 6 studies All used relaxation trainingAll used relaxation training Findings promisingFindings promising

• Improvement in pulmonary Improvement in pulmonary function, especially for function, especially for children who endorse children who endorse emotionally-triggered emotionally-triggered asthmaasthma

Stress Management Intervention Stress Management Intervention and Susceptibility to URI and Susceptibility to URI (Hewson-Bower & (Hewson-Bower &

Drummond (2001)Drummond (2001)

Comprehensive stress management Comprehensive stress management intervention – relaxation training, intervention – relaxation training, emotion management, coping skills emotion management, coping skills training and problem solvingtraining and problem solving

Associated with reduction of URI Associated with reduction of URI symptoms among children with symptoms among children with recurrent URIs recurrent URIs

THOUGHT

Things you say to yourself

FEELINGS

How you feel

YOURBODY

ACTIONSThings you do

The Asthma Model

ASTHMA

Session 1: The Role of BreathingSession 1: The Role of Breathing

Introduction to ProgramIntroduction to Program Point SystemPoint System Introduce relationships between stress, Introduce relationships between stress,

breathing, and asthmabreathing, and asthma Introduce biofeedback and belly Introduce biofeedback and belly

breathingbreathing

HomeworkHomework Daily breathing practiceDaily breathing practice Stress logStress log

Session 2: Physical responses to Session 2: Physical responses to Stress and RelaxationStress and Relaxation

Learn about stress (focus on physical Learn about stress (focus on physical responses)responses)

How can stress trigger asthmaHow can stress trigger asthma Learn about relaxation (physical responses) Learn about relaxation (physical responses) Teach body awareness relaxation with hand Teach body awareness relaxation with hand

temperature feedbacktemperature feedback

HomeworkHomework• Daily body awareness exercise Daily body awareness exercise

recording hand temperaturerecording hand temperature• Continue stress logContinue stress log

Session 3: Thoughts and FeelingsSession 3: Thoughts and Feelings

Use Stress journal to introduce relationship Use Stress journal to introduce relationship between thoughts and feelings (CBT exercises) between thoughts and feelings (CBT exercises)

Discuss different methods of coping – including Discuss different methods of coping – including distraction and shifting attentiondistraction and shifting attention

Discuss the physical symptom of muscle Discuss the physical symptom of muscle tensiontension

Introduce progressive muscle relaxation with Introduce progressive muscle relaxation with EMG feedbackEMG feedback

HomeworkHomework• Daily PMR practiceDaily PMR practice• Thoughts and feelings exerciseThoughts and feelings exercise

Progressive Muscle Relaxation

Session 4: Coping with Session 4: Coping with EmotionsEmotions

Introduce range of emotions Introduce range of emotions Link emotions to physical reactionsLink emotions to physical reactions How to cope with emotionsHow to cope with emotions

• Tolerance/ calm thoughts/expressing emotion. Tolerance/ calm thoughts/expressing emotion. Shifting attention Shifting attention

Emotions and asthmaEmotions and asthma Guided imagery as method of relaxation with Guided imagery as method of relaxation with

hand temperature feedbackhand temperature feedbackHomeworkHomework

• Daily imagery relaxation practice Daily imagery relaxation practice • Coping with emotions work sheetCoping with emotions work sheet

Session 5: Session 5: Thoughts, Feelings, Thoughts, Feelings, Sensations, and AsthmaSensations, and Asthma

Relationships between thoughts, Relationships between thoughts, feelings, behaviors and asthma feelings, behaviors and asthma

Apply coping strategies to situations in Apply coping strategies to situations in stress logstress log

Apply coping strategies to handling Apply coping strategies to handling asthmaasthma

Practice preferred relaxation and Practice preferred relaxation and discuss generalization of skillsdiscuss generalization of skills

HomeworkHomework• Daily practice of relaxation of choiceDaily practice of relaxation of choice• CBT worksheetCBT worksheet

Session 6: Session 6: My Coping with My Coping with Emotions and Asthma PlanEmotions and Asthma Plan

Pull together coping strategies and Pull together coping strategies and develop an individualized plan for develop an individualized plan for coping with asthma coping with asthma

Review skills and discuss Review skills and discuss maintenancemaintenance

Practice preferred relaxation and Practice preferred relaxation and discuss generalization of skillsdiscuss generalization of skills

Rewards and goodbyesRewards and goodbyes

MY COPING SKILLS

Belly Breathing Relaxing and calming down by slow breathing using the muscles of the diaphragm so that the belly moves in and out.

Pursed Lip Breathing Controlling wheezing by breathing out through pursed lips to help get air in and out of the lungs

Body Relaxation Controlling tension in the body by breathing deeply and moving attention away from a stressful thought and concentrating on parts of the body.

Exercise and playing Controlling feelings of stress or tension by exercising or playing

Caring for yourself- eating and sleeping well Controlling feelings of stress or tension by getting a good nights sleep and eating a balanced diet

Thought Digging/ Positive thinking Change negative thoughts to more positive thoughts that make you feel better and control tension

Many meanings Changing negative thoughts by searching for different meanings to change your thoughts about an event

Shifting attention Moving attention away from a stressful thought or feeling by concentrating on something else instead or changing what you are doing.

Muscle Relaxation Controlling tension in the body by tensing and relaxing muscles

Surfing Unpleasant Feelings 1. Thinking calm thoughts2. Letting emotions out (talking, writing..)3. Releasing emotions – exercise, relaxation4. Shifting Attention

The Smiling Trick Smiling to yourself to let go of tension in the face and feel better

Relaxation using Imagery Controlling tension in the body by imagining something pleasant

Mini Relaxations Reducing the tension from a stressful event, a thought or wheezing with a short break for relaxation

Steps in Research ProcessSteps in Research Process

1.1. Identify clinical populationIdentify clinical population• Dr. David Skoner – Pulmonologist/Co-IDr. David Skoner – Pulmonologist/Co-I

““Recruitment will be no problem”Recruitment will be no problem” Secure funding for pilot studySecure funding for pilot study

• Fetzer Institute – funded a 2 year pilot project Fetzer Institute – funded a 2 year pilot project in June 2003 (no cost extension – grant ended in June 2003 (no cost extension – grant ended June 2006)June 2006)

1.1. Create intervention materials: Create intervention materials: • 6 months – complete December 20046 months – complete December 2004

The “I Can Cope” Pilot StudyThe “I Can Cope” Pilot Study

Subjects: 20 childrenSubjects: 20 children• 8-12 year-old8-12 year-old• Diagnosis of moderate, persistent Diagnosis of moderate, persistent

asthmaasthma• Endorse emotional triggersEndorse emotional triggers

Randomly assigned to intervention Randomly assigned to intervention (N = 10) and control (N=10) groups(N = 10) and control (N=10) groups

Intervention: Six 60 minute Intervention: Six 60 minute individual sessions within 3 month individual sessions within 3 month periodperiod

Pre- and post-intervention Pre- and post-intervention MeasuresMeasures

2 week daily diary completed in morning and at 2 week daily diary completed in morning and at bedtimebedtime• Asthma symptomsAsthma symptoms• Affect measure - POMSAffect measure - POMS• Perceived Stress - PSSPerceived Stress - PSS• Open ended stress questionOpen ended stress question• Peak flow measurePeak flow measure

Lung function- spirometryLung function- spirometry Salivary cortisol: measured 4 times/day for 2 daysSalivary cortisol: measured 4 times/day for 2 days Questionnaires completed by guardian and child – Questionnaires completed by guardian and child –

CBCL/ POMS/ CDI/ STAI/ PSSCBCL/ POMS/ CDI/ STAI/ PSS

Recruitment NightmareRecruitment Nightmare Recruitment started in January 2004 and Recruitment started in January 2004 and

finished in September 2006finished in September 2006 Enormous recruitment effortsEnormous recruitment efforts

• Letter to all Dr. Skoner’s patientsLetter to all Dr. Skoner’s patients• Asthma fair in 2004 and 2005Asthma fair in 2004 and 2005• Asthma basketball clinic 2005Asthma basketball clinic 2005• Respiratory Alliance newsletter – to 3,000 Respiratory Alliance newsletter – to 3,000

individuals in Western PAindividuals in Western PA• UPMC and Pitt voice mailUPMC and Pitt voice mail• TV/newspaper/magazinesTV/newspaper/magazines• Extended recruitment to CHPExtended recruitment to CHP• Letters to pediatricians/flyers in doctors Letters to pediatricians/flyers in doctors

officesoffices• Presence in CHP clinicsPresence in CHP clinics

ResultsResults

Total number screened: 28Total number screened: 28 24 eligible24 eligible 8 not interested (too far, don’t drive, child 8 not interested (too far, don’t drive, child

not interested)not interested) 16 enrolled (13 intervention/3 control)16 enrolled (13 intervention/3 control) 11 completed intervention (2 dropouts 11 completed intervention (2 dropouts

after session 1 – practical reasons)after session 1 – practical reasons) 1 completed control (2 dropouts- no 1 completed control (2 dropouts- no

response)response)

Decrease in Depression** and Decrease in Depression** and Anxiety* (POMS)Anxiety* (POMS)

Child Self-Reported Anxious and Depressed Affect before and after the Intervention (N = 11)

00.5

11.5

22.5

3

Pre- Post-

Intervention

PO

MS

Sc

ore

Anxiety

Depression

** t=3.37, p<.006** t=3.37, p<.006 * t=1.52, p<.16* t=1.52, p<.16

Decrease in Perceived Stress Decrease in Perceived Stress (PSS)**(PSS)**

Child Perceived Stress in Response to the Intervention (N = 11)

8

13

18

23

Pre- Post-

Intervention

Pe

rce

ive

d S

tre

ss

S

ca

le S

co

re

** t=4.44, p<.001** t=4.44, p<.001

Improved Lung Function*Improved Lung Function*

Lung Function Measures for Pre and Post Stress Management Interventions

1

1.2

1.4

1.6

1.8

2

2.2

2.4

2.6

2.8

A02 A03 A04 A05 A07 A09 A13 A14

Participants

Sp

iro

metr

y R

ead

ing

s

Pre InterventionPost Intervention

* t=-3.02, p<.02* t=-3.02, p<.02

Results, Cont’dResults, Cont’d

Additional trends:Additional trends:

• Increased self-reported social support from Increased self-reported social support from teachers (t = -1.16, p < .14 )teachers (t = -1.16, p < .14 )

• Parent-reported reductions in problems on Parent-reported reductions in problems on CBCL:CBCL:

School problems (t = 1.64, p < .14)School problems (t = 1.64, p < .14) Social problems (t = 1.60, p < .14)Social problems (t = 1.60, p < .14) Attention problems (t = 1.46, p < .18)Attention problems (t = 1.46, p < .18) Total problems (t = 1.42, p < .19)Total problems (t = 1.42, p < .19)

Feedback from ParticipantsFeedback from Participants

Overall positive:Overall positive: Skills to avoid asthma episodesSkills to avoid asthma episodes Skills used to handle stress in general Skills used to handle stress in general

(relationships, school, auditions)(relationships, school, auditions) Improvement in a participant’s eczemaImprovement in a participant’s eczema Requests to bring non-asthmatic Requests to bring non-asthmatic

siblings in for trainingsiblings in for training Very encouragingVery encouraging

Obstacles to StudyObstacles to Study

Lack of interestLack of interest Location – many unwilling to come Location – many unwilling to come

into Oakland for 6 sessions – “too into Oakland for 6 sessions – “too intense”intense”

Busy lives – difficult to schedule Busy lives – difficult to schedule sessionssessions

““Too many questionnaires”Too many questionnaires” Busy doctorsBusy doctors

Moral of the StoryMoral of the Story