Psychosomatic Medicine Tips for Better Browsing
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
This Article
Right arrow Abstract Freely available
Right arrow Figures Only
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Stevenson, J.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Stevenson, J.
Related Collections
Right arrow Personality
Right arrow Pulmonary
Right arrow Stress and Coping
Psychosomatic Medicine 65:971-975 (2003)
© 2003 American Psychosomatic Society

ORIGINAL ARTICLES

Relationship Between Behavior and Asthma in Children With Atopic Dermatitis

Jim Stevenson, PhD for the ETAC Study Group

Center for Research into Psychological Development, Department of Psychology, University of Southampton, United Kingdom, on behalf of the ETAC Study Group.

Address for correspondence and reprint requests to Professor Jim Stevenson, Center for Research into Psychological Development, Department of Psychology, University of Southampton, Highfield, Southampton SO17 1 BJ, UK. E-mail: jsteven{at}soton.ac.uk


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
OBJECTIVE: The significance of psychological factors in asthma is a subject of considerable dispute. This study addressed the little investigated question of the potential role of psychological factors in the initial onset of asthma.

MATERIALS AND METHODS: Data on the validated, standardized Behavior Screening Questionnaire were obtained prospectively from 35 to 53 months for 150 atopic children who had asthma by age 53 months and for 115 who did not.

RESULTS: At each age, the children who had asthma by 53 months had more behavior problems. There was no evidence that the subsequent behavior of those children who had asthma became more problematic. However, for those children without asthma by 35 months, an elevated behavior problem score at that age was related to the subsequent onset of asthma by age 53 months. The behavior problem score added significantly to the prediction of asthma onset (OR adjusted: 1.15; 95% CI: 1.02–1.29) when known risk factors of asthma and IgE levels for grass pollen and house dust mite at age 17 months were taken into account.

CONCLUSIONS: Behavior problems may precede asthma onset in young atopic children. In this age group, behavior problems are not secondary psychological reactions to asthma onset. They may act as a marker for stress in the child’s life. The presence of behavior problems should alert clinicians that the child may be at increased risk for transition from atopic dermatitis to asthma.

Key Words: atopic dermatitis, • asthma, • child behavior, • cetirizine.

Abbreviations: ETAC = Early Treatment of the Atopic Child study;; BSQ = Behavior Screening Questionnaire;; HDM = house dust mite;; GP = grass pollen;; ITT = intention to treat.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
The relationship between psychological factors and symptoms of asthma and other allergic disorders has long been a topic of interest. Initial studies addressed the question of whether asthma was associated with a distinctive personality type, with psychopathology, or should be considered to be a psychosomatic disorder (1). Such studies faced the difficulty of differentiating whether any distinct psychological profile in people with asthma was a contributing cause of the condition or whether it arose as a consequence of the experience of the illness. Attention moved to the possible role of stressful life events and acute asthma episodes in adults (2) and in children (3). These studies have suggested that both chronic difficulties and acute life events stresses contribute to the likelihood of an asthma episode. There have been studies reporting elevated rates of behavior problem in children with early (before the age of 3 years) and with late-onset (after 3 years) asthma compared with those without asthma (4). However, the latter study did not investigate whether behavior differentiated those in whom asthma developed from those in whom it did not.

The present study is concerned with psychological aspects of initial asthma onset in children at risk because of atopic dermatitis and having a family history of atopy. Because the study is longitudinal, the impact of asthma onset on behavior can be determined. It is postulated that elevated levels of behavior problems predict initial asthma onset and that this accounts for the well-documented association between asthma and behavior problems. The latter is shown by the behavioral adjustment difficulties scores for children with asthma being elevated by 0.57 SD in a systematic meta-analysis of 28 samples (5). There have been no studies that have directly addressed the issue of the role of behavior problem in transition to asthma using a prospective study of children with atopic dermatitis. This article aims to establish in a longitudinal study whether those children with atopic dermatitis in whom asthma develops show higher levels of behavior problems before asthma onset than those children with atopic dermatitis without asthma.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
Design
The data were obtained as part of the Early Treatment of the Atopic Child study (ETAC), which is a randomized controlled trial of the antihistamine cetirizine to prevent the onset of asthma in children with atopic dermatitis and a family history of atopy who were initially free of asthma. The study protocol was given ethical approval at each of the sites in the 14 countries involved in ETAC. The children were enrolled into the study between their first and second birthdays after written informed consent was obtained from their parents or guardians. They had atopic dermatitis and had at least one parent or sibling with a history of atopic dermatitis, allergic rhinitis, or asthma. Children with severe developmental or behavior problems, a history of neonatal distress, or sleep apnea (subject or siblings) were not included in the trial. Full details on subject selection can be found (6,7).

Cetirizine 0.25 mg/kg body weight or placebo was administered orally twice daily, once in the morning and once in the evening. At each clinic visit the appropriate dosage according to the child’s weight was evaluated by the investigator. Accuracy of dosing was ensured by the use of a table of correspondence between body weight, dose, and number of drops per intake and by weighing the remaining study samples at the end of the treatment period. It has been shown that the prolonged use of cetirizine did not adversely affect the children’s behavior (8). Indeed, there were no significant differences between the placebo and cetirizine groups in their behavior scores. For the purposes of the present article, these two groups have been analyzed together, and treatment (placebo vs. cetirizine) has been used as a factor in the analyses to check that there were no interactions between treatment and other factors.

Measures
The children’s behavior was assessed using the Behavior Screening Questionnaire (BSQ) (9). The BSQ is a semi-structured screening interview that provides a series of validated questions addressed to the parents concerning the child’s health, behavior, and development in the past 4 weeks. The BSQ deals with the following 12 aspects of behavior: eating, soiling, sleeping, activity, concentration problems, relationships, dependency, management problems, tantrums, moods, worries, and fears. The interviews were performed at the time of visits to the clinic by medical staff specifically trained in the use of this measure.

For each aspect of behavior, standardized questions are asked that prompt the parents into providing detailed accounts of the frequency, intensity, and duration of behavior. On the basis of these accounts, a rating was made of the severity with which the behavior was affected using a prespecified set of categories. In twelve areas of behavior, a 0-1-2-scoring system was used in which 0 indicated the absence of problems in that area, 1 indicated the behavior is present for a mild degree, and 2 indicated that a behavior problem is definitely present. These items were aggregated to give a total BSQ score with a possible range from 0 to 24 (for details of the scoring see (10)). The BSQ can be analyzed either in terms of a mean total BSQ score or by determining the number of individuals that exceed a cutting point of 10 or more, which has been shown to identify a group of 3-year-old children at risk for long-term behavioral difficulties (11).

Timing of Assessment
On entry to the ETAC protocol, the children had a mean age of 17 months. They were seen over a period of 18 months during which they took the study treatment, either cetirizine or placebo (visits 1–8), and then for three subsequent visits after the study medication had been stopped (visits 9–11, 24 to 36 months after inclusion). The BSQ was obtained after 15 and 18 months (visits 7 and 8) of the treatment period and during the posttreatment follow-up period 6, 12, and 18 months after discontinuation of the treatment (visits 9–11). The number of children providing data on the BSQ at visit 7 was reduced as a consequence of a delay initiating BSQ measures in some centers. Accordingly, results will be presented for visits 8 through 11 when the children were, on average, 35, 41, 47, and 53 months of age, respectively.

Asthma Status
The children’s asthma status was assessed on average at 35, 41, and 53 months of age. A child was designated as having asthma if there had been three episodes of nocturnal cough with sleep disturbance lasting for at least 3 nights in succession and/or wheezing, separated by at least 7 days, in a clinical setting in which asthma was likely and conditions other than allergy had been excluded. Even in the absence of the family history it is standard clinical practice to use such criteria to justify commencing asthma therapy (12). The child’s sensitization to allergens were measured at entry to the study for serum total and specific (grass pollen, cow’s milk, egg, house dust mites, and cat dander) IgE antibody levels using the Pharmacia CAP system (Pharmacia & Upjohn, Uppsala, Sweden). These analyses were conducted by a central laboratory (Institut Pasteur-Bio Contract Research, Lille, France) according to manufacturer’s instructions and routine clinical laboratory procedures. Previous analysis had shown raised IgE to house dust mite (HDM) and/or to grass pollen (GP) to be significantly related to subsequent asthma onset (6). In the present analysis these two risk factors were treated as binary values (IgE HDM or IgE GP >=0.35 kUA/L or neither). The initial severity of atopic dermatitis was measured at entry to the study when the children were, on average, 17 months using the SCORAD measure (13).

Statistical Methods
All the data were analyzed using the SAS 6.12 version. The population used in the analysis consisted of all children included in the ITT population (ie, all randomized subjects who received at least one dose of study treatment and for whom follow-up information was available) and for whom data on the BSQ were available.

By 53 months, there were 150 children who had asthma and 115 children who had not and for who in both groups there were BSQ data at all four ages. With two samples of that size, there was 80% power to detect an effect size of 0.35 (the difference in means divided by the pooled SD) with two-tailed alpha of 0.05 (14). This effect size (0.35) would be equivalent to a difference in means on the BSQ of 1.05. This difference is smaller than that which would be considered as clinically significant (14) and the power of the study was therefore adequate.

The total BSQ scores were first analyzed using a repeated measures analysis of variance at ages 35, 41, 47, and 53 months (age). The aim of this analysis was to investigate the effect of age on behavior and whether this age effect was different for children with asthma or those without. The impact of asthma status on behavior at different time-points was determined using multiple regression. The BSQ score at 41 months was predicted by BSQ at 35 months at the first step. Asthma status at 35 months was then added at the second step as a predictor. A comparison between the two models at steps 1 and 2 was performed using the F-test to assess whether asthma status added significantly to the prediction of behavior change between 35 and 41 months. A similar analysis was repeated for change in behavior between 41 and 47 months and between 41 and 53 months. Finally, the possible role of behavior in predicting asthma onset was examined in the subset of children with no asthma at 35 months. A logistic regression was conducted with asthma status at 53 months as the dependent variable and behavior at 35 months as predictor. In addition other known risk factors (IgE levels for house dust mite and grass pollen on entry to the study at age 17 months) were included in the model as predictors of asthma onset. All statistical tests were carried out two-tailed at the 5% significance level.

As patients were allocated in two treatment groups (placebo/cetirizine), all models included treatment effect. In addition, the interaction between treatment and explanatory variables was investigated to ensure the consistency of the overall effect of these explanatory variables between the two treatment groups.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
Association Between Asthma and Behavior Problems
The sample was divided into those with asthma by 53 months (N= 150) and those without (N= 115) and for whom BSQ scores were available at 35, 41, 47, and 53 months. A repeated measures ANOVA showed that there was a significant decline in BSQ score with Age [F (3, 783) = 40.59, p< 0.001]. Children with asthma had higher scores than those without [F (1, 261) = 7.68, p< 0.006], but the decrease in BSQ score with age was similar in both classes of children. There was an interaction between age and treatment [F (3, 783) = 2.84, p< 0.05) produced by the placebo group having a higher score at 41 months only.

In all subsequent analyses the main effects of treatment and interactions with treatment were examined and none was found to be significant. These will not be reported further.

Behavior Change Consequent to Asthma Onset
A series of multiple regression analyses were used to test whether the presence of asthma adversely affected subsequent behavior. Asthma status at 35 months (T1) was used to predict behavior at 41 months (T2) simultaneously with behavior at 35 months and treatment. This was repeated for 41, 47, 41, 53 months as T1 and T2, respectively. The results are summarized in Table 1. For every pair of ages the only significant predictor of the BSQ score at time 2 was the BSQ score at time 1. This autoregressive pattern would be expected given the continuity on behavior problems over a 6-month period at this age. However, there was no statistical evidence for a significant impact of treatment or asthma status on change in behavior between time 1 and time 2 for any pair of ages.


View this table:
[in this window]
[in a new window]
  		TABLE 1. Multiple Regression Analysis Predicting Behavior from Treatment, Asthma Status, and Initial Behavior
 
Asthma Onset and Previous Behavior
The children with no asthma by 53 months have the lowest lower BSQ scores at all ages (Figure 1). Those children with asthma onset after 35 months had higher BSQ scores at 35 months (ie, before asthma onset) than those who do not have asthma. The mean behavior score was as high as it was for those who already had asthma by 35 months (Figure 1).



View larger version (18K):
[in this window]
[in a new window]
  		Figure 1. Mean behavior problem scores (± 95% CI) by age for children with no asthma and for those with asthma onset before and after 35 months.

 
A logistic regression analysis was used to predict asthma onset for those atopic children not showing asthma symptoms at 35 months. Table 2 presents the estimated the odds ratios, for the effects of treatment, levels of IgE to HDM and GP at baseline, and behavior at 35 months and interactions. The behavior score was a significant predictor when other risk factors were present in the model (adjusted OR: 1.15; 95% CI: 1.02–1.29). The prediction of asthma onset was significantly improved when BSQ score was added to the effects of IgE and treatment ({Delta}{chi}2 = 5.52, df = 1, p< 0.02).


View this table:
[in this window]
[in a new window]
  		TABLE 2. Logistic Regression Analysis Predicting Asthma Onset from Initial Behavior and IgE Sensitization
 
It was possible that these elevated BSQ scores were a reflection of a greater initial severity of atopic dermatitis since more severe atopic dermatitis symptoms are more likely to be irritating and upsetting for the child. To test this possibility a measure of severity at entry to the study at 17 months (SCORAD) was correlated with the BSQ scores at 35, 41, 47, and 53 months. At no age was this correlation significant (range r= -0.03–0.09) and the prediction of asthma onset from BSQ score is therefore not an indirect effect of initial atopic dermatitis severity.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
ACKNOWLEDGMENTS
 REFERENCES
 
Children who show an elevated level of behavior problems are at increased risk for subsequent asthma onset. In this young age group, behavior problems are not a secondary psychological reaction to asthma onset. Instead alongside other risk factors such as sensitization to grass pollen and house dust mite behavior problems are an additional risk indicator of asthma onset.

There are number of reasons why behavior might be related to later asthma onset. There is a set of explanations whereby it may act as a marker for other causally important risk factors, ie, by itself behavior does not play a causal role. First the association only reflects the impact of initial severity of atopic dermatitis on behavior. Those children in whom asthma develops show elevated behavior problem scores because their more severe atopic dermatitis creates more discomfort and upset. The findings did not support this explanation since atopic dermatitis severity as assessed by the SCORAD measure was not significantly correlated with behavior score.

Second, elevated behavior scores might be an indicator of chronic or acute stresses in the child’s life (16). More generally, elevated behavior scores could be a product of social disadvantage. However the association between asthma and poverty seems to be specific to the USA (17) and in Europe, where the ETAC was conducted, asthma is associated with affluence (18). It is therefore unlikely that the results presented here are caused by a common association between asthma, behavior, and disadvantage.

Third, the association between atopy and behavior arises through shared genetic influences (19,20). Behavior could then be a marker of pathophysiological processes arising from this genetic basis that have yet to manifest as clinical diagnosis of asthma. This possibility would be consistent with the suggestion that asthma develops slowly in the airways before the first signs of the disease are apparent (21). Increases in behavior problems may then be an indicator that child is experiencing symptoms that are yet to be apparent to the parent or physician.

These are noncausal mechanisms linking behavior and asthma onset. It is also possible that behavior is causally related to asthma onset via an indirect or a direct route. Children with behavior problems provoke greater levels of criticism by their parents (11), which in turn can act as a stress experience increasing the risk of asthma onset (22). The emotional dysregulation accompanying behavioral difficulties may act to enhance asthma risk (23) mediated via the impact of stress on the immune system (24) and to which children with atopic dermatitis may be particularly susceptible (25).

Preventive intervention for asthma onset that attempts to reduce behavior problems will only be effective if behavior problems are either indirectly or directly causally related. If they simply act as a marker for stress or pathophysiological processes, then intervention will only be effective if directed at these factors themselves. However, even if they are not causally implicated, behavior problems may be a valuable indicator for the clinician of the risk of asthma onset in children with atopic dermatitis.

ETAC STUDY GROUP
Scientific Advisory Board:
J.O. Warner (Southampton, GB), L. Businco (Roma, I) 61, G. Casimir (Bruxelles, B), T.L. Diepgen (Heidelberg, D), M. Kjellman (Linköping, S), K. Knol (Groningen, NL), J.L. Menardo (Montpellier, F), C. Naspitz (Sao Paulo, Brasil), F.E.R. Simons (Winnipeg, Canada), U. Wahn (Berlin, D).

Investigators and Co-Investigators:
M. Albertini, T. Bourrier (Nice, F), C.P. Bauer, R. Franz (München, D), G. Bellon, M. Prudon (Lyon, F), E. Bodart (Yvoir, B), A. Boner, P. Fortunati (Verona, I), J. Botey, A.M. Marin (Barcelona, SP), G. Cavagni, M. Gardenghi (Brescia, I), R. Clifford, H. Griffith, G. Tutt (Dorchester, GB), J.P. Darras (Béziers, F), F.M. de Benedictis, P. Pazzelli (Perugia, I), L.E. De Raeve, A. Kempinaire, B Deruyter (Brussels, B), G. Dutau, F. Rancé, M. Dufourg (Toulouse, F), I. Eichler, R. Rath (Wien, A), J.L. Fauquert, A. Piollet, A. Labbé, D. Masclaux (Clermont-Ferrand, F), A. Fiocchi, M. Travaini (Milano, I), R. Fölster-Holst, I. Lange (Kiel, D), K.D. Foote, R. Cottam, P. Gandy (Winchester, GB), R.W. Griffioen, J.H. Sillevis Smitt, J.C. Van Nierop, M. de Langue, J. Aalbers (Amsterdam, NL), A. Grimfeld, F. Sahraoui, F. Lefèvre (Paris, F), M.H. Guillet, G. Guillet (Brest, F),D. Gustafsson, L. Ekholm (Örebro, S), D. Hamel-Teillac, Y. de Prost (Paris, F), I. Huttegger (Salzburg, A), M.T. Laso-Borrego, A. Mesa-Palomino (Madrid, SP), J. Leclercq-Foucart, V. Heinrich (Liège, B), R. Lever, G. Ward (Glasgow, GB), W. Lipschutz (Antwerpen, B), G. Lorette (Tours, F), C. Marguet (Rouen, F), M. Masi, F. Specchia (Bologna, I), P. Meglio, P. Lucenti, M.T. Moretti (Roma, I), C. Möller, G. Forsberg (Umeå, S), F. Muñoz-Lopez, M.T. Giner-Muñoz (Barcelona, SP), A.P. Oranje, A. Wolkerstorfer, H.J. Neijens (Rotterdam, NL), A.M. Oudesluys-Murphy, RN Sukhai (Rotterdam, NL), K.P. Paul, R. Nickel (Berlin, D), M. Petrus, M. Rhabbour, A. Trapes (Tarbes, F), I. Pollock, M. Baird-Snell (Enfield, GB), A. Prehn, R. Seger (Zürich, CH), S. Ridout, S. Matthews, F.C. Kennedy, D. Pearson (Newport, GB), J. Ring, D. Abeck, D. Vieluf (München, D), J. Robert, E. Maumet-Verrot (Lyon, F), U. Schauer, S. Köhler (Bochum, D), R. Seligmann, C. de Beaufort (Luxembourg, L), V. Spièak (Praha, CZ), J.F. Stalder, F. Phéline, M.F. Baudrand (Nantes, F), J. Stevenson (Southampton), I.L. Strannegård, M. Borres (Göteborg, S), A. Taïeb, C. Labrèze, D. Chevalier (Bordeaux, F), J.P. Van Biervliet (Brugge, B), J.K. Van der Woude (Enschede, NL), V. Vanderheyden (Leuven, B), G. Von Pilgrim (Mainz, D), S. Wille, A. Warner (Helsingborg, S), E. Young (Amersham, GB), and the UCB ETAC Team.


   ACKNOWLEDGMENTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
REFERENCES
 
The study on which these findings are based was funded by UCB Pharma, S.A. (Brussels, Belgium).

I am very grateful to Catherine Fortpied of UCB Pharma for her expert assistance with data analysis. This analysis was only possible because of efforts of the investigators on the ETAC study. I thank them and the ETAC Study Board for providing access to the data set and for comments on an earlier draft of the article.

Received for publication October 3, 2002.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 

  1. Graham PJ, Rutter ML, Yule W, et al. Childhood asthma: a psychosomatic disorder? Some epidemiological considerations. Br J Prev Soc Med 1967; 21: 78–C85.[Medline]
  2. Ritz T, Steptoe A, DeWilde S, et al. Emotions and stress increase respiratory resistance in asthma. Psychosom Med 2000; 62: 401–412.[Abstract/Free Full Text]
  3. Sandberg S, Paton JY, Ahola S, et al. The role of acute and chronic stress in asthma attacks in children. Lancet 2000; 356: 982–987.[CrossRef][Medline]
  4. Mrazek DA, Schuman WB, Klinnert M. Early asthma onset: risk of. Emotional and behavioral; difficulties. J Child Psychol Psychiatry 1998; 39: 247–254.[CrossRef][Medline]
  5. McQuaid EL, Kopel SJ, Nassau JH. Behavioral adjustment in children with asthma: a meta-analysis. J Dev Behav Pediatr 2001; 22: 430–439.[Medline]
  6. Wahn U. on behalf of the ETAC Study Group. Allergic factors. associated with the development of asthma and the influence of cetirizine in a double blind, randomized, placebo control trial: First results of ETAC Pediatr Allergy Immunol 1998; 9: 116–124.[Medline]
  7. Warner JO on behalf of the ETAC Study Group. A double blind randomized placebo controlled trial of cetirizine in preventing the onset of asthma in children with atopic dermatais: 18 months treatment and 18 months post-treatment follow-up. J Allegrgy Clin Immunol 2001; 108: 929–937.[CrossRef][Medline]
  8. Stevenson J, Cornah D, Evrard P, et al. A on behalf of the ETAC Study Group. Long-term evaluation of the impact of the H1-receptor antagonist cetirizine on the behavioral, cognitive and psychomotor development of very young children with atopic dermatitis. Pediatr Res 2002; 52: 251–257.[CrossRef][Medline]
  9. Richman N, Graham PJ. A behavior screening questionnaire for use with three year old children: Preliminary findings. J Child Psychol Psychiatry 1971; 12: 5–33.
  10. Hogg C, Rutter M, Richman N. Emotional and behavioral problems in children In: Sclare I ed. Child psychology portfolio. Windsor: NFER-Nelson; 1997: 35–45.
  11. Richman N, Stevenson J, Graham PJ. Pre-school to school. A. behavioral study London: Academic Press; 1982.
  12. Castro-Rodriguez JA, Holberg CJ, Wright AL, et al. A clinical index to define risk of asthma in young children with recurrent wheezing. Am J Resp Crit Care Med 2000; 162: 1403–1406.[Abstract/Free Full Text]
  13. Oranje AP, Stadler J-F, Taieb A, et al. Scoring of atopic dermatitis by SCORAD using a training atlas by investigators from different disciplines. Pediatr Allergy Immunol 1997; 8: 28–34.[Medline]
  14. Cohen J. Statistical power analysis for the behavioral sciences. Hillsdale, NJ: Lawrence Erlbaum; 1988.
  15. Jacobson NS, Truax P. Clinical significance -a statistical approach to. Defining meaningful change in psychotherapy-research. J Consult Clin Psychol 1991; 59: 12–19.[CrossRef][Medline]
  16. Rietveld S, Everaerd W, Creer TL. Stress-induced asthma : a review of research and potential mechanisms. Clin Exp Allergy 2000; 30: 1058–1066.[CrossRef][Medline]
  17. Halfon N, Newacheck PW. Childhood asthma and poverty: differential impacts and utilization of health services. Pediatrics 1993; 89: 56–61.
  18. Von Mutius E, Martinez FD, Fritsch C, et al. Prevalence of asthma and atopy in two areas of West and East Germany. Am J Respir Ctri Care Med 1994; 149: 358–364.[Abstract]
  19. Wamboldt MZ, Schmitz S, Mrazek D. Genetic association between atopy and behavioral symptoms in middle childhood. J Child Psychol Psychiatry 1998; 39: 1007–1016.[CrossRef][Medline]
  20. Simonoff E. Extracting meaning from comorbidity: genetic analyses that make sense. J Child Psychol Psychiatry 2000; 41: 667–74.[CrossRef][Medline]
  21. Warner JO, Pohunek P, Marguet C, et al. Progression from allergic sensitization to asthma. Pediatr Allergy Immunol 2000; 10: 1–3.
  22. Gustafsson PA, Bjorksten B, Kjellman NIM. Family dysfunction in asthma: a prospective study of illness development. J Pediatr 1994; 125: 493–498.[CrossRef][Medline]
  23. Wright RJ, Rodriguez M, Cohen S. Review of psychosocial stress and asthma. an integrated biopsychosocial approach. Thorax 1998; 53: 1066–1074.[Free Full Text]
  24. Schmid-Ott G, Jaeger B, Adamek C, et al. Levels of circulating CD8(+) lymphocytes, natural killer cells, and eosinophils increase upon acute psychosocial stress inpatients with atopic dermatitis. J Allergy Clin Immun 2001; 107: 171–177.[CrossRef][Medline]
  25. BuskeKirschbaum A, Jobst S, Wustmans A, et al. Attenuated free cortisol response to psychosocial stress in children with atopic dermatitis. Psychosom Med 1997; 59: 419–426[Abstract/Free Full Text]



This article has been cited by other articles:


Home page
 Psychosom. Med.Home page
Y. Chida, M. Hamer, and A. Steptoe
A Bidirectional Relationship Between Psychosocial Factors and Atopic Disorders: A Systematic Review and Meta-Analysis
Psychosom Med, January 1, 2008; 70(1): 102 - 116.
[Abstract] [Full Text] [PDF]

Home page
 Psychosom. Med.Home page
T. Ritz, A. Steptoe, C. Bobb, A. H. S. Harris, and M. Edwards
The Asthma Trigger Inventory: Validation of a Questionnaire for Perceived Triggers of Asthma
Psychosom Med, November 1, 2006; 68(6): 956 - 965.
[Abstract] [Full Text] [PDF]

Home page
 PsychosomaticsHome page
J. M. Feldman, A. N. Ortega, E. L. McQuaid, and G. Canino
Comorbidity Between Asthma Attacks and Internalizing Disorders AmongPuerto Rican Children at One-Year Follow-Up
Psychosomatics, August 1, 2006; 47(4): 333 - 339.
[Abstract] [Full Text] [PDF]

Home page
 Am. J. Respir. Crit. Care Med.Home page
R. Calam, L. Gregg, A. Simpson, B. Simpson, A. Woodcock, and A. Custovic
Behavior Problems Antecede the Development of Wheeze in Childhood: A Birth Cohort Study
Am. J. Respir. Crit. Care Med., February 15, 2005; 171(4): 323 - 327.
[Abstract] [Full Text] [PDF]

Home page
 Psychosom. Med.Home page
R. Calam, L. Gregg, and R. Goodman
Psychological Adjustment and Asthma in Children and Adolescents: The UK Nationwide Mental Health Survey
Psychosom Med, January 1, 2005; 67(1): 105 - 110.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Figures Only
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Stevenson, J.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Stevenson, J.
Related Collections
Right arrow Personality
Right arrow Pulmonary
Right arrow Stress and Coping

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS