Association of Asthma Illness Representations and Reported Controller Medication Adherence Among School-Aged Children and Their Parents

Jennifer Sonney, PhD, APRN, PPCNP-BC; Kathleen C. Insel, PhD, RN; Chris Segrin, PhD; Lynn B. Gerald, PhD, MSPH; Ida M. Ki Moore, DNS, RN, FAAN


J Pediatr Health Care. 2017;31(6):703-712. 

In This Article


To our knowledge, this is the first study to describe asthma illness representations of children and their parents, examine their interdependence, and describe the relationship between asthma medication adherence and illness representations of parents and school-aged children. Parent asthma illness representations indicate that asthma severity, duration, and symptom domains were the most problematic. Parents in this study believed that their child's asthma medications were efficacious, that medication necessity outweighed concerns, and that they had good control over their child's asthma. For children, asthma duration was the most problematic illness representation domain, followed by personal control and symptoms, such that children believed they had little control over their asthma duration and symptoms. Children had very little concern over their asthma severity and medication efficacy. Like their parents, children believed that medication necessity outweighed concerns.

With one exception, there were weak or no significant correlations between respective parent and child illness representation domains. These findings indicate that parent and child asthma illness representations were not interdependent, as one might expect, but rather independent. The only known study that has previously described correlation between parent and child illness representation variables reported significant correlations for both parent and child BMQ necessity (r = 0.74, p < .001) and BMQ concerns (r = 0.53, p = .009; Yilmaz et al., 2012). The sample in Yilmaz et al. (2012), however, comprised 24 children and their parents presenting to the emergency department for an asthma exacerbation, and child respondents were 7 years of age or older. The present study showed a much weaker relationship, although the children in the present study had relatively well-controlled asthma and no exacerbations for at least 30 days.

"Parent and child asthma illness representations were not interdependent, as one might expect, but rather independent."

Possible explanations for the independence of parent and child asthma illness representations found in this study may relate to how one experiences childhood asthma and the cognitive capacity of the child. The inherent challenge in understanding parent–child asthma illness representations is that children subjectively experience their disease, whereas the parental perspective is more objective or based on observations (Sonney, Gerald, & Insel, 2016). By extension, these varied experiences with asthma may account for the differences in asthma illness representations. Another possibility relates to the cognitive capacity of the child. School-aged children may lack the capacity for appreciating the more abstract components of asthma, such as consequences of disease.

Predictors of reported medication adherence varied among parents and children. Parent medication necessity–concern differential and child beliefs about treatment efficacy were predictive of parent-reported medication adherence. The medication–concern differential has frequently been cited as predictive of controller medication adherence in adult asthma literature (Horne and Weinman, 2002, Menckeberg et al., 2008, Ponieman et al., 2009, Sofianou et al., 2013). No other parental illness representation variables were predictive of parent-reported medication adherence. This contrasts with the adult asthma literature, where self-reported timeline, identity, and consequences domains have all been described as predictors of adherence (Horne and Weinman, 2002, Sofianou et al., 2013). These findings suggest that there may be important differences between predictors of adult self-management and parent–child shared management of asthma. To our knowledge, the only published study that described parental asthma illness representations reported that illness representation domains had direct effects on medication adherence, but the respective effects of each illness representation domain were not described (Yoos et al., 2007).

Although there are some similarities between parent and child asthma illness representations, parents do not appear to influence children's estimation of controller medication adherence. The only predictor of child-reported medication adherence was child medication necessity–concern differential. This finding suggests that BMQ differential is an important predictor of asthma controller medication adherence regardless of age or respondent type (self or proxy).

There are several important limitations to this study that may limit the generalizability of findings. First, the convenience sample recruited from a respiratory center may not be representative of all school-aged children with persistent asthma and their parents/caregivers. The sample was recruited from the Tuscon area, and most the children had well-controlled asthma. Self-report instruments were used to assess asthma illness representations, medication adherence, and asthma control, which risks potential reporting bias. The sample size limited the power of the available statistical analyses, although it was sufficient for regression analyses with two predictor variables. It is possible, however, that a Type I error led to some of the reported significant correlations. When available, citations from existing literature were used to corroborate findings; however, the pool of relevant literature is extremely limited.

Findings from this study indicate that there is little interdependence between parent and child asthma illness representations, nor do parent or child illness representations predict the other's estimation of asthma controller medication adherence. Although the parental representations of asthma severity and duration may be more aligned with the professional model, failure to account for the child perspective is a critical omission. School-aged children spend increasing amounts of time away from their parents (e.g., school, friends) and therefore assume increasing responsibility for their asthma management. Given that asthma illness representations are potentially modifiable (Klok et al., 2011, Ponieman et al., 2009), improved undestandng of parent and child asthma illness representations may inform future medication adherence interventions. It is possible that interventions may need to target different illness representation domains for parents and children.

"Interventions may need to target different illness representation domains for parents and children."

There are no other known studies describing child asthma illness representations with which to compare these findings; therefore, results of this study highlight an opportunity for further investigation of the role of parent and child asthma illness representations on controller medication adherence. Importantly, findings from this study indicate that school-aged children develop illness representations somewhat independently from their parents and, therefore, are critical participants in asthma care and research.