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A Risk and Resistance Model for Predicting Medication Adherence in Young Children with Asthma

Permanent Link: http://ufdc.ufl.edu/UFE0024507/00001

Material Information

Title: A Risk and Resistance Model for Predicting Medication Adherence in Young Children with Asthma Role of Parent Stress, Child Temperament, and Social Support
Physical Description: 1 online resource (40 p.)
Language: english
Creator: Lipe, Megan
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2009

Subjects

Subjects / Keywords: adherence, asthma, caregiving, parenting, pediatric, stress, temperament
Clinical and Health Psychology -- Dissertations, Academic -- UF
Genre: Psychology thesis, M.S.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

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Abstract: A Risk and Resistance Model for Predicting Medication Adherence in Young Children with Asthma: Role of Parent Stress, Child Temperament, and Social Support By Megan Rae Lipe Asthma is the most common chronic illness in children and can lead to negative outcomes if not properly controlled through good regimen adherence. This study aimed to fill gaps in the extant pediatric asthma literature by examining risk and resistance factors associated with medication adherence in preschool-aged children with asthma. Participants included 43 caregivers of children aged 2 to 5 years with persistent asthma. Assessment involved the measurement of general and illness-related parenting stress and child temperament as possible risk factors, social support as a potential protective factor, and review of pharmacy refill records to measure adherence objectively. Linear regression analyses revealed that the proposed risk and resistance factors were not significantly associated with medication adherence. These findings suggest that caregivers of young children with asthma may be a unique population as the results were not comparable to previous studies assessing similar relationships in caregivers of older children with asthma (Carson & Schauer, 1992; DeMore, Adams, Wilson, & Hogan, 2005). Future research should focus on examining the way in which length of diagnosis and other factors related to a young asthmatic population may contribute to the relationship between caregiver psychosocial factors and child medication adherence. Given that asthma is a chronic condition, it is necessary to understand and establish good adherence behaviors in children early in life to facilitate healthy lifestyles in the future.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Megan Lipe.
Thesis: Thesis (M.S.)--University of Florida, 2009.
Local: Adviser: Pereira, Deidre B.
Electronic Access: RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2009-11-30

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2009
System ID: UFE0024507:00001

Permanent Link: http://ufdc.ufl.edu/UFE0024507/00001

Material Information

Title: A Risk and Resistance Model for Predicting Medication Adherence in Young Children with Asthma Role of Parent Stress, Child Temperament, and Social Support
Physical Description: 1 online resource (40 p.)
Language: english
Creator: Lipe, Megan
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2009

Subjects

Subjects / Keywords: adherence, asthma, caregiving, parenting, pediatric, stress, temperament
Clinical and Health Psychology -- Dissertations, Academic -- UF
Genre: Psychology thesis, M.S.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: A Risk and Resistance Model for Predicting Medication Adherence in Young Children with Asthma: Role of Parent Stress, Child Temperament, and Social Support By Megan Rae Lipe Asthma is the most common chronic illness in children and can lead to negative outcomes if not properly controlled through good regimen adherence. This study aimed to fill gaps in the extant pediatric asthma literature by examining risk and resistance factors associated with medication adherence in preschool-aged children with asthma. Participants included 43 caregivers of children aged 2 to 5 years with persistent asthma. Assessment involved the measurement of general and illness-related parenting stress and child temperament as possible risk factors, social support as a potential protective factor, and review of pharmacy refill records to measure adherence objectively. Linear regression analyses revealed that the proposed risk and resistance factors were not significantly associated with medication adherence. These findings suggest that caregivers of young children with asthma may be a unique population as the results were not comparable to previous studies assessing similar relationships in caregivers of older children with asthma (Carson & Schauer, 1992; DeMore, Adams, Wilson, & Hogan, 2005). Future research should focus on examining the way in which length of diagnosis and other factors related to a young asthmatic population may contribute to the relationship between caregiver psychosocial factors and child medication adherence. Given that asthma is a chronic condition, it is necessary to understand and establish good adherence behaviors in children early in life to facilitate healthy lifestyles in the future.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Megan Lipe.
Thesis: Thesis (M.S.)--University of Florida, 2009.
Local: Adviser: Pereira, Deidre B.
Electronic Access: RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2009-11-30

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2009
System ID: UFE0024507:00001


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1 A RISK AND RESISTANCE MODEL FOR PREDICTING MEDICATION ADHERENCE IN YOUNG CHILDREN WITH ASTHMA: ROLE OF PARENT STRESS, CHILD TEMPERAMENT, AND SOCIAL SUPPORT By MEGAN RAE LIPE A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE UNIVERSITY OF FLORIDA 2009

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2 2009 Megan Rae Lipe

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3 To Sandra and Robert Lipe

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4 ACKNOWLEDGMENTS First, I than k Dr. Christina Adams for he r mentorship in guid ing me through the conceptualization and initiation of this project. I am most thankful for her encouragement to begin and maintain my own research study as th is process has provided me with invaluable knowledge and experience of th e research process from beginning to end. I extend my appreciation to Dr. Deidre Pereira, my current research mentor, who has offered her support and has played a large role in guidi ng me through the preparation and pr esentation of these results. I would like to thank Dr. Leslie Hendeles and Dr. Sarah E. Chesrown, collaborators from the University of Florida Pediatric Pulmonary clinic at Shands, for their involvement in this study. I also acknowledge and thank the members of my committee, Dr. William Perlstein, Dr. Michael Robinson, and Dr. Sheila Eyberg. I extend my gr atitude to the Center for Pediatric Psychology and Family Studies for providing funding for this project. I would like to thank my fa mily, specifically my pare nts, for their continued encouragement. Without their love and support, none of this would have been possible. I thank my friends, both near and far, and my classmates as my experience in graduate school would not have been as meaningful and enjoyable as it has been thus far without th em. I thank my Lord, Jesus Christ, for all of the blessings that have been bestowed upon me including my health and my ability to pursue my career and life goals. Lastly, I extend my appreciation to the careg ivers who offered their time and effort to participate in this research and I wish them and their families the very best.

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5 TABLE OF CONTENTS page ACKNOWLEDGMENTS ............................................................................................................... 4LIST OF TABLES ...........................................................................................................................7LIST OF FIGURES .........................................................................................................................8ABSTRACT ...................................................................................................................... ...............9 CHAP TER 1 INTRODUCTION .................................................................................................................. 11Epidemiology, Symptoms, and Treatment of Asthma ............................................................ 11Medication Adherence in Children with Asthma ................................................................... 12Parenting Stress as a Risk Factor for Low Medication Adherence ........................................13Parent-Reported Barriers to Medication Adherence ...............................................................15Difficult Child Temperament as a Risk Factor for Low Medication Adherence ................... 16Social Support as a Resistance Factor ....................................................................................16Discrepancies in Extant Literature .......................................................................................... 17Current Study ..........................................................................................................................172 METHODS ....................................................................................................................... ......20Design ........................................................................................................................ .............20Participants .................................................................................................................. ...........20Procedure ..................................................................................................................... ...........20Psychosocial Measurement .....................................................................................................21Parenting Stress ...............................................................................................................21Caregiving Stress ............................................................................................................. 22Difficult Child Temperament .......................................................................................... 22Social Support .................................................................................................................22Measurement of Medication Adherence ................................................................................. 23Statistical Procedures ..............................................................................................................233 RESULTS ....................................................................................................................... ........25Demographics .................................................................................................................. .......25General Parenting Stress and Difficult Child Temperament .................................................. 25Caregiving Stress ............................................................................................................. .......26Social Support .........................................................................................................................26Medication Adherence .......................................................................................................... ..27Relations between Psychosocial Variables and Medication Adherence ................................27Relations between Parenting Stress and Medication Adherence ............................................27Relations between Caregiving St ress and Medication Adherence .........................................28

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6 Relations between Difficult Child Temp eram ent and Medication Adherence ....................... 28Social Support as a Moderator ................................................................................................284 DISCUSSION .................................................................................................................... .....32Study Limitations ............................................................................................................. .......34Future Directions ....................................................................................................................35LIST OF REFERENCES ...............................................................................................................37BIOGRAPHICAL SKETCH .........................................................................................................40

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7 LIST OF TABLES Table page 3-1 General parenting stress pred icting child m edication adherence ....................................... 303-2 Caregiving stress predicting child medication adherence ..................................................303-3 Difficult child temperament predic ting child medication adherence ................................. 303-4 Moderator analyses: Predicting medica tion adherence from parenting stress and social support .....................................................................................................................313-5 Moderator analyses: Predicting medication adherence from caregiving stress and social support .....................................................................................................................313-6 Moderator analyses: Predicting me dication adherence from difficult child temperament and social support .........................................................................................31

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8 LIST OF FIGURES Figure page 1-1 Family illness model for predicting medication adherence in young children with asthm a ........................................................................................................................ ........19

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9 Abstract of Thesis Presen ted to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Science A RISK AND RESISTANCE MODEL FOR PREDICTING MEDICATION ADHERENCE IN YOUNG CHILDREN WITH ASTHMA: ROLE OF PARENT STRESS, CHILD TEMPERAMENT, AND SOCIAL SUPPORT By Megan Rae Lipe May 2009 Chair: Deidre Pereira Major: Psychology Asthma is the most common chronic illness in children and can lead to negative outcomes if not properly controlled through good regimen adherence. This study aimed to fill gaps in the extant pediatric asthma literature by examining risk and resistance factors associated with medication adherence in presc hool-aged children with asthma. Participants included 43 caregivers of children aged 2 to 5 years with persistent asthma. Assessment involved the measurement of general and illness-related pare nting stress and child temperament as possible risk factors, social support as a potential prot ective factor, and review of pharmacy refill records to measure adherence objectively. Linear regression analyses revealed that the proposed risk and resist ance factors were not significantly associated with medication adherence. These findings sugges t that caregivers of young children with asthma may be a unique population as the results were not comparable to previous studies assessing similar relationships in caregivers of older children with asthma (Carson & Schauer, 1992; DeMore, Adams, W ilson, & Hogan, 2005). Future research should focus on examining the way in which length of diagnosis and other f actors related to a young asthmatic population may contribute to the rela tionship between caregiver psychosocial factors

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10 and child medication adherence. Given that as thma is a chronic condition, it is necessary to understand and establish good adheren ce behaviors in children early in life to facilitate healthy lifestyles in the future.

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11 CHAPTER 1 INTRODUCTION Epidemiology, Symptoms, and Treatment of Asthma In 2005, it w as estimated that asthma prevalence rates in children were as high as 9% or 6.5 million in the United States (National Center for Health Statistics, 2006), with the largest increase in prevalence rates seen recently in children age 4 or younger (Mannino et al., 1998). Given these high rates, control of childhood asthma has become one of the top priorities of health professionals and research ers. Indeed, reduction of pe diatric asthma related deaths, hospitalizations, and emergency department visits are cited as goals of the Healthy People 2010 initiative (United States Department of Health and Human Services, 2000). Asthma is a chronic disease defined by symp toms including tightening of the chest, coughing, and wheezing that result from restricted bronchial airw ays and increased mucous in the airways. If asthma is not managed effec tively and treatment regimens are not followed consistently, it can lead to poor outcomes, incl uding school absences, missed work for parents, and even death of the child (American Lung Association, 2006). Asthma -related hospitalization rates have been reported to be highest in preschool-aged childr en (Centers for Disease Control and Prevention, 1996). Taken together with the hi gh prevalence rates in this age range, these statistics provide further evid ence emphasizing the need for add itional research in the very young asthmatic population. In children with persistent asthma (i.e., symptoms occurring on a weekly basis), the treatment regimen includes the r ecognition and avoidance of envi ronmental triggers that may exacerbate symptoms and the regular use of c ontroller or preventative medication. A popular prophylactic option for persistent asthma is th e use of anti-inflammatory medications (e.g., inhaled corticosteroids) that re duce airway restriction. As the airways become less restricted,

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12 they are less sensitive to environmental triggers ; therefore, allowing for greater symptom control and fewer flare-ups (American L ung Association, 2007). Parents ar e often unable to use inhalers with young children because it is difficult for chil dren to coordinate th eir breathing with the quick release of the medication. Consequently, medications are not sufficiently consumed when such difficulties are present (Canny & Levis on, 1988). As a result, young children are often given their preventative asthma medications using nebulizers or pressurized metered dose inhalers (pMDI) with spacers and/or facemasks. Nebulizers are machines that use compressed air to deliver medications as a mist that can be inhaled passively. The use of spacers, tubes that can be connected to inhalers th at contain the medication, with pM DI devices slows down the rate at which doses are delivered, making it easier for young children to synchr onize their inhalation with actuation. Facemasks are often used in co njunction with spacers to maximize inhalation in children under the age of 4 (OConnell, 2005). The complex equipment involved in these methods of delivery and the requirement of child ren to remain stationary for a number of minutes may potentially provide a barrier to tr eatment success in children, especially those exhibiting difficult behaviors. Regardless of the delivery method, these anti-inflammatory medications must be taken regularly (i.e. daily) in order to be effective, and beneficial results are less likely to occur if they are not taken accordin g to instruction or if child behavior precludes proper use. Medication Adherence in Children w ith Asthma Given the risks of poorly controlled asthma, medication adherence is a key component of asthma management that deserves research focu s. Non-adherence to long-term daily asthma controller medications has been found to correlate with asth ma morbidity (i.e., increased emergency room visits and number of school abse nces) in children aged 8-16 (Walders, Kopel, Koinis-Mitchell, & McQuaid, 2005). Moreover, in children and adults, re gular use of inhaled

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13 corticosteroids has been associated with a signifi cant decrease in hospitalizations (Suissa, Ernst, & Kezouh, 2002). A literature review of adhere nce in pediatric asthma reported that nonadherence rates range between 17%-90% across multiple studies (Lemanek, 1990). Even in preschool children requiring pare ntal administration of medicati on, adherence has been found to be less than optimal despite freque nt parent-reported asthma sympto ms in their children (Gibson, Ferguson, Aitchison, & Paton, 1995). Furthermore, in a study of young urban children aged 2 to 9, approximately 28% of children with persistent asthma did not refill a ny controller medications within a 6-month period (Mudd, Bollinger, Hsu, D onithan, & Butz, 2006). Adherence rates vary across research studies; however, they consistently indicate that a significant number of children and families do not follow physician recommended dosages for asthma medications. Parenting Stress as a Risk Fact or for Lo w Medication Adherence Asthma does not just impact the patient, but ha s the potential to affect the childs entire family. In fact, asthma has been conceptu alized as a family illness (Hookham, 1985), necessitating consideration of f actors outside the child when s eeking to understand adherence and disease management. At a young age, childr en with persistent asthma are unable to remember to take and administer their asthma medications independent ly without parental prompting, guidance, and direct assistance. Aside from physical limitations in initiating medication treatment, young children do not yet ha ve the mental capacity to recognize the relationship between symptoms and symptom re duction in the context of regular use of preventative medications; therefore, the responsibility fa lls on their caregivers to be cognizant of the benefits attributable to following prescription guideline s (Rand, 2002). In addition to everyday parenting demands, the requirement of di rect parental involvement in administering medications with preschoolers potentially can be a significant burden for families.

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14 Within the family context, children with asthma have been found to have difficult temperament characteristics that can be stressful to the family. As compared to healthy controls, children with asthma present with low adapta bility, demanding behavior, and negative mood (Carson & Schauer, 1992), as well as social w ithdrawal (Liu & Wan, 2001). In a school-aged sample, children with severe as thma demonstrated nearly three times the odds of having severe externalizing or aggressive beha vior problems as compared to h ealthy children (Bussing, Halfon, Benjamin, & Wells, 1995). Consequently, not only does the childs behavior have the potential to adversely affect parental ad justment, but such negative behavior also has the potential to increase parental demands related to an asth ma treatment plan. Research has shown that managing discipline, providing developmental and emotional support, and handling asthma episodes can be quite burdensome for mothers of children with asthma. Mothers in one study reported managing their own fatigue as the most difficult task in maintaining the role as caregiver (Svavarsdottir, McC ubbin, & Kane, 2000). Moreover, in a study of children with asthma aged 8 to 13 years, mothers had parenting stress scores approachin g the 85th percentile as compared to mothers in the normative sample (Carson & Schauer). Th ese authors speculated that a variety of factors were associated w ith stress, including difficult child temperament characteristics and lack of self -efficacy in the parenting role. What is particularly concerning about these results is that the mothers were appr oaching clinically signifi cant levels of stress, given that scores at or above the 90th percentile are considered grounds for referral for further evaluation and possible treatment (Abidin, 1995). The amount of stress and fatigue associated with caring for a child with asthma, particularly in the context of diffi cult child behavior, may potentially present significant barriers to treatment adherence in families with preschool-aged

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15 children who require more medication assistance. To date, research examining similar risk factors in younger children with asthma and their families has not been conducted. Parental psychosocial factors have also b een associated with asthma morbidity in children. One study of children with asthma aged 4 to 9 and their caregiv ers (Weil et al., 1999), found that an increased number of asthma-rela ted hospitalizations was associated with poor caregiver mental health and high ca regiver life stress. These factor s, in addition to child mental health, were also associated with lower child f unctional status. Furthermore, increased wheezing in children was associated with poor caregiver and child mental health. The relationship between parental psychosocial factors (e.g., life stress and mental health ) and child health is unclear; therefore, further resear ch examining such factors and be haviors associated with child health (e.g., regimen adherence) could potential ly provide useful information regarding the direction and nature of this relationship. Parent-Reported Barriers to Medication Adherence Extant literature provides evidence that parents of children with asthm a report barriers to treatment adherence, specifically in the use of inhaled corticostero ids. In one study, the majority (71%) of parents of school-aged children w ith asthma reported barriers to consistent administration of these medications (Modi & Qu ittner, 2006). Interestingly, parents of children in this group reported significantly more barrie rs to adherence to inha led corticosteroids as compared to parents of children with Cystic Fi brosis, a more severe pulmonary disease with a more complex and demanding daily regimen. Child oppositional behavior and forgetting were reported most commonly as barriers to treat ment by parents in the asthma group (Modi & Quittner). Although this study eluc idated barriers to adherence in school-aged children with asthma, more research is needed to understand if these same barriers, or perhaps others, exist for families with younger children.

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16 Difficult Child Temperament as a Risk Facto r for Low Medication Adherence Temperament, a construct primarily used in characterizing y oung children, has been found to positively correlate with oppositional behavior in preschoolers (Earls, 1982). Little is known about how child temperament may be associated with poor health outcomes among children with asthma. As previously discusse d, school-aged children with asthma have been found to exhibit greater difficult temperament characteristics and oppositional behaviors as compared to healthy controls (Carson & Schaue r, 1992; Liu & Wan, 2001; Bussing et al., 1995). However, no published research has examined whether difficult child temperament may be associated with poor health outcomes via opposit ional behavior and poor adherence to inhaled corticosteroids among preschool-aged children with asthma. Social Support as a Resistance Factor In contrast to risk factors su ch as barriers, research has s hown that social support m ay act as a buffer, or resilience factor, to alleviat e parenting stress (Sepa, Frodi, & Ludvigsson, 2004). Specifically, high levels of percei ved social support have also b een found to provide a buffer to assist caregivers responsible for children with ch ronic illnesses. This relationship was seen in a study of children with cancer and their parents, where overall social support was a protective factor against psychological dist ress in mothers, while fathers seemed to benefit most from primary support within the marriag e (Lavee, 2005). Similarly, high levels of perceived spousal support in mothers of adolescents wi th Type I diabetes have been a ssociated with lower levels of mother-adolescent conflict and be tter adolescent adherence to da ily insulin injections, dietary restrictions, and blood glucose monitoring (Lewa ndowski & Drotar, 2007). In children with asthma, research targeting innercity families has found parental perceived social support to be associated with less morbidity (i.e., wheezing) in their children (Weil et al., 1999).

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17 Discrepancies in Extant Literature Although research has exam ined parenting stre ss in pediatric asthma populations, it has been limited to school-aged children. Indeed, research has found that parental distress and difficult child temperament significantly predic t medication adherence; however, children of participating parents ranged in age from 6 to 12 years (DeMore, Adams, Wilson, & Hogan, 2005). It is likely that school -aged children are able to ta ke some degree of personal responsibility for the management of their asthma, whereas very young children require full parental monitoring and involvement. The demands involved in providing care to young children likely increase the parent al burden, especially if the child displays difficult temperament behaviors that would be stress ful even in the absence of managing a medical regimen for a chronically ill child. Research has not examined these variables (parenting stress and difficult child temperament) in their re lation to medication adherence in young children nor tried to identify buffers or resilience factors such as social support within this relationship. Current Study The purpose of this research study was to f ill g aps in the current pediatric asthma literature by examining risk and resistance fact ors associated with medication adherence in young children with asthma. It is important to understand how these variables are associated with adherence so that the content of family interventions aimed at improving adherence can specifically target key concerns. Using a fam ily illness model for understanding asthma, this research study aimed to identify both family and child factors associated with medication adherence by investigating the relationships between (a) parenting stress and medication adherence and (b) child temperament and medica tion adherence in young ch ildren with asthma. Parenting stress was assessed in two specific cont exts in general pare nting situations (e.g., giving up ones life to care for childs needs, pa rent-child dysfunctional in teraction) and in the

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18 context of caring for a child with a chronic illnes s in order to identify if varying types of parenting stress differed in their association with medication adhe rence. In addition, caregiver social support was evaluated as a possible moderator between th ese variables (parenting stress and child temperament) and the outcome (medication adherence) (Figure 1-1). Given support from existing literature, it was hypothesized that (a) greater difficult child temperament (e.g., children who excessively cry, fuss, and/or ar e easily upset), (b) greater parenting stress, and (c) lower perceived parent al social support (i.e., parents who reported having low social support) would be significantly associated with lower adherence to inhaled corticosteroids among young children with asthma. It was further hypothesized that parenting stress associated with caregiving for a chronically ill child would be a stronger predictor of lower medication adherence than parenting stress a ssociated with non-asthma related issues. Furthermore, it was also hypothesized that greater perceived parental support would buffer the relationships between difficult child temperament/parenting stress and lower medication adherence.

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19 Figure 1-1. Family illness model for predicti ng medication adherence in young children with asthma Parenting Stress Caregiving Stress Difficult Child Temperament Medication Adherence Social Support

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20 CHAPTER 2 METHODS Design The current study applied a cross-sectiona l design. Forty three caregivers of young children with asthm a completed a series of psychosocial questi onnaires and provided authorization to obtain their childs pharmacy refill history regarding prophylactic asthma medications. Statistical analyses examined the relationships between parenting stress and difficult child temperament as predictors of medica tion adherence, as well as social support as a moderator of these relationships. Participants Participants were recruite d as part of a study funded by the C enter for Pediatric Psychology and Family Studies at the Univer sity of Florida that was approved by the Institutional Review Board (IRB Project # 630-2007). All caregi vers of patients meeting the following criteria were eligible fo r participation: (a) child diagnos is of persistent asthma; (b) child age between 2 and 5 years; and (c) child pr escribed a daily controller or preventative medication for asthma. Caregivers were exclud ed if: (a) they were non-English speaking; (b) they had significant cognitive impairments that rendered them unable to consent and/or complete study-related measures; or (c) childs asthma me dications were obtained via samples (as opposed to pharmacy refill). Procedure Participan ts in this study were recruited from a pediatric pulmonary cl inic in north-central Florida. Caregivers meeting eligibility crit eria were approached by research staff during regularly scheduled clinic vis its. Once informed consent was obtained, the primary caregiver completed the study measures in random order. In accordance with clinic protocol, caregivers

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21 were informed that the research was secondary to the clinic visit and the health of the child to ensure that the appointment woul d not be disrupted due to involve ment in the study. Caregivers were also assured that their res ponses would not be shared with the pulmonary staff in order to decrease the risk of social desirability. Research staff regularly check ed with participating caregivers to address any questions they may have had concerning the measures. Upon completion, participants were co mpensated with a $5 gift card. For each pharmacy location that the caregiver reported using to obtain the childs asthma medication, a release form was completed by the re search staff, indicati ng the specific asthma medications of interest (i.e., controller or preventative medi cines), and then signed by the caregiver prior to contacting the pharmacies to obtain refill data. It is noteworthy that this procedure is common practice in the standa rd clinical care of asthma patients. Psychosocial Measurement Parenting Stress The Total Stress sco re from the Parenting Stress Index-Short Form (PSI-SF), an instrument common in pediatric asthma resear ch (Carson & Schauer, 1992; DeMore et al., 2005), was used as a measure of general parentin g stress (Abidin, 1995). The PSI-SF is a selfreport measure intended for parents of children ages 1 to 12 that is divided into 3 subscales: Parental Distress (PD); Parent-Child Dysfuncti onal Interaction (P-CDI); and Difficult Child (DC). Scores for each of these subscales are combined to yield a Total Stress score that takes into account each of these domains. Cronbachs alpha coefficients have ranged from .80 to .91, indicating good internal consistency. Satisf actory test-retest reliability has also been demonstrated with coefficients ranging fr om .68 to .85 in each of the subscales.

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22 Caregiving Stress The Pediatric Inventory for Parents (PIP) was used to m easure the frequency and difficulty of stressors related to the role of caregiver for a child with a chronic illness (Streisand, Braniecki, Tercyak, & Kazak, 2001). A 5-point Likert scale is us ed to examine stress across 4 domains: Communication, Emotional Distress, Me dical Care, and Role Function. Each domain is also measured across Frequency and Diffi culty scales, although only the Total Frequency score will be used for purposes of this study. Total Frequency scores have been found to be internally consistent, with Cronbachs alpha co efficient of .95. Individual subscales also demonstrate high internal consistency, with Cr onbachs alpha coefficients ranging between .80 and .96. Scores on this measure significantly co rrelate with other standardized self-report measures of parent stress and state anxiety, indicating c onstruct validity. Difficult Child Temperament The Difficult Child subs cale from the afor ementioned Parenting Stress Index Short Form (Abidin, 1995) was used as the measure of difficult child temperament. The Difficult Child subscale has demonstrated acceptable test-retest reliability ( r = .78) and internal consistency with a Cronbachs alpha coefficient of .85. Social Support The Multidim ensional Scale of Perceived So cial Support (MSPSS) was used to measure the perceived social support of caregivers in our sample (Zimet, Dahlem, Zimet, S.G., & Farley, 1988). The MSPSS is a self-report measure with 12 items that identifies levels of perceived social support across 3 subscales : Family, Friends, and Significa nt Other. Cronbachs alpha coefficients ranging from .85 to .91 have been reported to indicate strong internal consistency. Test-retest reliability values ar e acceptable with coefficients ra nging from .72 to .85. In a sample of college students, the MSPSS was significantly negatively correlate d with the Beck Depression

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23 Inventory (higher social support scores correlated with lower depression scores), indicating construct validity (Zimet et al., 1988). Measurement of Medication Adherence As an indire ct, but objective measure of medication adherence, pharmacy refill data were obtained for the childs preventive or controller asthma medication (e.g., inhaled corticosteroids). The desired time period for adherence calculation s was 6 months retrospective of caregiver participation in this study. Due to the timing of refills, however, refill history was obtained for the 9 months prior to the study visit in order to most accurately calculate 6 months of adherence data. For each medication, the number of doses refilled was divided by the number of doses prescribed, and then multiplied by 100 to yield a percentage of maximum possible adherence. This percentage was used as a continuous variable in our analyses; however as a rule of thumb, very poor adherence is characte rized by values between 0 to 50% less than optimal between 51 to 84%, and optimal adherence between 85 to 10 0%. This method has been found to be 92% accurate and compared to physician assessments, was able to detect very poor adherence in twice as many patients in its original application (Sherman, Hutson, Baumsterin, & Hendeles, 2000). Statistical Procedures Results presented in this paper are based upon cross-sectional psychosocial data and child pharm acy refill data. First, the relationships between potential demographic control variables and medication adherence were examined. One-sample t-tests were used to compare the average levels of the measured variables reported by caregivers in this sample to the averages obtained by standardization samples on the respective measures Linear regression analyses were used to examine the relationships between the predictors (e.g., parenting stress, caregiver stress, and difficult child temperament) and medication adhere nce. Furthermore, mo derator analyses were

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24 performed using Interaction! Version 1.3.1733 (Soper, 2006) to test the role of perceived social support as a potential moderator between these variables.

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25 CHAPTER 3 RESULTS Demographics Forty-six caregivers of children with asthm a were enrolled in this study. The results reported here are based on 43 participants on whom we were able to obtain pharmacy refill history for their childs daily as thma controller or preventative medication. Three participants were excluded from analyses because pharmacy refill histories were not available. The 43 caregivers ranged in age from 21 to 58 years ( M = 33 years, SD = 8.2 years). The majority of caregivers were birth mothers (84 %), with the remainder of the sample being comprised of adoptive mothers (7%), grandmothers (5%), and fathers (5%). The majority (65%) of caregivers were non-Hispanic/Caucasian, 26% were African American, and 9% were of Hispanic ethnicity. Approximately 58% of th e caregivers were married, whereas 35% were single/never married, 5% were divorced, and 2% were separa ted. The majority (58%) of caregivers were employed outside the home durin g their time of participation and averaged 34.2 hours ( SD = 80.7 hours) of time taken off of work in the previous 6 months to care or obtain treatment for their childs asthma. Children of the participating caregiver s ranged in age from 2 to 5 years ( M = 3.3 years, SD = 1.2 years) and were primarily male (67%). General Parenting Stress and Difficult Child Temperament Caregivers participating in this study reported Total Stress scores on the P arenting Stress Index-Short Form (PSI-SF) that fell, on average, in the 50th percentile (M = 69, SD = 23; maximum possible score = 180). Using the 90th percentile as a recommended clinical marker (Abidin, 1995), analyses revealed that approximately 21% of the caregivers in this sample reported clinically signifi cant parenting stress scores. With re gard to the individual subscales of the PSI-SF, the responses of 21% of caregivers revealed clinica lly significant elevations on the

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26 difficult child subscale, 16% of caregivers re ported clinically significant parent-child dysfunctional interactions, and 12% reported clinically significan t levels of parent al distress. The PSI-SF also includes a defensive responding scale that aims to identify participants who are faking good. Approximately 35% of ca regivers in this sample met criteria for defensive responding. In an attempt to contro l for defensive responding, initial regression analyses were performed excluding caregivers w ho met these criteria; however, these results were identical to those obtained when the enti re sample was included. Therefore, the results presented later in this chapter did not exclude participants who met criteria for defensive responding. Caregiving Stress The Total Frequency score from the Pediatri c Inventory for Parents (PIP) was used to determine the extent to which caregivers experi enced disease-related stressors. On average, caregivers in this sample reported simila r frequency of health-related stressors ( M = 90.1, SD = 28.4) to caregivers of children with cancer ( M = 94.0, SD = 33.3), who comprised the standardization sample for this measure, t (34) = -0.82, p = .42 (Streisand, 2001). Social Support Using the Multid imensional Scale of Percei ved Social Support (MSPSS) scale ranging from 12 to 84, with higher scores indicating higher levels of pe rceived social support, caregivers in this sample reported levels of total perceived social support ( M = 65.6, SD = 19.6) that were not significantly different th an those reported by a sample of college students in the standardization sample, t (41) = -1.33, p = .19 (Zimet et al., 1988). With regard to the individual subscales, which ranged from 4 to 28, perceived support from significant ot her was reported as the highest source of support ( M = 22.5, SD = 6.9), followed by friends ( M = 21.7, SD = 6.8), and family ( M = 21.5, SD = 7.4).

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27 Medication Adherence Although attem pts were made to calculate medication adherence based on the 6 month time period prior to caregi ver participation in the study, pharmacy refill data revealed that some children had prescription historie s less than 6 months in duration. Given that the present study included pre-school children, this was likely due to recent treatment initiation. On average, medication adherence was calculate d based on 151.7 days of data (SD = 47.8 days). Pharmacy refill patterns revealed that on average, the maximum possible adherence rates of children whose caregivers participated in this study were le ss than optimal, as outlined by Sherman, Hutson, Baumsterin, and Hendeles (2000). Furthermore, ther e was a great deal of variability within the sample ( M = 57%, SD = 31%) as the modal maximum possi ble adherence percentage was 0% and the median was approximately 56%. Relations between Psychosocial Variables and Medication Adherence A series of bivariate correlations and one-way ANOVAs were conducted to identify possible continuous and categorical variables th at m ay have confounded existing relationships between the predictors and medicat ion adherence. Caregiver age, r (43) = .12, p = .46, marital status, r (43) = -.22, p = .15, and number of peopl e living in the household, r (43) = -.13, p = .40, were unrelated to medication adherence. Thus, there were no control variables entered into the regression analyses that follow. Relations between Parenting Stress and Medication Adherence Using the P SI-SF Total score as a measure of general parenting stress, linear regression analysis failed to reveal a significant asso ciation between parenti ng stress and adherence, = 0.22, t (41) = -1.46, p = .15. Contrary to the hypothesis, a significant proportion of variance in adherence was not explained by self-r eported general parenting stress, R2 = .05, F (1,41) = 2.12, p = .15. (Table 3-1).

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28 Relations between Caregiving Stress and Medication Adherence Linear regression analysis reve aled that caregiv ing stress wa s not significantly associated with adherence, = -0.13, t (34) = -0.78, p = .44. Furthermore, a significant proportion of variance in child medication adherence wa s not explained by caregiving stress, R2 = .02, F (1,33) = 0.61, p = .44. (Table 3-2). Relations between Difficult Child Temperament and Medication Adherence Linear regression analysis was perform ed to evaluate the relationship between difficult child temperament as measured by the PSI-SF difficult child subscale and child medication adherence. Contrary to hypothesis, there was no association between temperament and adherence, = -0.16, t (41) = -1.06, p = .30. Difficult child temperam ent failed to account for a significant proportion of variance in adherence, R2 = .03, F (1,41) = 1.12, p = 0.30. (Table 3-3). Social Support as a Moderator Moderator analyses were perform ed using Interaction! Version 1.3.1733 (Soper, 2006) to examine whether social support moderated (buffere d) a relationship between the predictors of interest (parenting stress, caregiv er stress, child temperament) a nd child medication adherence. Three hierarchical linear regression analyses were performed to determin e whether the respective interaction terms were significant above and bey ond the main effects of each of the predictor variables and the proposed modera tor (social support). In the first equation, child medication adherence was regressed on the main effects of PSI-SF total (predictor ) and MSPSS (moderator) (Block 1) and the centere d interacted term (PSI-SF total x M SPSS total) (Block 2). In the second equation, PIP frequency was substituted as the pr edictor; and in the th ird equation, PSI difficult child was entered as the predictor. In the first equation, the overall model fa iled to account for a significant amount of variance in medication adherence, R2 = .13, F( 3,31) = 1.50, p = .23. Furthermore, the centered

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29 interaction term (PSI-SF total x MSPSS total) was not a significant pr edictor of medication adherence above and beyond the main effects of PSI-SF total and MSPSS, = 0.01, t (34) = 1.15, p = .26. (Table 3-4). In the second equation, social support also fa iled to moderate the relationship between caregiving stress and medication adherence. The overall model was not significant, R2 = .06, F (3,31) = 0.69, p = .57. The centered interaction term (P IP frequency x MSPSS total) was not a significant predictor above and beyond the main effects of PIP frequency and MSPSS total, = 0.01, t (34) = 0.66, p = .52. (Table 3-5). In the third equation, the ove rall model did not account for a significant amount of variance in medication adherence, R2 = .07, F (3,31) = 0.73, p = .54. Furthermore, the centered interaction term (PSI difficult child x MSPSS tota l) was not a significant predictor of medication adherence above and beyond the main effects of PSI difficult child and MSPSS total, = 0.03, t (34) = 0.92, p = .36. (Table 3-6).

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30 Table 3-1. General parenting stress predicting child medication adherence Step number Predictor variable R2 F of R2 1 PSI Total Score .05 -0.22 2.12 N =42. Significance of Model, F (1, 41)=2.12 p=.15 *p< .10, **p< .05 Table 3-2. Caregiving stress predicting child medication adherence Step number Predictor variable R2 F of R2 1 PSI Total Frequency .02 -0.13 0.61 N =34. Significance of Model, F (1, 33)=.61 p=.44 *p< .10, **p< .05 Table 3-3. Difficult child temperament predicting child medication adherence Step number Predictor variable R2 F of R2 1 PSI: Difficult Child .03 -0.16 1.12 N =42. Significance of Model, F (1, 41)=1.12 p=.30 *p< .10, **p< .05

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31 Table 3-4. Moderator analyses: Predicting medication adherence from parenting stress and social support Step number Predictor variable R2 t p value 1 PSI Total MSPSS Total -0.33 -0.52 -1.25 -1.55 .22 .13 2 PSI Total x MSPSS Total interaction 0.01 1.15 .26 N=34, Significance of Model, R2 = .13, F (3,31) = 1.50, p=.23 *p< .10, **p< .05 Table 3-5. Moderator analyses: Predicting medica tion adherence from caregiving stress and social support Step number Predictor variable R2 t p value 1 PIP Total Freq. MSPSS Total -0.20 -1.02 -1.02 -0.92 .31 .36 2 PIP Total Freq. x MSPSS Total interaction 0.01 0.66 .52 N=34, Significance of Model, R2 = .06, F (3,31) = 0.69, p=.57 *p< .10, **p< .05 Table 3-6. Moderator analyses: Predicti ng medication adherence from difficult child temperament and social support Step number Predictor variable R2 t p value 1 PSI-DC MSPSS Total -0.59 -0.43 -1.00 -1.24 .33 .23 2 PSI-DC x MSPSS Total interaction 0.03 0.92 .36 N=34, Significance of Model, R2 = .07, F (3,31) = 0.73, p=.54 *p< .10, **p< .05

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32 CHAPTER 4 DISCUSSION Research has consistently demonstrated that adherence to preventative asthma medications in children is poor in many familie s (Lemanek, 1990) despite evidence associating regular use of daily preventative medications with decreased morbidity (Suissa, Ernst, & Kezouh, 2002). In preschool-aged children, hospita lizations related to asthma have been reported to be the highest (Centers for Dis ease Control and Preven tion, 1996), although the factors that are associated with these high levels of morbidity have not yet been determined. Pediatric research has found that mothers of school-aged children with asthma report higher levels of parenting stress as compared to mo thers of healthy children (Carson & Schauer, 1992) and that children with asthma display more difficult behaviors than healthy children (e.g., demandingness, negative mood, low adaptability, a nd social withdrawal) (Carson & Schauer, Liu & Wan, 2001; Bussing et al., 1995). Furthermor e, although recent research by DeMore et al. (2005) revealed a predictive relationship between parenting stress, difficult child behavior, and medication adherence, their sample was limited to school-aged children a nd, therefore, did not take into account the additional parenting challeng es associated with providing care for a very young child. The current study was the first, to our knowledge, to use a family illness model (Hookham, 1985) to examine risk factors (e.g., parenting stress and difficult child temperament) and a resistance factor (e.g., soci al support) associated with p oor adherence to daily asthma preventative medications in preschool-aged childre n. Regarding the proposed risk factors, it was hypothesized that higher levels of parenting stre ss (both general and sp ecific to the role of caregiver for a chronically ill child) and higher levels of difficult child temperament would be associated with greater non-adherence in young children. However, none of the hypothesized

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33 risk factors emerged as predictors of medication a dherence in this sample. In addition, contrary to published research suggesting that social suppor t may serve as a resistance factor to protect caregivers of chronically ill children from ps ychological distress (Lavee, 2005), social support failed to buffer the relationships between our hypot hesized risk factors a nd medication adherence in our sample. The lack of significant findings may possibly be explained by the prevalence of defensive responding by caregivers in this sample. Overall, caregivers in our sample reported average (50th percentile) levels of parenting stress that were not clinically significant. These findings were inconsistent with previous research suggesti ng that mothers of asthmatic children typically reported levels of parenting stress that approached or met criteria for clinical significance (Carson & Schauer, 1992). Given that caregivers in our sample were caring for children of a younger age, these considerably lower levels of parenting stress as compared to mothers of school-aged children were highly unexpected. Approximately 34.9% of caregivers met criteria for faking good on the PSI-SF defensive respo nding subscale and although results from our regression analyses did not differ when these part icipants were excluded, the rate of defensive responding in this sample suggests that a considerable portion of caregivers may have underreported levels of parenting stress and difficult child temperament. Therefore, it is possible that a significant relationship between the hypothe sized risk factors and medication adherence may have failed to emerge due to defensive or socially desirable responses provided by caregivers. However, while defensive responding may have contributed to these null findings, these results also suggest that adherence to asthma medications in young children may be better explained by other risk and resi stance factors that were not measured in this study. For example,

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34 the discrepancy in reported levels of parent ing stress between caregivers in our sample as compared to those reported in previous studies with parents of school-aged children may indicate that the experiences for caregivers of asthmatic children are vastly different as a function of the length of diagnosis. Given the relative recency of asthma diagnoses in preschool-aged children, caregivers in our sample may not have yet experienced their childrens asthma as a chronic stressor, and perhaps it is the chronic stress of parenting/caregivi ng for a young child with asthma that most strongly affects adherence. This will be important to consider in future research endeavors with families of very young asthmatic children in order to identify the unique factors contributing to poor medicatio n adherence in this population. Study Limitations There are several lim itations to this study that should be considered when interpreting the reported results, such as the modest sample si ze and the cross-sectiona l design, the latter of which precludes our ability to in fer causal relationships between any of our measured variables. The use of self-report measures and the nature of our study proce dures (i.e., dire ctly obtaining completed questionnaires from caregivers in the c linic) are also limitations to this study because participating caregivers may have been more lik ely to respond in a socially desirable manner under these conditions. Another limitation is the across subject variability in the intervals on which child pharmacy refill history was obtained. More specifically, some children of caregivers who participated in this study were prescribed their daily asthma preventativ e medication only one to two months prior to caregiver pa rticipation; therefore, their ra tes of adherence were based on shorter intervals of time than desirable (e.g., 6 m onths). This may be problematic for several reasons. First, adherence data based on shor ter intervals may be more variable and less representative of true adhere nce than those based upon longer intervals. Second, a shorter

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35 interval of medication usage may indicate that the child was recently diagnosed and/or recently initiated treatment, although thes e areas were not formally assessed in this study. As alluded to above, parenting and caregiver stress, as well as adherence, may be associated with length of time since diagnosis and/or treatment initiation. For instance, caregivers of children with newly prescribed medications may be mo re adherent initially because they are more vigilant about maintaining the medication regimen or because parenting stress may not have emerged as a significant problem early on in the treatment pro cess. Thus, the variability across subjects in length of time since diagnosis and/or treatment in itiation may have impacted our findings and/or the generalizability of these resu lts to the population given that pr eventative asthma medications are typically part of a long term treatment. Future Directions This study is one of the first to examin e a family illness model of child medication adherence in the very young asthmatic population. The results of th is study suggest that further investigation is needed to dete rmine risk and resistance factors associated with non-adherence in pediatric asthma. Families of the preschool-aged asthmatic population should continue to receive focus as it is clear from the results of this study that the ch allenges of maintaining adherence for parents of very young children are quite different th an those faced by parents of school-aged children. Consistent with asthma-re lated adherence researc h, medication adherence was quite poor in this sample, and in some cases, families failed to refill any preventative asthma medications within six month time periods or longer It is unclear as to whether these families were having difficulty refilling the medications, if they encountered barriers to administration of these medications, if they simply did not believe in the efficacy of the medications, or if they were experiencing a combination of these and othe r factors. Notwithstanding these inconclusive findings, the results highlight th e necessity of further research to identify the barriers to

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36 adherence in pediatric asthma and ultimately the development of interventions to assist families with children who are not receiving thei r asthma medications as prescribed. The variables examined in the present st udy were broad psychoso cial factors, and considering that these did not pred ict adherence in this sample, car egiver health beliefs regarding asthma treatments may be a worthwhile predictor to incorporate into a family illness model of non-adherence. Extant literature suggests that adults with as thma who have more skeptical beliefs about the necessity and efficacy of thei r prescribed asthma medi cations (e.g., belief that they do not have to use their preventative medica tion when symptoms are not present) refilled their asthma medications significantly fewer tim es than those who did not hold these beliefs (Menckeberg et al., 2008). Pediatric research has revealed similar relationships with regard to caregivers who provide care to children with as thma; however, these earli er results were based on parent-reports of adherence ra ther than objective measurements (Conn, Halterman, Lynch, & Cabana, 2007). Taken together, th is evidence suggests that examin ing caregiver health beliefs may potentially be useful in explaining the rela tionships between medication adherence and the risk and resistance factors m easured in the present study. Given that asthma is a chronic condition, it wi ll be important to es tablish behaviors that will facilitate good adhere nce to preventative medications in children at a young age. As caregivers of these children model adherent practices to their children early in life, the children will be much more likely to engage in similar health behaviors as they age and begin to take more responsibility for their own treatment. Thus, continued research is needed to identify the most salient factors associated w ith adherence such that we are ab le to develop interventions to assist families in maximizing their ch ilds care and ultimately their health.

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37 LIST OF REFERENCES Abidin, R.R. (1995). Parenting Stress Index: Professional Manual. Florida: Psychological Assessm ent Resources, Inc. American Lung Association. (2006, August). Childhood Asthma Overview. Retrieved September 25, 2007, from http://www.lungusa.org/site/pp.asp?c=dvLUK9O0E&b=22782. Am erican Lung Association. (2007). Asthma, Steroids, and Other Anti-Inflammatory Drugs. Retrieved September 27, 2007, from http://www.webmd.com/asthma/guide/asthma_c ontrol_with_anti-inflammatory-drugs Bussing, R., Halfon, N., Benjamin, B., & Wells, K. B. (1995). Prevalence of behavior problems in US children with asthma. Archives of Pediatrics and Adolescent Medicine, 149 (5), 565-572. Canny G.J. & Levison, H. (1988). Aerosols: ther apeutic use and delivery in childhood asthma. Ann Allergy, 60, 11. Carson, D.K., & Schauer, R.W. (1992). Mother s of children with asthma: Perceptions of parenting stress and the mother-child relationship. Psychological Reports, 71 (3, Pt 2), 1139-1148. Centers for Disease Control and Prevention. (1 996). Asthma mortalit y and hospitalization among children and young adults: United States, 1980-1993. Morbidity and Mortality Weekly Report, 45 350-353. Conn, K. M., Halterman, J. S., Lynch, K., & Cabana, M. D. (2007). The impact of parents' medication beliefs on asthma management. Pediatrics, 120 (3), 521-526. DeMore, M., Adams, C., Wilson, N., & Hogan, M. B. (2005). Parenting Stress, Difficult Child Behavior, and Use of Routines in Rela tion to Adherence in Pediatric Asthma. Childrens Health Care, 34 (4), 245-259. Earls, F. (1982). Temperament characteristics an d behavior problems in three-year-old children. Annual Progress in Child Psychiatry & Child Development, 330-343. Gibson, N. A., Ferguson, A. E., Aitchison, T. C., & Paton, J. Y. (1995). Co mpliance with inhaled asthma medication in preschool children. Thorax, 50 (12), 1274-1279. Hookham, V. (1985). Family conste llations in relation to asthma. Journal of Asthma, 22 (2), 99114. Lavee, Y. (2005). Correlates of change in ma rital relationships under stress: The case of childhood cancer. Families in Society, 86 (1), 112-120.

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38 Lemanek, K. (1990). Adherence issues in the medical management of asthma. Journal of Pediatric Psychology, 15 (4), 437-458. Lewandowski, A. & Drotar, D. (2007). The Re lationship between Parent-Reported Social Support and Adherence to Medical Treatment in Families of Adolescents with Type 1 Diabetes. Journal of Pediatric Psychology, 32 (4), 427-436. Liu, C. & Wan, G. (2001). The study of te mperament in child ren with asthma. Chinese Journal of Clinical Psychology, 9 (3), 182-183. Mannino, D.M., Homa, D.M., Pertowski, C.A., Ashizawa, A., Nixon, L.L., Johnson, C.A., Ball, L.B., Jack, E., & Kang, D.S. (1998). Surveillance for asthma United States, 1960-1995. Morbidity and Mortality Weekly Report: Surveillance Summary 47, 1-28. Menckeberg, T.T., Bouvy, M.L., Bracke, M., Kapt ein, A.A., Leufkens, H.G., Raaijmakers, J.A., et al. (2008). Beliefs about medi cines predict refill adherence to inhaled corticosteroids. Journal of Psychosomatic Research, 64 (1), 47-54. Modi, A.C., & Quittner, A.L. (2006). Barriers to treatment adherence for children with cystic fibrosis and asthma: what gets in the way? Journal of Pediatric Psychology, 31 (8), 846858. Mudd, K., Bollinger, M. E., Hsu, V. D., Donitha n, M., & Butz, A. (2006). Pharmacy fill patterns in young urban children with persistent asthma. J Asthma, 43 (8), 597-600. National Center for Health Statistics. (2006, Nove mber). Asthma Prevalence, Health Care Use and Mortality: United States, 2003-2005. Retrieved September 25, 2007 from http://www.cdc.gov/nchs/fastats/asthma.htm. OConnell, E. (2005). Optimizing Inhaled Cortic osteroid Therapy in Children with Chronic Asthma. Pediatric Pulmonology, 39 74-83. Rand, C.S. (2002). Adherence to asthma therapy in the preschool child. Allergy, 57 (Suppl 74), 48-57. Sepa, A., Frodi, A., & Ludvigsson, J. (2004). Psychos ocial correlates of pare nting stress, lack of support and lack of confidence/security. Scandinavian Journal of Psychology, 45 (2), 169179. Sherman, J., Hutson, A., Baumsterin, S., & Hende les, L. (2000). Telephoning the patients pharmacy to assess adherence with asthma medications by measuring refill rate for prescription. Journal of Pediatrics, 136, 532-536. Soper, D. (2006). Interaction! (Version 1.3.1733) [Computer software]. Fullerton, CA.

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39 Streisand, R., Braniecki, S., Tercyak, K. P., & Kazak, A. E. (2001). Childhood illness-related parenting stress: The pediat ric inventory for parents. Journal of Pediatric Psychology, 26(3), 155-162 Suissa, S., Ernst, P., & Kezouh, A. (2002). Regular use of inhaled corticosteroids and the long term prevention of hospitalisation for asthma. Thorax, 57 (10), 880-884. Svavarsdottir, E.K., McCubbin, M.A., & Kane, J.H. (2000). Well-Being of Parents of Young Children with Asthma. Research in Nursing and Health, 23, 346-358. United States Department of Hea lth and Human Services. (2000). Healthy People 2010: Respiratory Diseases Washington, DC: Government Printing Office. Walders, N., Kopel, S. J., Koinis-Mitchell, D ., & McQuaid, E. L. (2005). Patterns of quick-relief and long-term controller medica tion use in pediatric asthma. J Pediatr, 146 (2), 177-182. Weil, C. M., Wade, S. L., Bauman, L. J., L ynn, H., Mitchell, H., & Lavigne, J. (1999). The relationship between psychosocial factors a nd asthma morbidity in inner-city children with asthma. Pediatrics, 104(6), 1274-1280. Zimet, G.D., Dahlem, N.W., Zimet, S.G., & Fa rley, G.K. (1988). The Multidimensional Scale of Perceived Social Support. Journal of Personality Assessment, 52 30-41.

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40 BIOGRAPHICAL SKETCH Megan Lipe graduated magna cum laude fr om Louisiana State University in 2007, receiving a Bachelor of Science degree in Ps ychology. During her time at Louisiana State University, she worked as a research assistant in a laboratory investig ating the psychological impact of Hurricane Katrina on school-aged children in Louisiana and was a research assistant in the Womens Health, Smoking Cessation, and Eating Behaviors laboratory at Pennington Biomedical Research Center in Baton Rouge, Louisiana. She al so worked as a school shadow for a child with autism, implementing A pplied Behavioral Analysis protocol. Megan began attending graduate school at the University of Florida in the Department of Clinical and Health Psychology in August 2007. She is focusing her research on psychooncology, with a specific interest in pediatrics, as well as wome ns health. She received her Masters degree in the spring of 2009 and is curre ntly pursuing her Ph.D. in Clinical Psychology.