Family Influences on Pediatric Asthma

Astrida Seja Kaugars,1 PHD, Mary D. Klinnert,2,3 PHD, and Bruce G. Bender,2,3 PHD
1
Marquette University, 2National Jewish Medical and Research Center and
3
University of Colorado Health Sciences Center

Objective To describe pathways by which families may influence the onset and course of a
child’s asthma. Methods We critically reviewed published articles and book chapters to

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identify research findings and integrated conceptualizations that demonstrate how families
affect pediatric asthma. Results Family emotional characteristics, asthma management
behaviors, and physiological factors account for key influences on pediatric asthma onset and
outcomes. Conclusions Multiple family characteristics are associated with pediatric asthma
onset and outcomes. Behavioral and physiological mechanisms may act independently or may
interact to affect asthma manifestations. Families with specific emotional characteristics may be
at an elevated risk for poorer asthma outcomes.

Key words family; pediatric asthma.

Asthma is a chronic inflammatory disease of the airways
that results from a complex interaction between genetic
and environmental factors (Howard, Meyers, & Bleecker,
2003). It includes the presence of recurrent but reversible
respiratory obstruction and is characterized by such symp-
toms as wheezing, coughing, chest tightness, and shortness
of breath. Asthma is a complex condition with wide vari-
ability in manifestation owing not only to physiological fac-
tors such as allergic status or bronchial hyperresponsiveness
but also to environmental factors such as variation in expo-
sure to tobacco smoke and other allergens. Psychosocial
characteristics of the child, parent, and family can also con-
tribute to variability in asthma presentation. Children with
genetic predisposition for affective disorders and asthma
may represent a subgroup of children at risk for developing
severe asthma (Wamboldt, Weintraub, Krafchick, &
Wamboldt, 1996). Given the increased prevalence and mor-
bidity of pediatric asthma—in particular among young chil-
dren and especially among non-Hispanic black children
(Akinbami & Schoendorf, 2002)—comprehensive asthma
intervention programs have targeted impoverished inner-
city communities at high risk for asthma morbidity and
mortality (Evans et al., 1999). Moreover, ongoing research
seeks first to identify origins of asthma and second to better
understand the natural history of asthma, which can further
inform intervention and treatment strategies (Lemanske &
Busse, 2003; Liu & Szefler, 2003).
It has become increasingly apparent that multidisci-
plinary approaches synthesizing biological, sociocultural,
psychological, and family perspectives are necessary to
better understand asthma (Wright, Rodriguez, & Cohen,
1998). Despite the growing number of studies examining
aspects of psychosocial functioning related to asthma, it
appears that psychological difficulties are not increased
among children with mild to moderate asthma (Bender,
Annett, et al., 2000). However, psychopathology, family
dysfunction, and medication noncompliance have been
found to be associated with increased risk of severe,
poorly controlled asthma (Bender & Klinnert, 1998).
Thus it is important for researchers to closely examine the
relationships between psychological factors and severe
asthma, since doing so may inform an understanding of
how psychological and family variables affect, or result
in, a variety of asthma manifestations.
The literature consistently demonstrates that early
family social environments that include conflict, agg-
ression, and deficient nurturing may represent a risk
profile—“risky families” (Repetti, Taylor, & Seeman,

All correspondence should be sent to Astrida S. Kaugars, Department of Psychology, Marquette University,
P.O. Box 1881, Milwaukee, WI 53201-1881. E-mail: astrida.kaugars@marquette.edu.

Journal of Pediatric Psychology () pp. –, 

doi:./jpepsy/jsh
Journal of Pediatric Psychology vol.  no.  © Society of Pediatric Psychology ; all rights reserved.
 Kaugars, Klinnert, and Bender

2002)—that presents implications for children’s mental
and physical health. Genetic and family factors interact
and may directly or indirectly contribute to emotional,
social, and biological disruptions that can continue to
have an impact on development throughout the life span
(Repetti et al., 2002). Among children with asthma, the
distinction of risky families may help identify those fam-
ilies with similar risk factors for whom managing a
child’s asthma is an additional challenge and for whom
the children have poorer asthma outcomes (Bender &
Klinnert, 1998). Moreover, this distinction reflects the
characteristics of distress in families—to asthma out-
comes. It is important to remember that every child with
severe, poorly controlled asthma does not necessarily have
family functioning characterized by distress and risk; sim-
ilarly, not all distressed families have children who go on
to develop severe, poorly controlled asthma.
Theoretical Model Summarizing Literature
This paper presents a selective review of the literature to
describe pathways by which families may influence the

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overrepresentation in the literature of children with a
multitude of risk factors and more severe asthma. The
National Cooperative Inner-City Asthma Study (NCICAS)
was conducted in response to the excessive burden of
asthma morbidity and mortality among poor and minor-
ity children. The study found a large number of risk fac-
tors for asthma morbidity in this population (Kattan et
al., 1997; Mitchell et al., 1997). Moreover, within this
sample of inner-city children and families, a variety of
psychosocial variables were assessed, and the study
found that psychosocial factors were significant predic-
tors of children’s asthma morbidity (Wade et al., 1997;
Weil et al., 1999). The present review focuses on the
research linking psychological variables—in particular,
onset and course of a child’s asthma. In the literature, a
variety of asthma outcomes have been examined, including
health care utilization, asthma and wheezing symptoms,
quality of life, activity restrictions due to asthma, risk of
death, and school attendance (see Table I).
First, we present a review of how family characteris-
tics are related to pediatric asthma outcomes (see Figure 1,
Path A). Then, we examine two pathways for understand-
ing these associations: first, how family characteristics
affect asthma management behaviors and thus asthma
outcomes (Paths B and C); second, how physiological
factors may help researchers understand the relationships
between family characteristics and asthma outcomes
(Paths D and E).

Table I. Summary of Family Characteristics, Mechanisms, and Asthma Outcomes Reviewed

Family characteristics Mechanisms Asthma outcomes

Caregiver psychological functioning Asthma management behaviors Healthcare utilization

Parent-child relationships • Medication adherence Asthma and wheezing symptoms
Child attachment • Exposure to allergens and tobacco smoke Quality of life
Parenting difficulties • Daily decision making Activity restrictions due to asthma
Family conflict • Patient and family health beliefs Risk of death
Emotion regulation Physiological functioning School attendance
Child adjustment and • Hypothalamic pituitary adrenal (HPA) axis
psychopathology and immune system
Racial and ethnic background • Autonomic nervous system
Family organization and responsibility • Symptom perception

A
Family characteristics Asthma outcomes

Asthma management behaviors

B C

Family characteristics Asthma outcomes

Figure 1. Proposed relationships among factors
contributing to pediatric asthma outcomes.
D E Path A: Diagram of direct relationship.
Physiological functioning Paths B–E: Diagram of mediation.

The majority of studies described in this review
examined models that exist implicitly; very few studies
explicitly delineated models that were empirically tested
(e.g., Bleil, Ramesh, Miller, & Wood, 2000; Wade et al.,
1997; Weil et al., 1999). Although there is evidence in
the literature of bidirectional and reciprocal relation-
ships among family characteristics and asthma outcomes,
Figure 1 illustrates unidirectional relationships to empha-
size how family characteristics can influence asthma
outcomes. Relevant findings in each domain are summar-
ized herein, and applicable methodological and meas-
urement concerns are highlighted, as they may affect
conclusions drawn from the study results. Implications
for treatment and future research is then addressed in
the conclusion. Theoretically relevant studies were selected
for inclusion in the present review utilizing computer
searches (e.g., PsychINFO and PubMed), manual searches
of relevant journals, inspection of reference lists from
published studies and reviews, and consultation with
pediatric psychologists. Research conducted in the past
20 years was the focus of the review, although several
seminal historical references were included as well.
Family Functioning and Asthma
Within families, caregiver functioning, interactions
between caregivers and children, and children’s func-
tioning influence pediatric asthma. Historically, the
psychosomatic family model introduced by Minuchin
and colleagues (1975) suggested that the structure and
functioning of families could affect children’s asthma
outcomes. However, empirical studies testing the psy-
chosomatic family model and measures of general fea-
tures of family functioning have provided limited insight
into how family functioning may interact with the
disease process. Families’ responses to the demands of
caring for a chronic pediatric illness vary greatly and
may have an effect of organizing and structuring some
families but of causing detrimental changes in others
(Wamboldt & Wamboldt, 2000). Thus, it has been use-
ful to identify specific psychosocial characteristics of
individuals and families that affect family functioning
and asthma outcomes. Recent conceptualizations have
emphasized reciprocal influences between psychological
factors and asthma morbidity (Wade et al., 1997). A
bidirectional relationship between psychological func-
tioning in the parents and children’s physical disorders
may exist such that family psychological factors contri-
bute to severe, poorly managed pediatric asthma. Alter-
natively, having a child with asthma is challenging for
families and thereby increases psychological stress and
Family Influences on Pediatric Asthma 
taxes psychological functioning. Incorporating a socio-
ecological model to better understand interactions of the
child, family, and extended environment in the context
of childhood illness reflects progress in understanding
how family and system functioning are linked to chil-
dren’s adaptation to illness and its treatment (Kazak,
Segal-Andrews, & Johnson, 1995).
The following section presents a review of the lite-
rature examining how family characteristics are related
to pediatric asthma outcome. The review summarizes
research in the following areas: caregivers’ psychological
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functioning, parent–child relationships, children’s adjust-
ment and psychopathology, and additional factors influ-
encing family functioning.
Caregivers’ Psychological Functioning
Parents’ and caregivers’ psychological functioning is a
major determinant of family functioning. A persistent
theme in the literature indicates that poorer caregiver
psychological functioning is associated with the worse
asthma outcomes for children. Among mothers of chil-
dren with asthma living in the inner city, almost half
(47%) reported clinically significant levels of depression
(Bartlett et al., 2001). Six months after their initial report,
mothers with high levels of depressive symptoms were
40% more likely to report having taken their children to
the emergency department in the ensuing time, in com-
parison to mothers with low levels of depressive symp-
toms. In another inner-city population, caregivers who
reported clinically significant mental health problems
had children who were 1.78 times more likely to be hos-
pitalized in the next 9 months, when compared to caregiv-
ers whose scores of psychopathology were not clinically
significant (Weil et al., 1999). Similarly, lower caregiver
mental health scores were associated with caregiver
reports of their children’s experiencing more asthma
symptoms and more acute care visits for asthma in the
previous year, when compared to those caregivers with
higher mental health scores (Wood et al., 2002). Among
children seen in suburban and inner-city pediatric
asthma subspecialty practices, caregiver-reported symptoms
of depression and negative life stressors in combination
with children’s sex (i.e., female) were the strongest pre-
dictors of children’s asthma morbidity, based on patterns of
symptoms and health service utilization (Shalowitz,
Berry, Quinn, & Wolf, 2001). Caregivers’ responses to
high stress levels, including managing chronic stress,
may affect their psychological functioning as well as
their infants’ respiratory problems. Caregivers’ perceived
stress when their infants were 2 to 3 months old was
associated with an increased risk of parent report of
 Kaugars, Klinnert, and Bender
infant wheezing during the first 14 months of life, inde-
pendent of factors associated with stress and wheezing
(Wright, Cohen, Carey, Weiss, & Gold, 2002). While
some studies demonstrate associations between caregiv-
ers’ psychological functioning and asthma outcomes,
more recent studies have utilized prospective designs to
better understand the directions of relationships.
Researchers must be aware of reporter bias, and
they must consider how study conclusions and general-
izability are affected by the background of the partici-
pants (e.g., low socioeconomic status) or by the study’s
methodology (e.g., caregiver report). All of the studies
described here included participants from low socio-
economic backgrounds and used asthma outcome data
from caregiver reports. Parental reporting of asthma out-
comes may be problematic since parental emotional
status may influence caregivers’ reporting of the impact
of asthma; likewise, caregiver-reported asthma morbid-
ity and actual morbidity may be discrepant. One type of
asthma outcome that has been studied, with some con-
troversy (Annett, 2001; Bender, 1996), is children’s and
parents’ reporting of the impact of on the family, includ-
ing quality of life. Objective measures of disease morbid-
ity during the year before admission to a pediatric day
program for asthma were unrelated to caregivers’ report
of quality of life (Price, Bratton, & Klinnert, 2002).
Instead, a caregiver’s negative affect (i.e., anxiety and
depression) was a significant predictor of a caregiver’s
reporting of quality of life at admission. This is consis-
tent with evidence demonstrating that factors such as
negative affect, perceived vulnerability, and depressive
symptoms may affect how individuals rate their quality
of life (Mishoe & Maclean, 2001). Among children and
families seen at a tertiary care hospital for asthma,
parental emotional distress was the strongest significant
predictor of how parents reported the extent to which
their child’s asthma affected the family (Frankel &
Wamboldt, 1998). A determination of asthma severity
based on parental report was not a significant predictor
of the illness’s impact on the family. This research high-
lights the influence of situational factors and respondent
characteristics on reports of quality of life and poten-
tially other asthma outcome measures, thus suggesting
the importance of careful attention to study design to
limit reporter bias.
Parent–Child Relationships
Child Attachment
Family relationships are associated with asthma out-
comes in a number of ways. An early observational study
examined interactional difficulties among mothers and
children with asthma (Block, Jennings, Harvey, & Simpson,
1964). Similarly, a more negative affective climate has
been documented among mothers and their preschool
children with asthma, in comparison to that of healthy
children (Mrazek, Anderson, & Strunk, 1985). How-
ever, causal mechanisms were not identified in these
studies (Klinnert, 1997b). Results from one small study
indicated that when compared to children without
asthma, a significantly greater proportion of preschool-
age children with severe asthma were rated as insecurely
attached (Mrazek, Casey, & Anderson, 1987). Among
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the children with asthma, those with a secure attach-
ment demonstrated significantly fewer overall behavior
problems than those who were more insecurely attached.
Similarly, among school-age children and adolescents
with asthma, parent–child relationships mediated the
impact of impaired functional status on depressive sym-
ptoms (Bleil et al., 2000). A secure attachment may
mediate the effects of early illness on children’s emo-
tional development because it may enhance a child’s
coping capacity and minimize the expression of psycho-
pathology (Mrazek et al., 1987).
Parenting Difficulties
Several longitudinal studies have examined the impact
of caregiving on asthma outcomes. A prospective study
of children at genetic risk for asthma demonstrated that
a combination of physical and psychosocial variables—
specifically, parenting difficulties assessed when infants
were 3 weeks old—were predictors of asthma onset and
persistence (Klinnert, Mrazek, & Mrazek, 1994; Klinnert
et al., 2001; Mrazek et al., 1999). Frequent illness in the
first year of life, elevated serum IgE levels at 6 months,
and early parenting difficulties were independently pre-
dictive of the development of children’s asthma at 3 years
of age (Mrazek et al., 1999). The parenting difficulties
measured in early infancy with the elevated 6-month IgE
levels continued to be associated with the persistence of
asthma in these children when they reached 6 and 8
years of age (Klinnert et al., 2001). The predictive
strength of the parenting rating is noteworthy given that
the rating was made before asthma onset when the infants
were 3 weeks old and that it focused on assessment of
the emotional caregiving environment (Klinnert et al.,
1994). These findings parallel those from a different lon-
gitudinal study where functional family interactions and
social networks for children 18 months old were associated
with a significantly lower risk for children’s having
continuing atopic illness at 3 years old, when compared
to those with dysfunctional interactions and networks
(Gustafsson, Kjellman, & Bjorksten, 2002). Thus difficul-
ties in parenting and the parent–child relationship appear

to be related not only to asthma onset but also to asthma
outcomes throughout early childhood.
Family Conflict
High levels of conflict among family members is a distin-
guishing characteristic of risky families (Repetti et al.,
2002), and it may place children at greater risk for mental
and physical health problems when compared to those
children without such conflict. In a sample of children
hospitalized for asthma, those who experienced more
family conflict—as assessed by parents’ reporting the
amount of openly expressed anger, aggression, and con-
flict among family members—were more likely to expe-
rience a greater number of lifetime hospitalizations
(Chen, Bloomberg, Fisher, & Strunk, 2003). In a semi-
nal study by Strunk and colleagues (1985), conflict
between children with asthma, their parents, and hospi-
tal staff differentiated those children who died of asthma
from a control group matched for asthma severity.
While global ratings of family discord and conflict are
revealing, more proximal measures of parent–infant or
parent–child relationships that describe affective quali-
ties of the relationship (e.g., critical affect, emotion regu-
lation) provide information about specific emotional
processes.
Critical parent affect has been examined as a possible
mechanism through which parent–child interactions are
related to asthma. Utilizing measures of expressed emo-
tion (EE), where parents are asked to speak about their
child in an unstructured setting (e.g., Five-Minute Speech
Sample; Magana-Amato, 1993), several studies have found
that in comparison to parents of healthy children, mothers
and fathers of children with asthma made significantly
more critical remarks and showed a more critical attitude
(Hermanns, Florin, Dietrich, Rieger, & Hahlweg, 1989;
Schobinger, Florin, Reichbauer, Lindemann, & Zimmer,
1993; Schobinger, Florin, Zimmer, Lindemann, & Winter,
1992). Among children with asthma, increased frequency
of asthma attacks and asthma severity were associated
with mothers’ critical attitudes but not with fathers’
(Hermanns et al., 1989; Schobinger et al., 1993; Schobinger
et al., 1992). These investigators considered whether the
association between criticism and asthma severity may
reflect critical attitude acting as a chronic stressor
(Hermanns et al., 1989; Schobinger et al., 1993) or whether
critical attitude may hinder compliance (Schobinger et al.,
1993; Schobinger et al., 1992). Among hospitalized ado-
lescents with asthma, higher parental criticism was more
likely to be associated with greater medical noncompli-
ance upon admission and with better response to treat-
ment when adolescents were separated from their parents
Family Influences on Pediatric Asthma 
and participating in a structured treatment regimen
(Wamboldt, Wamboldt, Gavin, Roesler, & Brugman,
1995). Thus, parental criticism may be another marker of
distressed families that may affect children’s asthma out-
comes.
Emotion Regulation
Emotion regulation is developed by repeated inter-
actions between child and caregiver in which caregivers
modulate and teach children how to regulate their emo-
tions. Emotion regulation is a critical dimension of
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behavior expression that has been demonstrated to con-
tribute to the development of psychopathology. Assess-
ment of children’s behavior and parent–child interactions
during a structured, challenging task found no signifi-
cant group differences among children with and without
asthma in their emotion regulation and negativity and in
their mothers’ emotion regulation and negativity when
observed alone and with their mothers (Klinnert,
McQuaid, McCormick, Adinoff, & Bryant, 2000). How-
ever, were related to difficulties with emotion regulation
demonstrated greater asthma severity. Furthermore, less
effective emotion regulation was a significant predictor
of asthma symptoms, after controlling for asthma sever-
ity, as measured by symptom frequency and required
medications. Clinician ratings of behavior problems were
associated with increasing levels of asthma severity. As
suggested by the authors, difficulties with emotion regu-
lation may be represented in behavior patterns that do
not reach diagnostic thresholds but nevertheless result in
parent–child relationships characterized by negativity
and conflict.
Child Adjustment and Psychopathology
Recent recognition of the complex relationship between
children’s adjustment and illness has resulted in closer
scrutiny not only of research designs and methods used
to examine this relationship but also of the discussion
regarding the mechanisms responsible for the relation-
ship. Children with early asthma onset (i.e., by 3 years
of age), face a greater risk for developing behavior prob-
lems, perhaps owing to their limited range of cognitive
and emotional strategies for managing symptoms, the
challenges that parents face in caring for children with
asthma, and the possibility of environmental stressors
having a heightened impact on very young children
(Mrazek et al., 1985; Mrazek, Schuman, & Klinnert,
1998). McQuaid and colleagues (2001) recently com-
pleted a meta-analysis examining studies of the behav-
ioral adjustment of children and adolescents with
asthma. They concluded that, in comparison to healthy
 Kaugars, Klinnert, and Bender
children, children with asthma are at greater risk for
having difficulties in behavioral adjustment, with dem-
onstrate greater evidence for internalizing, rather than
externalizing, problems. Increases in asthma severity
were related to more difficulties in behavioral adjust-
ment. Similarly, in a more current study, Ortega and col-
leagues (2002), using a structured diagnostic interview,
found that children with a history of asthma were more
likely than those without to be diagnosed with having
any psychiatric disorder—or more specifically, an anxi-
ety disorder—after controlling for potentially confound-
ing factors. Moreover, relationships between asthma and
anxiety disorders were particularly strong for children
with histories of asthma-related hospitalization. This
suggests that children with severe asthma may be more
likely to have an anxiety disorder, thereby providing fur-
ther support for the importance of examining the role of
illness severity. Similar to the finding that caregiver neg-
ative affects influences assessment of asthma outcomes
(e.g. Price et al., 2002), there is also evidence that when
children were asked to respond to asthma-related qual-
ity of life questions, children’s level of anxiety was a
strong predictor of quality of life responses, regardless
of whether the anxiety was directly attributable to the
child’s asthma (Annett, Bender, Lapidus, DuHamel, &
Lincoln, 2001). Further unraveling the multifaceted rela-
tionship between children’s adjustment and illness will
require careful consideration of reporters as well as an
acute attention to the measures of illness being used.
It is unknown whether more severe asthma leads to
behavioral difficulties or whether poor psychological
functioning leads to more severe asthma. Another pos-
sibility is that characteristics of distressed families—for
example, conflict; aggression; and cold, unsupportive,
neglectful homes—may be influential not only in
asthma outcomes but also in children’s socioemotional
development, including the development of adjustment
problems or psychopathology (Repetti et al., 2002).
Additional Factors Influencing Family Functioning
Lack of social support—including not having spouses,
friends, and family members who provide material and
psychological resources to a family—may be another
marker of families who are not functioning well. Clinical
and empirical literature suggests that social support has
a direct positive effect on well-being and that it works to
protect individuals from potentially adverse effects of
stressful events (Cohen & Wills, 1985). However, the
mechanisms mediating these relationships, particularly
in pediatric populations and specifically among children
with asthma, have not been studied extensively. Even
less attention has been directed to examining social
support—in particular, support from friends or peers—
among adolescents with chronic illness (LaGreca et al.,
1995).
As described earlier, functional family interactions
and social networks for children at 18 months of age
were predictive of children’s lower risk for continuing
atopic illness at 3 years of age, when compared to chil-
dren with dysfunctional interactions and networks
(Gustafsson et al., 2002). However, it is unclear how
family functioning and social network functioning may
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be interrelated. Social support was the strongest predic-
tor of behavior problems among children with mild to
moderate asthma, explaining 11.6% of the variability,
after accounting for other variables (Bender, Annett, et al.,
2000). However, social support was unrelated to disease
variables. Parent’s perceived social support, children’s
absence from school, and children’s behavior problems
were the strongest predictors of parents’ perceptions of
how the child’s illness affects the family. These results
underscore how parents’ perceptions of disease, rather
than objective ratings of disease, affect reports about the
extent of disruption due to children’s asthma.
Intervention studies where social support needs to
be quantified for research purposes offer some clarifica-
tion about what aspects of social support may affect
health outcomes. Moreover, there are a multitude of
individual and community variables that may affect
whether interventions that offer social support are effec-
tive (Thompson & Ontai, 2000). Despite an emphasis in
practice of helping families establish contacts with other
families who have children with similar medical condi-
tions, there is limited empirical evidence that such strat-
egies are successful. Children with asthma were one
subgroup of participants in a randomized trial of com-
munity-based support for families (Chernoff, Ireys,
DeVet, & Kim, 2002). The study found that a family
support intervention—which involved visits, telephone
calls, letters, and special family events with child life
specialists and “experienced mothers”—had a modest,
positive effect on improving children’s adjustment, in
particular for children with low physical self-esteem at
baseline. There were no effects of the intervention on
children’s symptom unpredictability or activity limita-
tions. This intervention also demonstrated a reduction
in maternal symptoms of anxiety, and effects were
greater for mothers in poor health and for those with
higher baseline anxiety (Ireys, Chernoff, DeVet, & Kim,
2001). Thus, improving maternal psychological func-
tioning via social support interventions may in turn
affect children’s adjustment, but it may also have limited

impact on aspects of physical functioning for children
with a chronic illness. Research examining the impact of
social support, or lack of social support, for children
with asthma and their families must strive to further
identify mechanisms by which social support affects
children’s mental and physical health.
Potential Mechanisms Accounting
for Associations Between
Family Characteristics and Asthma Outcomes
As reviewed in the previous section, there is accumula-
ting evidence documenting relationships between family
and child characteristics and pediatric asthma outcomes.
Theoretical and empirical evidence supports two media-
tional models for understanding these associations.
First, family characteristics may affect asthma manage-
ment behaviors and lifestyle factors that in turn affect
asthma outcomes (see Figure 1, Paths B and C). Second,
an emerging literature has been investigating physio-
logical mechanisms that may link child and family
emotional processes and asthma outcomes (see Figure 1,
Paths D and E). The next two sections review evidence
for these possible models.
Family Functioning Affects Asthma Outcomes
Through Asthma Management
Effectively managing a child’s asthma involves health
care providers collaborating with the entire family system
and with alternative caregivers. Management of asthma
includes a complex set of behaviors, with one of the
family’s responsibilities being adherence to prescribed
medical regimens (Klinnert, McQuaid, & Gavin, 1997).
Five general areas of parental responsibility include sym-
ptom intervention, symptom prevention, use of medical
and educational resources, communication of caregivers,
and child development and family relationships (Wilson,
Mitchell, & Rolnick, 1993).
The most well-studied and specific aspect of asthma
management is adherence. It is well-documented that
child and family behaviors associated with adherence
are related to asthma outcomes (see Figure 1, Path C).
Adherence to prescribed treatment regimens for chil-
dren with asthma is a pervasive problem, with adher-
ence rates often below 50% (Bender, 2002). Families
who are unable to perform the health care behaviors
required in pediatric asthma might have children with
more poorly controlled asthma. In a study monitoring
inhaled corticosteroid usage for 90 days, lower rates of
compliance with inhaled corticosteroid therapy were
associated with disease exacerbation, thereby illustrating
Family Influences on Pediatric Asthma 
the potential risk and impact of medication nonadher-
ence (Milgrom et al., 1996). In the National Cooperative
Inner-City Asthma Study, children whose caregivers
reported more frequent nonadherence with a physician’s
recommendation for asthma management experienced
significantly worse morbidity on eight of nine measures,
regardless of illness severity (Bauman et al., 2002).
While research has sought to identify factors that may
potentially influence poor adherence, it is not known
what factors may facilitate high levels of adherence; fur-
thermore, the factors that promote adherence may be
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different from those that impede adherence (Drotar et al.,
2000). Four factors that do not predict adherence
include health insurance or health insurance status (e.g.
Bender, Wamboldt, et al., 2000; Weinstein & Faust, 1997),
asthma knowledge (e.g. Ho et al., 2003; McQuaid,
Kopel, Klein, & Fritz, 2003), illness severity (e.g. Apter,
Reisine, Affleck, Barrows, & ZuWallack, 1998), and
single-parent families (e.g. Weinstein & Faust, 1997). This
section discusses how family characteristics—including
family conflict and distress, racial or ethnic differences,
and family organization and responsibility—have been
found to affect adherence and, in turn, asthma outcomes
(see Figure 1, Paths B and C). For families experiencing
several of these predictors, asthma outcomes may be fur-
ther affected.
Conflict and Distress in Families
Family conflict and distress that undermine effective
asthma management behaviors may be manifested in
relationships within the family as well as in disagree-
ments with health care providers. Day-to-day asthma
management may be more difficult in high-conflict rela-
tionships since effective communication, supervision,
and division of responsibilities may be compromised
(Schobinger et al., 1993). A combination of psycholog-
ical adjustment, degree of family cohesiveness versus
conflict, and the interaction of these two variables have
been found to predict adherence. For instance, children
with high levels of family conflict and high levels of
behavior problems were at greatest risk for being non-
adherent, when compared to children with moderate or
low levels (Christiaanse, Lavigne, & Lerner, 1989).
Similarly, among hospitalized adolescents with asthma,
high parental criticism was associated not only with
greater noncompliance upon admission but also with
better response to treatment when the adolescents were
separated from their parents and participating in a
structured treatment regimen (Wamboldt et al., 1995).
Another study found that families in which parents
reported no displays of affection and where expectations
 Kaugars, Klinnert, and Bender
and consequences for children’s behavior were not
clearly expressed had poorer medication adherence than
did families with different levels of affection and expec-
tations (Bender, Milgrom, Rand, & Ackerson, 1998). In
another study, children with severe asthma participated
in a short-term inpatient rehabilitation program and
then were followed for the subsequent year. One year
later, those families who had significantly fewer prob-
lems with intrafamilial communication, more effective
ways of managing child care, and more efficient use of
resources had children who were more compliant with
treatment than families of children who were noncom-
pliant (Weinstein & Faust, 1997). Similarly, there is
emerging evidence that conflict in relationships with
health care providers may lead to poorer asthma adher-
ence outcomes. Difficulties communicating effectively
with a child’s treating physician and with other medical
personnel have been associated with ineffective asthma
management behaviors, including failure to provide
appropriate intervention for children’s asthma symptoms
(Wilson et al., 1993). Physicians’ reports of better treat-
ment alliance with adolescents at discharge from an
inpatient program was associated with better medication
adherence at program admission, better multifaceted
treatment adherence in the year after hospitalization,
and fewer urgent office visits in the subsequent year,
when compared to reports of less-effective treatment
alliance (Gavin, Wamboldt, Sorokin, Levy, & Wamboldt,
1999). Conflict with health care providers was one of
several factors associated with poor adherence and
increased risk of death in children with asthma (Strunk
et al., 1985). Accumulating evidence suggests that rela-
tionships characterized by conflict place children and
families at risk for having problems with effective asthma
management.
Parents who are suffering from psychopathology
have more difficulty caring for a child with a chronic ill-
ness than parents who are not suffering. A study with an
inner-city population distinguished between admitted
nonadherence and risk factors for nonadherence. The
poorer the caregivers’ mental health, the more they
admitted nonadherence. Also, cases in which caregivers
endorsed family characteristics and described asthma
regimens that placed themselves at risk for nonadher-
ence were more likely to have originated from caregivers
with clinically significant mental health problems and
children with clinically significant psychological symp-
toms (Bauman et al., 2002). Parental psychopathology
may impair parents’ ability to perform behaviors neces-
sary to effectively manage children’s asthma since
depressed patients, whether children or adults, are three
times more likely to be noncompliant with medical
treatment recommendations (DiMatteo, Lepper, &
Croghan, 2000). Maternal depression has been found to
be related to maternal behaviors associated with child
health; specifically, maternal depression was associated
with an decreased likelihood of administering vitamins
to children, of placing a child in a car seat all or most of
the time, and of being a nonsmoker (Leiferman, 2002).
Thus, depression likely affects a caregiver’s ability to per-
form daily behaviors associated with asthma management.
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Racial or Ethnic Background
A better understanding is needed of the underlying mech-
anisms for racial and ethnic group differences in medi-
cal adherence and asthma outcomes. For example, one
study found that non-White children (i.e., Black and
Hispanic), older children and adolescents, and children
from families with poorer functioning were more likely
to have poorer adherence as recorded by electronic
recording (Bender, Wamboldt, et al., 2000). Another
recent study documented that Black and Latino children
were more likely to underuse asthma preventive medi-
cations, in comparison to White children after adjusting
for sociodemographic variables and asthma status (Lieu
et al., 2002). Adolescence, Black race, and residence in
rural regions independently predicted failure of families
to get oral corticosteroid prescriptions filled following
children’s hospitalization or a visit to the emergency
department (Cooper & Hickson, 2001).
Understanding racial and ethnic differences in
asthma management behaviors is complex and requires
examining multiple determinants. Recent literature has
suggested examining whether asthma morbidity varies
among the subgroups of Latino children based on differ-
ences in ethnic and geographic origin (Lara, Morgenstern,
Duan, & Brook, 1999). The authors called attention to
specific risk and protective factors—including possible
genetic, environmental, and health care factors—that
may affect differences in asthma outcomes. The most
frequently reported barriers to the treatment of asthma
among parents from urban, minority backgrounds were
patient and family characteristics (43%), environmental
factors (28%), health care provider factors (18%), and
health care system factors (11%; Mansour, Lanphear, &
DeWitt, 2000). As noted by the authors, these responses
differed considerably from widespread beliefs that prob-
lems involving access to medical care, health insurance,
and continuity of care are primary barriers to quality
asthma care. Caregiver beliefs about asthma management
(e.g., not believing the appropriateness of daily medication
use without symptoms, concerns about side effects)

were significant predictors of caregiver–physician con-
cordance about medication (Riekert et al., 2003).
Addressing patient and family’s health beliefs and con-
cepts of disease and evaluating the cultural competence of
health care system practices may be particularly import-
ant for improving asthma outcomes (Lieu et al., 2002).
Reducing exposure to allergens and environmental
tobacco smoke is another behavioral requirement of
management of pediatric asthma. Family psychosocial
characteristics and racial or ethnic group differences are
related to environmental asthma management. A recent
study found patterns of family characteristics associated
with smoking to be different from those associated with
pet ownership (Wamboldt et al., 2002). Specifically,
household smoking was associated with more family
stress and poorer family resources (e.g., coping res-
ources, parental education level) than that of nonsmoking
households, whereas pet ownership was related to better
family behavioral control and better asthma knowledge
than that of households with no pet ownership. Different
patterns of environmental risk factors for childhood
asthma, such as environmental tobacco smoke and cat
and cockroach exposure, were found among European
Americans, African Americans, high-acculturated Hispan-
ics, and low-acculturated Hispanics (Klinnert, Price, Liu, &
Robinson, 2002). For example, the low-acculturated His-
panics had no measurable pet dander in the home, since
indoor pets are not normative in this immigrant group.
Within the African American group, better maternal
mental health was associated with lower infant urinary
cotinine and cat exposure. These findings suggest that
different mechanisms may underlie families’ efforts and
decisions to alter their home environments consistent
with treatment recommendations.
Family Organization and Responsibility
Effective management of pediatric asthma places demands
on children and adults and requires families to face
ongoing and new challenges and changes. A family’s
ability to organize and reorganize as new tasks emerge is
central to successful adherence. Tasks that may reflect a
family’s ability to organize include taking a child’s devel-
opmental status into account in dividing responsibilities
for asthma management and incorporating family rituals
and routines. A shifting set of responsibilities is indicated
as children grow and develop, which is characterized by
the transfer of self-management tasks from adults to
children with an appreciation for children’s socioemo-
tional and cognitive development (Miller & Wood,
1991). Asthma management expectations for children at
Family Influences on Pediatric Asthma 
different developmental levels have been delineated (as
described in Wamboldt & Wamboldt, 1995). Several
studies have examined assignment of responsibilities in
families of children with asthma. Paternal involvement
in caring for children’s asthma—that is, whether the
father was living in the home—was associated with
mothers’ reporting less disruption in their daily lives due
to childhood asthma; however, Hispanic ethnicity,
severity of child’s asthma, and child age were also asso-
ciated with maternal report of disruption (Wasilewski
et al., 1988). In the National Cooperative Inner-City
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Asthma Study, older children were rated by their parents
as assuming more self-care responsibilities, but 37 chil-
dren were identified as being the primary managers for
their asthma (Wade et al., 1997). Since participating
children were 6 to 9 years old, this extent of asthma
management likely exceeds their developmental capa-
cities (Klinnert, 1997a). A substantial level of disagree-
ment concerning allocation of family responsibility for
asthma management was found in a sample of Black
adolescents and their caregivers (Walders, Drotar, &
Kercsmar, 2000). Families where caregivers overesti-
mated the level of adolescents involvement for self-care
tasks had adolescents with increased nonadherence and
greater functional morbidity. Caretakers reported
decreasing responsibility for asthma management for
older adolescents, yet there was not a significant rela-
tionship between older adolescents assuming more self-
care responsibilities, a finding that highlights the need
for routine assessment of family members’ allocating res-
ponsibilities (Walders et al., 2000). Family rituals may
offer a protective function in families of children with
asthma and offer stability, organization, and meaning
(Markson & Fiese, 2000). Age-appropriate division of
responsibility among family members as well as routines
and continuity, which may be absent or diminished in
homes characterized by conflict and unsupportiveness, are
essential in maintaining adequate asthma management.
In summary, distressed families may be unable to
effectively manage asthma, owing to numerous factors.
In addition, racial or ethnic group differences and family
organization may also influence asthma management
behaviors. It is notable that family factors—not illness
severity or institutional barriers, as frequently hypothe-
sized—have been found to be predictive of adherence
behavior. Given the pervasive problem of nonadherence
among children with asthma and their families, research
and clinical work can be advanced with increasing
knowledge about what family characteristics predict
adherence, which may in turn affect asthma outcomes.
 Kaugars, Klinnert, and Bender
Family Functioning Affects Asthma Outcomes
Through Physiological Factors
Several physiological mechanisms have been proposed
to better understand how emotional factors in the con-
text of family functioning may be related to pediatric
asthma outcomes. Specifically, three mechanisms may
reflect interactions between psychological and physio-
logical processes: first, functioning of the hypothalamic
pituitary adrenal (HPA) axis and the immune system;
second, autonomic nervous system functioning; and,
third, symptom perception. Evidence supporting these
proposed mechanisms is the result of integrating multi-
disciplinary perspectives. Although the evidence at this
time is largely theoretical, we nonetheless reviewed the
preliminary data in support of these mechanisms.
HPA Axis and Immune System
The HPA axis may mediate the relationship between
emotional factors and asthma in two ways. First, the
HPA axis may be involved in the regulation of inflamma-
tion, which is a central component of asthma. Second,
the impact of emotional factors on the HPA axis’s func-
tioning has primarily been examined within the context
of better understanding individuals’ responses to stress.
There is accumulating theoretical and empirical evi-
dence suggesting that the HPA axis regulates allergic dis-
ease expression and allergic inflammatory responses. The
interaction between immune and nervous systems may
affect susceptibility and resistance to inflammatory dis-
eases (Sternberg, 2001). In particular, neuroendocrine
regulation of inflammatory and immune responses and
disease may occur through the release of glucocorticoids
by stimulation of the HPA axis, the presence of glucocor-
ticoids in immune organs, and the release of neuro-
peptides and neurohormones at sites of inflammation.
While glucocorticoids generally have anti-inflammatory
and immunosuppressive effects, excess stress hormone
responses are associated with enhanced susceptibility to
infection whereas inadequate stress hormone responses
are associated with enhanced susceptibility to inflamma-
tory, autoimmune, and allergic diseases. The interplay
between endogenous cortisol production and allergic
inflammation may be evident in a variety of ways: lung
function varies with plasma cortisol levels; the number of
circulating inflammatory cells varies with plasma cortisol
levels; and low levels of endogenous cortisol may be
associated with risk for asthma (Schleimer, 2000).
Recent promotion of a biopsychological model of
stress and asthma explains how psychological stressors can
modulate interactions among the central nervous system
and the immune system, which may affect inflammatory
processes (Wright et al., 1998). Also, stress-related
effects on the central nervous system and immuno-
logic changes can alter responses to pathogens. Several
researchers have suggested that early caregiver stress
and quality of caregiving may affect alterations in immune
development (Klinnert et al., 2001; von Hertzen, 2002;
Wright et al., 2002). Sustained maternal stress during
pregnancy may be associated with sustained excessive
cortisol secretion that could in turn alter the developing
immune system of the fetus (von Hertzen, 2002). In par-
ticular, cortisol might influence helper T cell phenotype
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differentiation and increase susceptibility to atopy and
asthma in genetically predisposed children. The ways in
which infants and children respond to stress, including
developing strategies to modulate their emotions and
behavior, may have an effect on their physiological func-
tioning. Numerous psychosocial factors—such as trauma
history, quality of caretaking in infancy and childhood,
psychopathology, or temperament—may be associated
with alterations in the HPA axis (Kelsay, Wamboldt,
Kaugars, Klinnert, & Robinson, 2004). These alterations in
the HPA axis’s functioning may interact with current
stressors in children with asthma to affect the severity of
their asthma. In addition, exposure to violence can be
considered a psychological and environmental stress that
may affect onset of asthma by triggering exacerbations
through neuroimmunological mechanisms (Wright &
Steinbach, 2001).
There is emerging evidence that individuals with
atopic conditions may also have an altered HPA axis
response. Adolescents with a history of atopic illnesses
demonstrated an attenuated cortisol response to the stress
of laboratory procedures, in particular a blood draw, in
comparison to adolescents who had no history of atopic
illness or to those with positive skin tests and no clinical
symptoms (Wamboldt, Laudenslager, Wamboldt, Kelsay,
& Hewitt, 2003). The authors suggested that an attenu-
ated cortisol response to a stressor may increase the like-
lihood that an individual develops an inflammatory
response to the stress and thus have one’s symptoms wors-
ened after the stress. Furthermore, children with allergic
asthma, in comparison to children without, demonstrated
significantly attenuated cortisol responses to psychosocial
stress (Buske-Kirschbaum et al., 2003), thereby extending
the existing literature’s examination of HPA axis’s respon-
siveness among individuals with atopic conditions.
Further investigation of neuroendocrine regulation
of inflammatory and immune diseases is necessary. A
better understanding is needed of HPA axis activity
among individuals with atopic conditions and the man-
ner in which HPA axis activity may be altered in
 Family Influences on Pediatric Asthma 

response to chronic and situation-specific stress. Long-
itudinal studies, preferably beginning in infancy, are
indicated to better understand the interplay of endocrine
and immune systems in the development of atopy and
asthma. Moreover, research is needed to examine how
differences in the way children regulate their responses
to different types of stress are related to the neuro-
endocrine system’s functioning throughout the course of
development.
Autonomic Nervous System
outcomes. More investigation is indicated to better
understand the specific mechanisms underlying the obser-
ved relationship. Replication and extension of existing
findings are needed, with particular attention to meas-
urement and a comprehensive understanding of the sub-
group of children for whom emotional factors contribute
to a particular type of asthma vulnerability.
Symptom Perception
Emotional factors may affect one’s accurancy in perceiving
symptoms and asthma outcomes. Perceptual accuracy is

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defined as “the degree to which subjective assessment of
A second mechanism that has been examined as a possi-
asthma symptomatology/severity corresponds with an
ble link between emotional factors and asthma is vagal
objectively measured rating of severity” (Fritz, Yeung,
mediation of the autonomic nervous system. In a review
et al., 1996, p. 158). Empirical work on perceptual accu-
of the empirical literature on possible effects of sugges-
racy in children with asthma has utilized various object-
tion and emotional arousal on pulmonary function
ive and subjective measures of respiratory status and
(Isenberg, Lehrer, & Hochron, 1992), the authors pro-
symptoms (Fritz & Wamboldt, 1998; Fritz, Yeung, et al.,
posed a model of parasympathetic mediation. In parti-
1996). More accurate symptom perception has been
cular, increases in vagus nerve activity may mediate
found to be related to fewer emergency medical visits
psychological influences resulting in constriction of the
and fewer days of school absence, after controlling for
upper airways. Results of the review pointed toward a
asthma severity (Fritz, McQuaid, Spirito, & Klein,
discrete subgroup of individuals with asthma who respond
1996). While few associations between psychological
to particular emotionally charged stimuli with increased
constructs (e.g., anxiety symptoms, internalizing behavior,
bronchial obstruction.
externalizing behavior) and accuracy of symptom per-
Similarly, Miller and colleagues have proposed a
ception have been demonstrated, children with higher
model of “psychophysiologically vulnerable asthma”
cognitive ability had more accurate symptom perception
(Miller & Strunk, 1989; Miller & Wood, 1997). The
than children with lower ability (Fritz, McQuaid, et al.,
model suggests that increased cholinergic activation in
1996). Future research directions for this area include
despairing, depressed, and hopeless states and choliner-
developing appropriate methodologies for assessing symp-
gically mediated airway reactivity in asthma result in a
tom perception, replicating existing studies with children
psychophysiologically vulnerable affective state (i.e., auto-
who have varying degrees of asthma severity, examining
nomic dysregulation and cholinergic bias), which may
how symptom perception contributes to adherence, and
in turn cause increased morbidity and mortality. In sup-
investigating the relationship between anxiety disorders
port of this model, sadness was found to evoke patterns
and symptom perception (Fritz & Wamboldt, 1998).
of autonomic influence that are consistent with cholin-
In summary, HPA axis functioning, autonomic ner-
ergically mediated airway constriction (Miller & Wood,
vous system functioning, and symptom perception have
1997). In contrast, states of happiness may be accompa-
been proposed as potential mechanisms that mediate rela-
nied by autonomic patterns, which would be consistent
tionships between emotional factors in families and
with better pulmonary function. The authors hypothe-
asthma outcomes. While a significant amount of research
sized that psychophysiologically reactive temperaments
is still needed to understand each of these mechanisms, it
or previous emotionally traumatic experiences may place
is important to examine interactions among multiple
some children at greater risk for developing psycholog-
mechanisms and to understand how the mechanisms may
ically vulnerable asthma. In a retrospective controlled
function differently among subtypes of pediatric asthma.
study comparing children who died of an acute attack of
asthma with children who survived a life-threatening
attack of asthma, significantly more children who died had
experienced recent or impending separation or loss and Conclusion
exhibited emotional states of hopelessness and despair in Childhood asthma is strongly affected by family factors,
the days preceding their deaths (Miller & Strunk, 1989). including the psychological functioning of the parent,
This research contributes to a literature that exam- the interactions between the parent and the child, and the
ines how emotional factors within families affect asthma children’s functioning. Some families may be particularly
 Kaugars, Klinnert, and Bender
at risk for difficulties in managing asthma, owing to
problems in their family social environment (“risky fam-
ilies”; Repetti et al., 2002) and to risk factors such as
poverty and minority status.
This literature review intends to summarize exist-
ing knowledge about relationships between family char-
acteristics and asthma outcomes. Although this
provides us with an overview of the field’s progress, sig-
nificant gaps exist in the literature that preclude devel-
opment of more sophisticated models that can examine
the direction of relationships and test mediating and
moderating factors. Specifically, prospective longitudi-
nal designs are essential first to delineate characteristics
of premorbid functioning of caregivers and children
and second to evaluate changes in functioning in
response to asthma. More information is needed about
normative development of the HPA axis among individ-
uals with atopic conditions so that individual differ-
ences in illness manifestation and responses to stress
can be better understood.
Future research will benefit from attention to
numerous additional methodological concerns. Since many
of the proposed relationships among aspects of psy-
chological functioning and asthma outcomes may be bidi-
rectional, more complex research designs need to take
into account the multiple factors potentially contribut-
ing to asthma onset, manifestation, and morbidity. Sam-
pling bias is rarely acknowledged in study limitations,
yet it is evident that the factors determining selection of
participants (e.g., socioeconomic background, asthma
severity) greatly affect findings and subsequent general-
izations. Although samples that represent population
extremes (i.e., severe caregiver psychopathology) may
provide significant relationships with asthma outcomes,
such samples characterizing extremes may not necessar-
ily be representative of the functioning of all children
with asthma and their caregivers. Small sample sizes also
limit generalizability of findings and require replication.
Finally, what will advance this field of research is atten-
tion to reporter bias and the utilization of objective,
multimethod assessment measures of psychological char-
acteristics and asthma outcomes.
We have proposed that two pathways may explain
the association between family characteristics and asthma
outcomes. First, family conflict and distress may affect
the asthma management behaviors in which families
engage (see Figure 1, Paths B and C). Greater family con-
flict and distress are associated with poorer adherence
and thus worse asthma outcomes. Moreover, family
organization and membership in certain racial or ethnic
groups have also been found to influence asthma out-
comes via asthma management behaviors.
Second, theoretical models with some empirical evi-
dence explain how HPA axis functioning, autonomic
nervous system functioning, and symptom perception
may contribute to the relationships between family char-
acteristics and asthma onset and outcomes (see Figure 1,
Paths D and E). Whereas much of the literature illum-
inates cross-sectional relationships, longitudinal designs
would help examine complicated, intertwining relation-
ships throughout the developmental process. This is an
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exciting area for future research that can utilize multi-
disciplinary approaches to better understand the complex-
ity of pediatric asthma. Most elements of the proposed
theoretical model have not been empirically tested; how-
ever, it is our hope that proposing this model will stimu-
late future research in this area.
If the morbidity associated with pediatric asthma is
to improve, it will be critical that assessment and treat-
ment take into account the various emotional, behav-
ioral, and physiological factors within families that affect
pediatric asthma outcomes. Integrating research find-
ings into treatment could benefit child and family func-
tioning as well as asthma outcomes. As discussed in this
review, multiple facets of family functioning, which in
some cases could be altered with intervention, may be
influential in pediatric asthma. As the treatment guided
by research develops, not only could it minimize the
functional and emotional impact of asthma on children
and families, but it could also help children and families
effectively manage asthma, with the aims of decreasing
disruption and integrating asthma management into
their lives. As we advance our understanding of develop-
mental processes, we will gain better insight into where
and how to intervene to improve asthma outcomes.
Acknowledgments
This work was supported by a National Institute of
Mental Health–funded institutional postdoctoral research
training program, the “Development of Maladaptive
Behavior” 5 T32 MH15442; by the Developmental Psycho-
biology Research Group at the University of Colorado
Health Sciences Center, Denver, Colorado; and by a
National Institute of Child Health and Human Develop-
ment–funded National Research Service Award, Individ-
ual Postdoctoral Fellowship 1 F32 HD042894.
Received April 23, 2003; revisions received September 15
and November 23, 2003; accepted November 26, 2003
 Family Influences on Pediatric Asthma 

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