Elsevier

The Lancet

Volume 356, Issue 9234, 16 September 2000, Pages 982-987
The Lancet

Articles
The role of acute and chronic stress in asthma attacks in children

https://doi.org/10.1016/S0140-6736(00)02715-XGet rights and content

Summary

Background

High levels of stress have been shown to predict the onset of asthma in children genetically at risk, and to correlate with higher asthma morbidity. Our study set out to examine whether stressful experiences actually provoke new exacerbations in children who already have asthma.

Methods

A group of child patients with verified chronic asthma were prospectively followed up for 18 months. We used continuous monitoring of asthma by the use of diaries and daily peak-flow values, accompanied by repeated interview assessments of life events and long-term psychosocial experiences. The key measures included asthma exacerbations, severely negative life events, and chronic stressors.

Findings

Severe events, both on their own and in conjunction with high chronic stress, significantly increased the risk of new asthma attacks. The effect of severe events without accompanying chronic stress involved a small delay; they had no effect within the first 2 weeks, but significantly increased the risk in the subsequent 4 weeks (odds ratio 1·71 [95% Cl 1·04–2·82], p≤0·05 for weeks 2–4 and 2·17 [1·32–3·57], p≤0·01 for weeks 4–6). When severe events occurred against the backdrop of high chronic stress, the risk increased sharply and almost immediately within the first fortnight (2·98 [1·20–7·38], p≤0–05). The overall attack frequency was affected by several factors, some related to asthma and some to child characteristics. Female sex, higher baseline illness severity, three or more attacks within 6 months, autumn to winter season, and parental smoking were all related to increased risk of new exacerbations; social class and chronic stress were not.

Interpretation

Severely negative life events increase the risk of children's asthma attacks over the coming few weeks. This risk is magnified and brought forward in time if the child's life situation is also characterised by multiple chronic stressors.

Introduction

Chronic diseases are one of the major health problems of children: about one child in ten experiences a longlasting illness by the age of 15 years.1 Of the chronic diseases of childhood, asthma is commonest, with reported prevalence in children ranging from 3% to 27% across different countries.2 Concern has also been expressed at the apparent increase in asthma morbidity despite progress in medical treatment.3

There is a consistent finding based on studies that children with increased psychosocial stress are significantly more likely to be ill and need hospital treatment, as well as use health services more frequently than other children.4, 5 Stress as a precipitating or provoking factor in adults has been implicated in heart disease, cancer, and various endocrine dysfunctions6, 7, 8 and in children with appendicitis, rheumatoid arthritis, and leukaemia, for example.9, 10 The role of stress in viral infections has been the focus of research involving both adults and children. Well controlled, prospective, and experimental studies have shown that adverse life events and other stresses significantly increase a person's susceptibility to acute and recurring upper respiratory tract infections.11, 12, 13, 14, 15, 16 One likely explanation for this association lies in stress compromising the body's immunological responses,15, 17 with the individual differences in susceptibility possibly being explained by differences in psychobiological reactivity.18

Most childhood asthma begins in infancy with about 80% of children having their first episode of wheeze before their third birthday. Adverse events in early life, possible allergen exposure, suboptimum infant feeding practices, and viral infections seem important precipitating factors.19 Stress in the form of early parenting difficulties (eg, excessive parental anxiety, poor coping, and lack of child-care skills) has been shown to predict the onset of asthma by the age of 3 years in children genetically at risk.20 Apart from predisposing to asthma and precipitating its development, high levels of stress also predict higher overall asthma morbidity in children,21, 22 and correlate with their poorer quality of life.23 In addition to stress, the frequency of upper respiratory tract infections is associated with the severity of childhood asthma.24 A longitudinal study25 of a cohort of school-age children showed that upper respiratory, principally rhinoviral, infections were associated with 80–85% of reported exacerbations of asthma. However, bearing in mind the studies quoted earlier, stress may well be a major factor in increasing susceptibility to viral infections in the first place.

Taken together, the results of these studies make a strong case for psychosocial stress increasing the risk of somatic diseases, particularly those that result from the weakening of the body's natural defence mechanisms. On several counts, childhood asthma can be thought of as belonging to such a category of illness. There is also evidence that stress, among other things, increases the overall chance of developing asthma in childhood, and also seems to predict greater morbidity over time among those who get it. Previous research, however, has failed to answer two important questions relevant both to treatment and prevention of childhood asthma. The first one relates to the type of stress—ie, is the risk stemming from chronic psychosocial adversity (usually closely related to the child's family situation) different from that stemming from acute negative life events (or from the combination of the two)? The second question is whether the timing of stressful experiences relates to the timing of asthma attacks—ie, do stressful life events actually provoke acute asthma exacerbations?

The objective of this study was to examine whether severely negative life events increase the risk of acute exacerbations of asthma in children. The following two hypotheses were tested: acute asthma attacks are more likely to occur in the first few weeks after a severe life event than at other times; and a background of chronic stress further increases the risk caused by acute life events.

Section snippets

Design

The study was done as a prospective follow-up over 18 months. Separate teams, who were unaware of the other team's results throughout the study, independently assessed the asthma and life experiences.

Patients

90 children, aged 6–13 years who had moderate to severe asthma were included in the study; all were regular attendees at a specialist asthma clinic in the Royal Hospital for Sick Children in Glasgow, Scotland. Recruitment took place in the asthma clinic, with the child's age being the only

Asthma and life experiences data

The mean length of observation time (date between the first and last recorded peak-flow) was 620 days (range 314–757, SD 73·8). Altogether 423 (mean number 4–7; mean duration 9 days) new asthma attacks occurred, ranging from none (ten children) to 21 (one child), see figure 2. In 80% (340) the exacerbation, based on child-recorded data, was confirmed by clinical data; 11% (50) of exacerbations resulted in the child being admitted.

The total number of severe events (life events carrying high

Discussion

Our study has shown that severely negative life events, especially when multiple chronic stressors were also present, significantly increased the likelihood of new asthma exacerbations during the 18 month follow-up in children aged 6–13 years. When severe events were not accompanied by high chronic stress their effect seemed to involve a small delay, increasing the risk of a new attack from the third to the sixth week after the life event. However, when chronic stress was also present, the

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