Tuesday, June 13, 2006

Obese, Asthmatic and Troubled: Plus The Libby Purves Solution To Children Who Need More Structured Care?

2 children: slogan is that sometimes parents forget to tell the children that it is OK if they are not shining starsWhat do you do for children who are obese, asthmatic and living chaotic lives? These are not children enmeshed in the poignant homelessness of those displaced by Hurricane Katrina, but those in the (sadly common) small, family drama described by Flea in My Mother, the Drug Seeker.
"Mary Ann has had a rough few years. She finally left her abusive, alcoholic husband and took her three children, aged 11, 8 and 2 to live in a battered women's shelter. Recently they had found subsidized housing on a farm in the same town where the kids had been attending school...All three children have asthma. All are obese, including the toddler. Mary Ann has battled depression and anxiety for which she had been hospitalized, as well as a history of chronic back pain."
I’m not even going to attempt to cover the impact of negative life events (e.g., upheavals, family splits) on children with asthma in this post but a crude summary would be that children are at almost five times the risk of an exacerbation within 48 hours of such events, and the susceptibility fluctuates, but they are still at double the risk between 5-7 weeks later. A long-term follow-up study of the children of depressed parents reports that:
The risks for anxiety disorders, major depression, and substance dependence were approximately three times as high in the offspring of depressed parents as in the offspring of nondepressed parents. Social impairment was also greater.
I recently suggested that if some children had their Hearts and Minds Age calculated (taking into account their personal and environmental risk factors), it would be significantly greater than their chronological age: I think that these children’s Hearts and Minds Age would be distressingly high.

I feel vaguely ridiculous when I refer to obesity as a personal risk factor for children. I do not believe that children become obese entirely through their own actions, inactions and decisions. However, once children are obese, helping them to manage their weight can seem like one long battle of personal restrictions (e.g., food choices) and curtailments (e.g., less TV or computer-gaming) that add to the stress levels and confrontations in what can already be a fraught household (anyone for Honey, We’re Killing The Kids?). A study reported no statistical association between asthma and obesity in Canadian children between 4-11 years. However, recent research in the UK suggests that
all of the obese children tested had a higher prevalence of asthma or other respiratory symptoms compared to non-obese children. Other symptoms included wheezing, exercise induced wheezing, coughing at night and speech limitation through wheezing.

Dr Shamssain says that obese and overweight children are not only at risk of asthma but other conditions such as diabetes and heart problems.
This is in line with earlier studies in the UK that reported that obesity may be a marker of recent lifestyle differences now associated with both asthma and overweight. There are significant problems in diagnosing lung disease in young children because the standard lung function tests are not suitable for them. There is some speculation that the greater degree of bronchial hyper-reactivity in non-obese asthmatic children compared to their obese counterparts suggests that obesity-related chest symptoms mimic asthma and may lead to an over-diagnosis of asthma.
Asthma, wheezing, and inhaler use were more common in obese children than in non-obese children. Symptoms were more prevalent among obese boys. Increasing BMI among children is a risk factor for asthma, which may in reality be obesity-related chest symptoms that mimic asthma.
An exchange of letters on the topic of asthma and obesity provides several references that report that
increases in BMI or birth weight are significant predictors of the development of asthma prospectively and independently of potential confounding factors, such as diet and physical activity.
A recent review concludes that there is evidence that obesity and overweight are associated with the development of asthma. The authors caution that the mechanisms of this association are unclear. They do conclude that weight reduction can result in improvements of lung function among asthmatic patients, and that this is a clinically significant strategy.

However, is this discussion relevant to the children in Flea's post? No. It sounds as if those children lead chaotic lives and that their mother is doing what she can but doesn't have the resources or energy to make the concerted intervention that would be necessary to control the children's weight and to mitigate the impact of their asthma.

Some schools are running programmes that are targeted at sedentary children or those with asthma or breathing disorders. These programmes are helpful but there is a limit as to what can be achieved if it is not practical to rely upon support at home. I run workshops for children with sleep-disordered breathing (sometimes I do this in school or pre-school settings); many of these children have asthma. If parents ask, I give general advice on sleep hygiene for children and I particularly recommend regular bed-times with a set routine, including reading or listening to stories. This can work very well for some children but it does depend upon a certain amount of household order and involvement. Sometimes one parent will establish a bed-time routine that is successful, but it doesn't fit in with the household routine of (say) the non-custodial parent when the children go for a weekend visit or a holiday and the progress is undone. Sadly, if parents are separated, there can be high levels of verbal hostility at hand-overs or in everyday communication that distress the children and contribute to stress responses that may worsen their asthma.

Back in the 1970s, there was a study of diabetic children who experienced chronic bouts of ketoacidosis despite being treated with appropriate medication. The children could be stabilised in the hospital but repeatedly relapsed upon return to the family home. Observations of the families of the children suggested that the children's metabolic disturbances were a reflection of parental conflict that involved the children ("Who is right, Daddy or Mommy?"). During stress interviews, the fatty acid levels of all the participants were measured. The parents' levels would rise during conflict but soon returned to baseline: however, for some of the children, the levels would remain elevated for hours.

The emotional demands on the children stimulated multiple physiological mechanisms that overrode the mechanism of the beta-blocker drugs that they were taking. Salvador Minuchin reported this as a poignant demonstration that:
behavioral events among family members can be measured in the bloodstream of other family members.
When the parents were coached in techniques that allowed them to resolve their conflicts directly, and without involving the children, the children could be stabilised at home without the use of the beta-blocker: they reduced the incidence of ketoacidosis and didn't require hospitalisation. There was an improvement in the children's medical outcome as a result of a successful intervention between people other than themselves.

There are support programmes such as Sure Start and Home-Start in the UK that are targeted at improving children's welfare through improving parenting skills and creating a secure and happy home environment but these have had disappointing levels of success (to be blunt, they are characteristed as "a spectacular failure").

Preliminary findings from recent studies with children suggest that the toxic impact of environmental exposure to verbal and physical aggression as expressed by poorer lung function and a greater incidence of asthma exacerbations is as great as that of environmental exposure to tobacco smoke. There are innovative programmes that have been likened to giving problem families Supernanny support, but, as explained by Tony Plant, they seem to have moved away from their “early intervention saves heartache, illness and money” stance to a more punitive one that is being set up for failure. Recently, Tony spoke about communication styles in families and how they are linked to the perception of violence and aggression in the home. In the follow-up discussion, he admitted that he sometimes wonders if some families need the assistance and reassurance of living in supportive communities, although he has some reservations about the civil liberties implications of such arrangements and the suggestion that some families or individuals might need to trade their privacy or autonomy for appropriate support.

In a different take on the idea of supportive communities, columnist Libby Purves recently discussed a Dept. of Education initiative in the UK that is investigating if some ‘looked-after children’ might benefit from being sent to boarding schools rather than being plunged into the chaotic foster system or council-run Care Homes.
[G]ood boarding provides not only educational stability but steady friends and mentors, routine and structure and quiet and probably more safety than some council homes… the long experience of a good housemaster or mistress might offer more understanding than an overstressed young social worker with a crazy caseload. For some children, boarding could be a blessed relief.
Purves anticipates that this suggestion might be derided by some social commentators.
There will be mean-minded contempt, and endless patronising assumptions about the inability of children in care to “cope”.
But she counters this argument in a typically robust fashion:
Poor little bastards, coping is often their A-star subject. They might adapt well to intelligent kindness, to the assumption of mutual courtesy between adults and children, and to classmates who have never had to learn aggression and the awful wisdom of the streets.
Keith Carson writes poignant, uplifting and disturbing posts about his experiences of working with people who have the many curses of addiction, chronic illness, chaotic lives and socio-economic deprivation. Keith's descriptions bear disturbing similarities to the family that Flea discusses. Children need to be with their family: and it is right that most social and family policy is intended to support families and to keep them together. However, for the sake of Mary Ann and her children, it does seem as if we need something more between what is currently available and the extreme measure of removing children from the family home. With a nod to Gladwell’s discussion of power-law economics, the "cost of doing nothing" is too great.


Blogger Impatient Patient said...

Beautiful Post, thoughtful and marvellous. Thank you for saying that most interventions designed to help are abysmal failures.

6:28 am  
Blogger Shinga said...

Thanks for the feedback. I was a little concerned that I was saying that the outlook is unremittingly bleak, but I firmly believe that if people have crawled through the data and report that these initiatives are a "spectacular failure" then we have to accept the implications of that.

Regards - Shinga

10:52 pm  
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