Psychosomatics 44:319-328, August 2003
© 2003 The Academy of Psychosomatic Medicine
Psychopathology and Quality of Life for Adolescents With Asthma and Their Parents
Gilbert Vila, M.D., Ph.D.,
Ridah Hayder, M.D.,
Catherine Bertrand, Ph.D.,
Bruno Falissard, M.D., Ph.D.,
Jacques de Blic, M.D., Ph.D.,
Marie-Christine Mouren-Simeoni, M.D., Ph.D., and
Pierre Scheinmann, M.D., Ph.D.
Received May 2, 2002; revision received Oct. 2, 2002; accepted Nov. 15, 2002. From the Department of Child and Adolescent Psychiatry and the Department of Pediatric Allergy and Pneumology, Groupe Hospitalier Necker-Enfants Malades. Address reprint requests to Dr. Vila, Groupe Hospitalier Necker-Enfants Malades, 149 rue de Sèvres, 75743 Paris Cedex 15, France.
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ABSTRACT
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Asthma is known to have a direct impact on the quality of life of children with asthma and their families as a consequence of the attacks on day-to-day life. Psychopathological factors may be associated with poor quality of life by modulating the handicap and the patient's experience of it. The authors' objective was to evaluate the relationship between emotional and behavioral problems and quality of life, as assessed by the Pediatric Asthma Quality of Life Questionnaire and the Pediatric Asthma Caregiver's Quality of Life Questionnaire. The study group consisted of 100 adolescent outpatients with asthma who were undergoing regular checkups: 70 boys and 30 girls, ages 12 to 19. They were evaluated by means of self-administered questionnaires completed by their parents. Path analysis was used to propose a model of relationships between psychopathology and quality of life. The quality of life of the children with asthma and their parents was clearly associated with the presence or absence of psychological problems in the patients. Emotional problems were associated with the quality of life of both the patients and their parents; behavioral problems had a smaller effect on the quality of life of the parents only. The authors proposed a structural model of the quality of life of adolescents with asthma and their parents in which quality of life is dependent on psychological variables and is responsible for emotional problems. Multivariate analyses indicated that the quality of life of the children with asthma and their parents and the correlation between quality of life and psychopathology depended little on medical variables such as the duration of illness, its pretreatment severity, or hospitalizations in the past year. In contrast, the quality of life of the parents depended on that of the children and vice versa. This study showed that scores on the Pediatric Asthma Quality of Life Questionnaire and the Pediatric Asthma Caregiver's Quality of Life Questionnaire reflected not only the medical status of the patients but also psychological variables, which appeared to be a consequence of the functional handicap associated with asthma. Patients who assess the quality of their lives as poor would benefit from psychological evaluation and support.
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INTRODUCTION
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Quality of life can be defined as the satisfaction felt by an individual with the various areas of his or her life. Numerous tools have been developed to assess quality of life associated with various conditions, particularly chronic disease. Interest in the impact of illness on day-to-day functioning is leading investigators to include both disease-specific and generic health-related quality-of-life questionnaires in a broad range of clinical studies. Asthma, particularly in its severe forms, is known to affect the quality of life of affected children and their families. The frequency and severity of attacks, hospital admissions, secondary effects of treatments, absences from school, limitations of sport and other activities, fatigue, and problems sleeping directly affect quality of life.1,2 With childhood illnesses, the family and particularly the primary caregiver may face a considerable burden. Quality of life of the patients and their families is increasingly considered a major medical outcome variable for medical diseases. The Pediatric Asthma Quality of Life Questionnaire3 and the Pediatric Asthma Caregiver's Quality of Life Questionnaire,4 by Juniper et al., are asthma-specific health-related quality-of-life questionnaires that are the most frequently employed instruments for asthma. The strength of these disease-specific quality-of-life instruments over generic instruments is that they focus on areas of function that are relevant to that particular condition, and as a result, they are most responsive to small but important changes. The scores on these scales are linked to the respiratory handicap and to nonpsychological factors, such as the medical control of asthma, spirometry, and the use of medication. However, quality of life may depend not only on the respiratory handicap but also on psychological factors.5,6
On the one hand, children having a bad quality of life because of severe asthma may have psychological problems.7 On the other hand, psychological problems may influence quality of life and its assessment. Children and adolescents with asthma have been shown to be at a higher risk for problems in behavioral adjustment, with the greatest risk in the most severely ill group. Children and adolescents with persistent asthma have been shown to have a high prevalence of anxiety disorders and more anxiety, more behavioral problems, and lower self-esteem than healthy youths and nonasthmatic patients.8–11 Children with psychological problems may have less well-controlled asthma, indirectly due to poor compliance or directly through psychophysiological pathways (a psychosomatic model).1,12 Moreover, young patients with psychological problems are more vulnerable to the stress caused by asthma and are more likely to judge their quality of life to be poor; their parents are also more likely to be preoccupied by their asthma.5 A correlation has been found between anxiety and depression and the reporting of asthma-related symptoms, independent of objective asthma-related variables, such as peak flow variability or response to methacholine.13 Finally, the clinical severity of asthma should play a direct role in the objective assessment of quality of life, but behavioral and emotional problems may also affect its subjective estimation and ad hoc questionnaire scores.5,7
It is important to study relationships between quality of life and psychological problems. Disease-specific health-related quality-of-life instruments are most sensitive to variations in health status and to variations in functional handicaps associated with the disease. In contrast, they may be less sensitive to the psychological state of patients, whether from their own vulnerability associated with mental problems or from psychopathological difficulties arising from asthma. We believe that this is not the case and that assessments of quality of life by the Pediatric Asthma Quality of Life Questionnaire and the Pediatric Asthma Caregiver's Quality of Life Questionnaire are not independent of psychological factors. However, the correlation between quality of life and psychopathology may be an indication of the extent to which the impact of asthma rather than—in disagreement with the instrument's validation data—the subjectivity of the measurement of quality of life and the absence of a relationship between it and objective measures of the severity of asthma. We are unaware of any study of the relationships between scores on the Pediatric Asthma Quality of Life Questionnaire and the Pediatric Asthma Caregiver's Quality of Life Questionnaire and psychopathology or the orientation of this relationship, and indeed, these questionnaires are often used as objective indices for the functional impact of asthma.
Our hypothesis was that the assessment of quality of life of asthmatic children by the Pediatric Asthma Quality of Life Questionnaire and the Pediatric Asthma Caregiver's Quality of Life Questionnaire was linked to psychiatric symptoms and, in particular, anxiety in these young patients. Our aims were to determine whether
- Scores on the Pediatric Asthma Quality of Life Questionnaire and the Pediatric Asthma Caregiver's Quality of Life Questionnaire were correlated with psychological problems, as measured by reference psychopathological scales.
- Objective subscores (symptoms and activities) on the Pediatric Asthma Quality of Life Questionnaire and the Pediatric Asthma Caregiver's Quality of Life Questionnaire were not independent of more subjective subscores (emotional) on the Pediatric Asthma Quality of Life Questionnaire and the Pediatric Asthma Caregiver's Quality of Life Questionnaire.
- Subscores on the Pediatric Asthma Quality of Life Questionnaire and the Pediatric Asthma Caregiver's Quality of Life Questionnaire were correlated with scores on psychopathological scales, even the more objective subscores.
- The orientation of these correlations between scores on the Pediatric Asthma Quality of Life Questionnaire and the Pediatric Asthma Caregiver's Quality of Life Questionnaire and psychopathological scales meant that a poor quality of life is responsible for more psychological problems and that children with psychological problems have a poorer quality of life. The hypothesis was that mostly quality of life determines the mental state of patients—that is, that patients who feel the largest functional handicap, as measured by health-related quality of life, have the greatest psychopathological difficulties.
- The Pediatric Asthma Quality of Life Questionnaire and the Pediatric Asthma Caregiver's Quality of Life Questionnaire assess present asthma state, independent of previous health status (duration of asthma, pretreatment severity, or even control of the attacks during the past year), which does not affect present scores for quality of life or the association between psychopathological problems and poor health-related quality of life (although these variables may contribute to representations of the disease).
- The Pediatric Asthma Quality of Life Questionnaire and the Pediatric Asthma Caregiver's Quality of Life Questionnaire are disease-specific health-related quality-of-life questionnaire-type instruments that are not dependent on nonspecific variables like age of the patient, sex, or family socioeconomic status; the association between psychopathological problems and poor health-related quality of life is independent of these nonspecific variables.
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METHOD
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Patients
All of the patients included in the study were recruited from the same center. The study group consisted of 100 outpatients with asthma who were undergoing regular checkups at a hospital. It was composed of 70 boys and 30 girls, ages 12–19 years (mean=14.2, SD=1.9). According to the French Institut National de la Statistique classification system,15 12 families had a socioeconomic level of 2, 30 of 3, 14 of 4, 24 of 5, and 19 of 6. In this classification system, higher scores correspond to a higher socioeconomic level. The duration of asthma disease was 2 to 18 years (mean=10.8, SD=3.4). The control of attacks was judged to be good or poor on the basis of whether or not hospital admission had been necessary in the past year. Attacks were well controlled in 75 subjects and poorly controlled in 25 subjects. The adolescents had mild to severe asthma defined according to recent classifications on the basis of clinical features, pretreatment, and type and frequency of medication prescribed to the children.16 In this study group of 100 adolescents, six patients had mild persistent asthma, 59 had moderate persistent asthma, and 35 had severe persistent asthma. All of the patients were assessed on a day on which they were not suffering from an asthma attack.
Measures
The quality of life of the adolescents with asthma was evaluated by use of the Pediatric Asthma Quality of Life Questionnaire3 by Juniper et al. This questionnaire contains 23 items that children with asthma have identified as troublesome in their daily lives. It includes three domains (symptoms, activity limitations, and worries), with three subscale scores and a total score. "How much did asthma attacks bother you during the past week?" "How much were you bothered by your asthma while doing your activities during the past week?" and "How often did your asthma make you feel frustrated during the past week?" are examples of questions for symptom, activity, and emotional factors, respectively. It is able to detect changes in patients whose health status has changed (clinical asthma control and spirometry) because of treatment or natural fluctuations in illness and to differentiate these patients from those whose asthma has remained stable.
The quality of life of the parents was assessed with use of the Pediatric Asthma Caregiver's Quality of Life Questionnaire4 by Juniper et al., a 13-item questionnaire completed by the parents of the adolescents with asthma. It evaluates the impact of asthma on the daily activities of parents of children with asthma and the fears and preoccupations of their asthmatic child. It includes two domains (activity limitations and worries) with two subscale scores and a total score. "During the past week, how often did your family need to change plans because of your child's asthma?" and "During the past week, how often did you feel helpless or frightened when your child experienced coughing, wheezing, or breathlessness?" are examples of items for activity limitations and emotional factors, respectively. Results of the Pediatric Asthma Caregiver's Quality of Life Questionnaire are reproducible in subjects who are stable; it showed acceptable levels of longitudinal and cross-sectional correlations with the child's asthma status (clinical asthma control, beta-agonist use, and spirometry) and health-related quality of life.
Responses to each item on the Pediatric Asthma Quality of Life Questionnaire and the Pediatric Asthma Caregiver's Quality of Life Questionnaire are given on a 7-point scale, in which 1 represents severe impairment and 7 represents no impairment. The results are expressed as a mean score per item for each of the domains (symptoms, activity limitations, or emotions), as well as for overall quality of life. Therefore, both the domain and overall scores range from 1 to 7. We used the French versions from McMaster University (Hamilton, Ontario, Canada) for the Pediatric Asthma Quality of Life Questionnaire and the Pediatric Asthma Caregiver's Quality of Life Questionnaire. These questionnaires are widely used in France. In our French group, Cronbach's alpha was 0.93 for the total score and 0.89, 0.76, and 0.84 for symptom, activity limitations, and emotional factors, respectively, on the Pediatric Asthma Quality of Life Questionnaire; Cronbach's alpha was 0.88 for total score and 0.81 and 0.84 for emotional and activity limitations factors, respectively, on the Pediatric Asthma Caregiver's Quality of Life Questionnaire.
Psychiatric symptoms were evaluated by use of self-administered questionnaires completed by the children (Spielberger's State-Trait Anxiety Inventory for Children17 for trait anxiety and the Toulouse Self-Esteem Scale for self-esteem18) or their parents (the Child Behavior Checklist19) with scores for social skills, academic achievement, and activities, and a total score for symptoms, a score for internalization, and a score for externalization.
The State-Trait Anxiety Inventory for Children is a self-administered questionnaire that is widely used to measure anxiety in children and adolescents. It consists of two separate 20-question rating scales for state (transitory) and trait (predisposition to) anxiety. In this study, only the trait subscale, which measures long-term susceptibility to anxiety, was administered. The French version of this scale has been used in recent studies and has been validated in asthmatic children and adolescents.20 Trait scores on the State-Trait Anxiety Inventory for Children clearly distinguish patients with asthma who suffer from DSM-IV anxiety disorders (mean=36.5, SD=5.6) from nonasthmatic comparison subjects and from asthmatic patients without anxiety disorders (cutoff score=34, range=20–60). Internal consistency was 0.75 for French children and adolescents with asthma.
The Toulouse Self-Esteem Scale is a 60-item questionnaire for completion by adolescents ages 12 to 18 years. Each item is rated 0 or 1 (total score: range=0–60). It evaluates self-esteem in social, academic, and physical dimensions and emotional control and self-projection into the future. It was developed in French and has been validated in a large general population sample.18 The mean total self-esteem score was 40.95 (SD=7.44) for boys and 38.53 (SD=7.52) for girls; a higher score indicates better self-esteem. In a French sample of adolescents, Cronbach's alpha was 0.66 for total score.
The Child Behavior Checklist19 is a 138-item questionnaire that was completed by the parents. Responses to each item in the Child Behavior Checklist are given on a 3-point scale (0–2). It provides a standardized description of skills and emotional and behavioral problems in children ages 4–16 years. The first part concerns social skills, participation in organizations, contact with friends, participation and skills in sports, and ratings for academic performance. The second part concerns emotional and behavioral problems classified as internalized or externalized. Internalized behavior problems are those affecting principally the child himself or herself and include anxious/depressed, withdrawn, schizoid, and somatic behavioral. Externalized problems are overt in nature, having direct effects on others. They include delinquency and cruel and aggressive behavior. Child Behavior Checklist scores and subscores are T scores, which, by definition, have a population mean of 50 (cutoff score=70). The French version of the Child Behavior Checklist has been shown to be valid and reliable in community sample of 2,480 children.21 We found that children and adolescents with asthma and DSM-IV anxiety disorders had an internalizing mean score of 63.8 (SD=8.1) when they suffered from DSM-IV anxiety disorders,20 and those who suffered from DSM-IV disruptive behavior disorders had an externalizing mean score of 65.3 (SD=14.3) when they suffered from DSM-IV disruptive behavior disorders.11
Procedures
During the course of 1 year, all children over the age of 11 who were followed up for at least 1 year for their asthma were consecutively recruited from the Department of Pediatric Allergy and Pneumology of Groupe Hospitalier Necker-Enfants Malades in Paris. One hundred families were asked to participate in the study. All of the patients and their parents were informed of the aims and methods of the study and gave informed consent, which conformed to French legal guidelines. None of these families, all regularly seen, refused to participate. All questionnaires were completed by the parents and children on the same day, but independently, during a hospital visit. As Juniper et al.3,4 did previously, we recruited the child's primary caregiver, that is, the parent who lived with the child at least 75% of the time.
Analyses
The results are expressed as frequencies, means, and standard deviations. The analyses were performed by using SPSS-PC+ (SPSS, Chicago). For quantitative variables, group means were compared by using Student's t test. The significance threshold was set at p=0.05. Correlations (two-tailed) were calculated by using Pearson's coefficients and Spearman's coefficients for semiquantitative variables. The relationship between quality of life and psychiatric symptoms was assessed by using multiple linear regression (backward method) with SPSS 11.0 for Windows and a path analysis with SAS (the CALIS procedure) (SAS Institute, Cary, N.C.). Multivariate analysis was used to determine the variance in the correlations between quality of life and psychopathological problems that can be explained by nonspecific variables, sociodemographic variables, and variables linked to previous health status because of emotional and behavioral disorders. Path analysis was used to study complex patterns of relationships between the different variables of interest for which standard dichotomy-dependent/nondependent variables are neither totally satisfactory nor fully relevant. Structural models can be used to address the idea of causality, although strictly, only a longitudinal study can demonstrate causality: in this case, the orientation (i.e., the principal order: quality of life  psychopathology) of the relationship between psychopathology and quality of life.
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RESULTS
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Quality of Life and Psychopathology
Coefficients for correlations between scores on the questionnaires concerning the quality of life for the children and their parents and scores for the psychological questionnaires (the Toulouse Self-Esteem Scale, the State-Trait Anxiety Inventory for Children, and the Child Behavior Checklist) are given in Table 1. The quality of life for the children was significantly associated with total, emotional, and physical self-esteem scores, self-assessed anxiety scores, total symptom scores on the Child Behavior Checklist, and internalization and anxiety/depression subscores. The quality of life of the parents was significantly associated with the child's emotional and academic self-esteem scores, the child's anxiety scores, and the child's total symptom scores and anxiety/depression, internalization, and externalization subscores on the Child Behavior Checklist. The quality of life scores of the child and his or her parents were significantly correlated (r=0.34, p=0.002). There was no correlation between quality of life scores and subscores on the Child Behavior Checklist concerning activities, academic performance, and social skills.
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TABLE 1. Pearson's Correlations Between Quality of Life of Adolescents With Asthma and Their Parents and Scores on Psychopathological Questionnaires Completed by 100 Asthmatic Outpatient Children or Their Parentsa
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Multiple linear regression (stepwise) with the quality of life of the child as the dependent variable and severity of asthma, hospital admissions, total self-esteem score, anxiety score (on the State-Trait Anxiety Inventory for Children), and the internalization and externalization subscores on the Child Behavior Checklist as independent variables indicated that anxiety and internalized behavioral problems accounted for most of the variance (R2=0.39; F=6.77, p=0.002). The backward method of regression retained only the score on the State-Trait Anxiety Inventory for Children (F=11.50, df=1, 75, p<0.001).
Multiple linear regression (stepwise) with the quality of life of the parents as the dependent variable and the severity of asthma, number of hospital admissions, and the child's anxiety, self-esteem, internalization and externalization scores on the Child Behavior Checklist as independent variables indicated that most of the variance in the quality of life of the parents was explained by internalization (R2=0.42). The backward method of regression retained only internalized problems measured by the Child Behavior Checklist (F=11.34, df=1, 75, p<0.001).
The correlation matrix for scores in questionnaires concerning the quality of life of the children and their parents showed that in our study group, the factors proposed by Juniper et al.3,4 (symptoms, emotions, and activities) were not independent (Table 2). In particular, the two emotion factors are significantly correlated with the symptoms and activities factors. The symptoms factor of the Pediatric Asthma Quality of Life Questionnaire was significantly correlated with the score for the State-Trait Anxiety Inventory for Children and the Child Behavior Checklist internalization subscore (Table 2). Similarly, the activities factor of the Pediatric Asthma Quality of Life Questionnaire was significantly correlated with the scores for anxiety/depression, internalization, and externalization, and total score for the Child Behavior Checklist (Table 2).
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TABLE 2. Pearson's Correlations Between Factors on the Quality of Life Questionnaires Administered to Adolescents With Asthma and Their Parents and Scores on Psychopathological Questionnaires Completed by the 100 Asthmatic Outpatient Children or Their Parentsa
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Figure 1 shows the path analysis of the relationships between quality of life and psychological problems, studied as latent variables. Three slightly different models were originally designed on the basis of psychopathological considerations and by observation of the correlation matrix. The one model presented in Figure 1 led to the best fit and could not be improved substantially by minor modifications. This analysis showed that the higher weights are significant in the direction of psychological disorders (–0.52 versus –0.38) (p=0.03, computed from the standard errors of the two path coefficients). The highest weight for the children's quality of life was for the symptoms domain (0.94).
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FIGURE 1. Path Analysis of the Relationships Between Quality of Life and Psychological Problems in 100 Adolescent Outpatients With Asthma, Studied as Latent Variablesa
aQuality of life of adolescents with asthma was measured by using the Pediatric Asthma Quality of Life Questionnaire. Psychopathological questionnaires completed by the asthmatic children were the Toulouse Self-Esteem Scale and the State-Trait Anxiety Inventory for Children.
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Severity of Asthma and Hospital Admissions
The participants' perceptions of the participants were that there was a moderate impact of asthma on quality of life for most patients (Pediatric Asthma Quality of Life Questionnaire score: mean=6.1, SD=0.8, range=4–7) and for their parents (Pediatric Asthma Caregiver's Quality of Life Questionnaire score: mean=6.2, SD=0.9, range=4–7). There was no significant correlation (Spearman's r) between the severity of asthma and scores concerning quality of life, self-esteem, emotional and behavioral problems, activities, or social or academic skills. The mean scores for the questions concerning quality of life, activities, social and academic skills, and psychological problems did not differ between children whose attacks were well controlled and those whose attacks had necessitated hospital admissions in the past year (Student's t test).
Sociodemographic Characteristics
There was no significant relationship between sociodemographic variables (sex, age of the patient, and socioeconomic level of the family) and the quality of life of the children or their parents or psychological data (scores on the Toulouse Self-Esteem Scale, the State-Trait Anxiety Inventory for Children, and the Child Behavior Checklist). The duration of the disease was not correlated with either quality of life (the Pediatric Asthma Quality of Life Questionnaire or the Pediatric Asthma Caregiver's Quality of Life Questionnaire) or scores on psychiatric questionnaires. The only observed differences were that total (39.1 and 43.9, respectively) (t=2.5, p=0.02), physical (7.6 and 9.4) (t=3.4, p=0.001), and social (8.5 and 9.4) (t=2.1, p=0.04) self-esteem scores were lower for the girls than for the boys.
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DISCUSSION
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Our findings clearly indicate that the quality of life for adolescents with asthma and their parents is associated with emotional problems (which depend on the quality of life for both the asthmatic children and their parents) and behavioral problems (which have a moderate impact on the quality of life of the parents only). Internalized problems accounted for most of the variance in the relationship between psychopathology and quality of life. The self-esteem and anxiety of the adolescents were linked to the impact of asthma on themselves and their parents. The association between scores on the Pediatric Asthma Quality of Life Questionnaire and the Pediatric Asthma Caregiver's Quality of Life Questionnaire and psychopathology has not been studied in adolescents. However, our results are consistent with those of previous studies showing that in adults with asthma, the quality of life of patients is correlated with psychological factors such as mental health status or scores on the Psychological Well-Being Questionnaire.22,23 We have shown that internalized problems are of particular importance and, indeed, that the prevalence of anxious disorders is high in children and adolescents with asthma.11
A correlation between quality of life and psychopathological problems was found not only for the component of the Pediatric Asthma Quality of Life Questionnaire and the Pediatric Asthma Caregiver's Quality of Life Questionnaire that was a priori the most subjective (the emotions factor) but also for the more objective components: the symptoms and activities factors. These more objective factors are clearly linked to the respiratory handicap and to nonpsychological factors, such as the medical control of asthma, spirometry, and the use of medication, as shown by the discriminatory value and concordance of the results of the questionnaire for these factors. The correlation between the emotions factor on the Pediatric Asthma Quality of Life Questionnaire and Pediatric Asthma Caregiver's Quality of Life Questionnaire and the more concrete symptoms and activities factors confirms that objective factors are associated with psychological factors, particularly emotional problems.
We propose, in Figure 1, a structural model of the quality of life of asthmatic adolescents and their parents in which quality of life is dependent on psychological variables. Path analysis shows that, primarily, a poor quality of life because of asthma increases anxiety and emotional problems, even if psychological problems also reduce scores for quality of life. The scores of Juniper et al.3,4 reflected present severity of asthma. In another study,10 we had shown that asthmatic youths had a high prevalence of anxiety disorders and were more anxious than children and adolescents suffering from other chronic diseases. Our results are consistent with the view that asthma is a stressor, the effect of which is to increase its own impairment by an excess of emotional problems. The causal relationship suggested by path analysis between a poor quality of life and excess psychopathological problems needs to be confirmed by longitudinal studies of the chronology of onset of psychopathological problems with respect to asthma and the changes in its functional impact and quality of life. Diagnostic interviews would reveal whether patients with poor quality of life due to psychopathological problems are those who suffer anxiety disorders or depression, as assessed by DSM-IV.
Our results show that the current quality of life of children with asthma and their parents does not depend on past medical variables such as the duration of the disease, its initial severity, or its past control by treatments, and multivariate analysis shows the same for the relationship between quality of life and psychopathology. Most of our patients, despite having moderate or severe persistent asthma, currently have well-controlled attacks. This bears witness to the efficacy of current treatments and the rapid changes in recent years in the adaptation profile of asthmatic patients. The initial severity of asthma no longer reflects a good indicator of the handicap.24,25 The questionnaires of Juniper et al.3,4 assessed symptoms in the last week, and it seems that the psychological attributions that may influence the scores do not depend on past medical states.
Multivariate analysis indicates that the relationship between quality of life and psychopathology is independent of sociodemographic factors. The quality of life of children with asthma and their parents was independent of demographic variables such as age and sex, consistent with the results of Juniper et al.3,4 There also seemed to be no association between the quality of life of adolescents and their parents and the socioeconomic level of the family. In contrast, for adults with asthma, it has been shown that variables such as low educational level, unemployment, having a family income below $20,000, being on public assistance, or having no health insurance have a negative influence on quality of life.26 This is consistent with the idea that family support protects children. Such interaction between factors linked to parents and those linked to children is also illustrated by the observation that the quality of life of parents clearly depends on that of the children, and doubtless, the converse is also true, regardless of whether it is assessed by total scores for questionnaires or the factors proposed by Juniper et al.,3,4 not only the emotions factor but also by the activities and symptoms factors. Parents of children with asthma are so troubled and concerned for their children that asthma has a great impact on their daily lives.
The quality of life of children with asthma and their parents is correlated with the findings of psychological questionnaires filled in by adolescents and their parents—two different sources of information. The validity of our results was enhanced, and biases limited, by the use of multiple sources of information. There is good concordance between correlations obtained from adolescent questionnaires and from parent questionnaires even if, with regard to internalized disorders, children are better evaluators of their internal states than their parents.20 One of the possible criticisms of our study is that only self-administered questionnaires were used. Both quality of life and psychopathology were evaluated from the same source, although use of both the child and parent questionnaires reduced the bias. The use of a standardized diagnostic interview to characterize mental disorders involved in this association between psychopathology and quality of life would be an independent source for evaluation and could provide interesting results by identifying the disorders most frequently concerned.
We cannot exclude recruitment bias. All of our adolescents were outpatients undergoing regular checkups in a specialist hospital center and were well informed concerning treatment. Patients who are less well informed and followed up less regularly might have more frequent and severe attacks and a greater degree of impairment of quality of life. Similarly, hospitalized patients and patients living in specialist centers (climatic cure centers) may present different characteristics. We did not include patients with benign asthma of the intermittent type, who have a profile close to that of the general population. Our patients were therefore not representative of all asthmatics, and our results concern only patients with persistent, well-followed asthma.
Nevertheless, our findings confirm the value of assessing the quality of life of young patients with asthma. Scores on the Pediatric Asthma Quality of Life Questionnaire and the Pediatric Asthma Caregiver's Quality of Life Questionnaire, indicators of the functional impact of asthma and its current severity, appear to be predictive of psychopathological problems in young patients. Furthermore, they are predictive of the pretreatment severity, duration of asthma, or frequency of hospitalization. Longitudinal studies could confirm any causal relationship between overall handicap due to asthma and the presence of psychopathological problems. Patients reporting a poor quality of life could benefit from systematic evaluation and psychological support. Indeed, this putative causal relationship between handicap and psychopathology suggests that preventive psychological measures would be valuable.
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