Thursday, June 29, 2006

Stress, Asthma Exacerbations And Children

Young boy, sparked out and asleep in a plastic laundry tubChildren are remarkably resilient. Children can also be mimosaphants: a creature with the delicacy of a mimosa when its own sensitivities are threatened, but the grace of an elephant when dealing with the sensitivities of others. Perspective is difficult enough for adults: young children are still struggling with the concept that things exist, even when they put their hands over their eyes. Anyone who has put their feet up 'while the children are playing', and then had to separate sparring toddlers who are trading death threats and landing their lumps while tearfully protesting, "She started it", or has had to handle a 30 minute tantrum because the gravy is touching the potato, knows that children can be stressed by both small and large events.

A child can be in a frenzy of excitement, popping veins, flushing a dark shade of red and generally knotting her physiology before she collapses asleep in the nearest receptacle, a few minutes later. At other times, when some children are upset or distressed, they can withdraw and seem very subdued. Despite their renowned resilience, do children experience consequences for stress-related events: does the nature of the stress matter?

Sandberg and her colleagues studied children with asthma, between the ages of 6-13: they looked at the impact of negative life events that would be distressing or unsettling to most children of comparable age (Sandberg et al., 2004). Examples of these events include births, changes in family relationships (break-ups and new relationships), separations from family, illness, and hospitalisation.

The researchers conclude that there is a strong correlation between stressful negative life events and asthma exacerbations in children. The most striking finding is that within the first 48 hours of such an event, there is almost five times the likelihood of a new asthma attack (the reported effective increase of risk is 4.69). The risk subsides within 3-10 days but flares up again, 5-7 weeks after the event, this time to almost double the risk (reported, 1.8).

The researchers speculate that the initial increase in risk might be an amalgam of inflammatory and airway responses initiated by the stress-relase of hormones, brain chemicals, and their influence on the nervous system. The second spike in risk suggests that there are delayed effects of stress on the immune system, although the mechanisms of that are unclear. However, it is apparent from this and similar studies (e.g., Liu et al., 2002; Laube et al., 2003) that there is an immunological response to the stress of a negative life event as well as on-going stress.

There is some variable scientific support for the relationship of stress, emotional triggers and asthma: McEwen’s recent elaboration of the theory of allostasis and allostatic load (1998; McEwen et al, 1999) may have some merit as a partial explanation. Allostasis is the state whereby we maintain stability (or homeostasis) through change, and it allows us to adjust to different states of the body such as resting or active. Allostatic load describes the ‘wear and tear’ that the body experiences as a consequence of repeated cycles of allostasis in addition to the inefficient turning-on or shutting-off of these responses.

Allostatic load moves beyond the concept of chronic stress to explain why there are many contributing factors in an individual’s life that influence the level, timing, and regulation of the mediators of allostasis. Allostatic load can reflect genetically-, developmentally- or behaviourally-programmed inefficiency in handling the common challenges of daily life related e.g., the sleep-wake cycle, smoking, or inactivity.

Recent studies propose that there are different immunological consequences to stressors (Okumura, 1998; Niaura et al, 2000; Hashiro et al, 1998; Kemeny, 2003). For people with asthma, there are indications that it may be useful to distinguish emotional arousal and stress, and that within the arena of stress there are different behavioural opportunities and responses that carry different immunological consequences. E.g., if a child is worried, there may be different immunological consequences depending upon whether the child responds with hostility or helplessness.

Current research suggests that we may eventually have to accept that, for children, the toxic impact of environmental exposure to verbal and physical aggression is as great as that of environmental exposure to tobacco smoke. It seems that there are useful distinctions to be made between emotional triggers and stressful negative events, and the immunological consequences of an individual’s response to them. Latest developments in stress relief and stress management can help people with asthma to reduce the impact of a negative life event, and to learn new strategies for coping with ongoing stress. Better stress management makes a significant contribution to the success of an asthma self-management care plan. Parents may increasingly be advised to help their children to practise quiet time and to encourage activities that promote their resilience.


Hashiro, M. & Okumura, M. (1998). The relationship between the psychological and immunological state in patients with atopic dermatitis. Jnl. of Dermatol. Sci. 16 (3): 231-235.

Kemeny, M.E. (2003). The psychobiology of stress. Current Directions in Psychological Science 12 (4): 124-129.

Laube, B.L., Curbow, B.A., Fitzgerald, S.D. & Spratt, K. (2003). European Respiratory Jnl. 22: 613-618.

Liu, L.Y., Coe, C.L., Swenson, C.A., Kelly, E.A., Kita, H. & Busse, W.W. (2002). School examinations enhance airway inflammation to antigen challenge. Am J Respir Crit Care Med 165:1062–1067.

McEwen, B. S. (1998). Protective and Damaging Effects of Stress Mediators. New England Jnl.Med. 338: 171-179,

McEwen, B., & Seeman, T. (1999). Protective and damaging effects of mediators of stress. Elaborating and testing the concepts of allostasis and allostatic load. Ann NY Acad Sci 896: 30–47.

Niaura, R., Banks, S.M., Ward, K., Stoney, C.M., Spiro, A. III, Aldwin, C.M. Landsberg, L. & Weiss, S.T. (2000). Hostility and the metabolic syndrome in older men: The Normative Aging Study. Psychosomatic Medicine 62, 7-16.

Sandberg, S., Järvenpää, S., Penttinen, A., Paton, J.Y. & McCann, D.C. (2004). Asthma exacerbations in children immediately following stressful life events: a Cox’s hierarchical regression. Thorax 59: 1046-1051.


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