Violence, Stress Associated With Increased Asthma Severity in Children

Deborah Brauser

March 12, 2010

March 12, 2010 (New Orleans, Louisiana) — Stress and violent crime can contribute to the severity of childhood asthma, according to a longitudinal study presented here at the American Academy of Allergy, Asthma and Immunology (AAAAI) 2010 Annual Meeting.

Although these associations have been suggested in previous research, Ruchi Gupta, MD, MPH, assistant professor of pediatrics at Children's Memorial Hospital in Chicago, Illinois, told meeting attendees that the way "factors affect children remain unclear. This is the first study to look at the impact of real vs perceived violence on asthma."

"Our findings show that, in addition to stress, there may be other things causing this increased asthma severity," Dr. Gupta said in an interview with Medscape Allergy and Clinical Immunology. "The whole built-in environment that the children are living in may influence it and, where there is high violence, there may be other issues. I think this is the first study to address those factors."

Violent Crime Exposure Predicts Asthma Severity

Asthma rates are greater than 20% in certain areas of Chicago, with subsequent hospitalization rates being twice the national average and asthma-related deaths among the highest in the country, reported Dr. Gupta.

In this analysis, her team evaluated data from the Chicago Initiative to Raise Asthma Health Equity study, which included information on asthma burden, caregiver stress, and child/caregiver exposure to violence in 561 children (58.7% male; 57.4% black, 25.1% white, 15.9% Hispanic) with asthma between the ages of 8 and 14 years.

"The actual incidence of violence was obtained from the Chicago Police Department," explained Dr. Gupta.

Clinical data examined included radioallergosorbent tests, spirometry, body mass index, and saliva specimens.

Results at the end of the 18-month analysis showed that 41% of the children had moderate/severe asthma, and 49% had asthma classified as intermittent/mild.

When caregivers reported hearing or seeing violence, experienced high levels of stress, or lived in areas that had high levels of violent crime, the odds of their children having moderate/severe asthma were significantly increased:

Odds of Children Having Moderate/Severe Asthma by Caregiver-Reported Environment

Caregiver-Reported Environment Odds Ratio Confidence Interval
Heard violence 1.50 1.05 - 2.15
Witnessed violence 1.84 1.20 - 2.82
Had high levels of stress 2.13 1.24 - 3.67
Lived in area with high incidence of violent crime 2.43 1.43 - 4.14

However, "after adjustment for age, gender, household asthma status, and socioeconomic status, only the incidence of violent crime remained significant predictors of asthma severity [odds ratio [OR], 1.79; 95% confidence interval [CI], 1.02 - 3.17]," reported Dr. Gupta.

After adding stress to the model, violent crime remained predictive of moderate/severe asthma (OR, 1.98; 95% CI, 1.11 - 3.54). After adding race/ethnicity to the model, the risk remained but was no longer statistically significant.

"Although heightened levels of actual violence, perceived violence, and stress all appear to be associated with asthma in children, our data suggest that actual incidence of violence and caregiver stress are more predictive of asthma severity," said Dr. Gupta.

"While actual violence may be affecting asthma through the stress pathway, our findings suggest that additional mechanisms may be at work," she added.

When asked about potential implications of this study, Dr. Gupta said that the identification of mutable community contributors to asthma severity could alter approaches to asthma on multiple levels, including management plans and anticipatory guidance from primary care physicians, awareness efforts and intervention strategies from public health and translational researchers, and investigation into the development and progression of asthma.

"This reinforces the need to consider [the contribution of] gene-environment interactions or biophysiological pathways to outcomes."

The research team hopes to move into communities to explore possible asthma contributors. "The problem with databases is that there are always so many variables," said Dr. Gupta. "You try to isolate what you think is most important but the only real way to know is to actually go in there and ask, and then figure out what interventions work best."

Tying Together Subjective Symptoms and Objective Findings

"This is very interesting because it was able to tie in not only subjective symptoms but also the objective findings from the Chicago Police Department reports [regarding] actual acts of violence and then correlating that to asthma control," said session moderator Asriani Chiu, MD, associate professor of allergy at the Medical College of Wisconsin in Milwaukee and chair of AAAAI's Underserved Committee.

"I think that what is extremely important, especially in chronic diseases such as asthma, is that there are many different factors besides physiologic mechanisms of the disease process, such as the psychosocial effects that are in [a patient's] environment," added Dr. Chiu. "I think that clinicians really need to pay attention to this. There have been other studies, but this one pointed out more objectively how much of a role violence can play in the control of these chronic diseases."

Dr. Chiu, who was not involved with the study, noted that she would have liked to have seen some additional data, such as medication use and its adherence, and the examination of other coping mechanisms, such as community youth groups. "But as I understand it, those might be things they'll look at as they continue delving into their research."

"I don't know if most major cities would have the resources to conduct this type of study, but they can certainly use the data and extrapolate it, especially if their demographics and other information are similar," she added. "I think regardless of whether a particular city would be able to [conduct such a] study, they can use this information to benefit all their patients and healthcare providers."

Dr. Gupta and Dr. Chiu have disclosed no relevant financial relationships.

American Academy of Allergy, Asthma and Immunology (AAAAI) 2010 Annual Meeting: Abstract 480. Presented February 28, 2010.

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