The fourth monkey

We all know of the three monkeys, who respectively see no evil, hear no evil and do no evil. The fourth monkey, not (as far as we know, infiltrated into MI5) has asthma but perceives no evil. This is a major problem in paediatric practice—asthmatic children may not perceive that they are bronchoconstricting, so they may not take their reliever medication or indeed realise they are on the verge of a serious asthma attack. This has important implications for the use of questionnaire scores, no matter how well validated, for the assessment of asthma control. Feldman et al gave children from the Bronx a device which automatically recorded their peak flow; half were blinded to the results, half received immediate feedback (Editor's Choice, page 1040). These children were found to be at high risk, both from under-perception of symptoms and (unsurprisingly) poor adherence. However the feedback group, who estimated their peak flow and then found out immediately …