Here at Breath Spa we run up a tidy monthly bill in bubble solution, bicarbonate of soda, vinegar and clean-up cloths for our workshops. We do a lot of bubble work (both large and small) to teach children about the size of breath and breathing rate. The children learn how mixing things together can release energy: yes, the soda volcano is not going out of fashion on our watch. We sing songs that are adapted from nursery rhymes for younger children or gross-out numbers for older children (I'm still trying to purchase a recording of the brilliant, Rhinotillexomania
). Other people run tidier, quieter and less messy workshops, but it can entirely depend on the age-group with which you are working. And the number of boys. Unless they are painting Warhammer figures or doing something else that fully absorbs their attention, boys tend to be rambunctious.
The Breath Spa Project
re-trains the breathing of children who have sleep-disordered breathing: the majority of the children with whom we work also have asthma. We work with children from aged 2 years and up, so we simple emphasise behavioural techniques with children. I've previously described a workshop for young children
. When we work with older children, we keep the experiments and the games but include some biofeedback, primarily in the form of their end-tidal carbon dioxide levels (ETCO2), their breathing rate and various other breathing-related data. The children tend to be fascinated to learn that their posture, their emotional state, or how they concentrate when they are performing various tasks can all change these data. E.g., when children are asked to recall a time when they felt safe and happy, in general, their ETCO2 may move up a few points (depending on the baseline)and the breathing-rate may drop. If children are asked to complete a pop quiz in maths, they might have a lot of muscular tension, they may breath-hold or increase their breathing rate and various other changes.
Breath Spa mostly concentrates on behavioural interventions with children and their families. Parents and significant adults have to consent to the programme and participate in it so that they know which new habits we want them to re-inforce and which habits we would like their help to extinguish. We try to involve all of the signicant adults and family members because we need their help in making sure that they children practise good breathing habits and learn how to breathe well and appropriately all of the time. I'm interested in breathing re-training that helps children to breathe well, even when asleep, and at other times when the breathing is not under conscious control. I am wary of programs that teach breathing techniques that are only used as a rescue remedy
or as an intervention when symptoms have already started. I think that it is difficult enough for adults to be collected enough to remember to use these techniques when they are already experiencing symptoms, it is that much harder for children.
I am interested in the role of stress in children's asthma flare-ups
, as well as asthmatic children's response to environmental exposure to hostility and aggression
. I have wondered if there is a role for some form of combined resilience training (something like the popular schools-based Penn Resiliency Program
) and the breathing re-training. I favour schools-based programmes
rather than individual sessions, because my experience is that it improves take-up of the programme but I am open to different approaches with different emphases.
So, I was very intrigued to read about a new project in Pittsburgh, I Can Cope
(ICC). ICC works with children between the ages of 8 and 12 who have a diagnosis of moderate, persistent asthma. The purpose of ICC is to evaluate the effectiveness of a program that is designed to teach children more robust ways of coping with the stresses and daily challenges that affect them. The researchers hope that increasing the children's coping skills will reduce the frequency and severity of asthma symptoms or attacks.
In overview, the program consists of six training sessions over the course of three months. The children attend the university for the sessions. During these one-on-one sessions, the children are coached in different methods of coping with emotions and handling challenges. They learn how to relax and breathe well at times when they are upset or experiencing symptoms of asthma.
All of the children in the program complete a daily diary for four weeks: two weeks at the beginning of the study and two weeks at the end. The diary includes questions about stress, medications and asthma symptoms experienced each day. Children record their peak flow measurement every evening by blowing into a peak flow meter. The children also collect saliva samples, which are used to estimate levels of cortisol, and are understood to be a biological measure of stress.
I have some reservations about the usefulness of measuring cortisol levels. I would need to know more about the study inclusion criteria before I could comment fully. If the children use the commonest reliever or preventer medications on a regular basis then I would question the usefulness of the cortisol levels. Relievers tend to be beta2-agonists, and would therefore stimulate the sympathetic system and perhaps promote the release of cortisol. Similarly, inhaled corticosteroids (ICS) might also provide an artificial bump to steroid production. ICS use has been known to flatten the body's natural cortisol slope. So, I do need to know a lot more about the timing of the saliva collection and the significance that is attributed to the cortisol levels.
Parents and their children are asked to complete a series of questionnaires about their mood and current stresses. The children need to visit the supervising hospital twice, once at the beginning of the study and once at the end, for breathing tests.
The Pittsburgh Post-Gazette
recently published a story that gives some insight into the content of the sessions
. A 9-year-old girl, Hayley Hardcastle, sits in a darkened room. She imagines that she is a turtle, at rest, on a rock by a peaceful pond. Kirstin Long, the graduate student who runs the sessions, tells her that she senses danger and directs Hayley to pull in her head for safety.
Hayley tenses her neck and shoulder muscles, then relaxes them as the imagined threat disappears. Hayley has sensors on her shoulder that pick up the muscle tension of stress, and display this on a computer screen, giving her visual biofeedback on her body's reaction to stress. This exercise and similar activities are intended to help children like Hayley to cope with their asthma by changing their response to feelings that could leave them upset.
The ICC program helps children to understand how their thoughts, actions and feelings can work together to affect their asthma. The course manual tells them:
How you are feeling or what you are thinking does not cause you to have asthma. But you are more likely to have an asthma attack or begin wheezing at times when you are upset, scared or excited.
By learning to cope with these feelings, you can learn to be in charge of your asthma and to reduce the chance of asthma attacks.
They children use what they have learned to note the stressful situations they encounter in their diaries and reflect on how they can respond more positively. The children are coached in ways that they can stop themselves from making their unpleasant feelings worse, such as talking to a friend or shifting their attention to something else.
The course teaches common relaxation techniques such as "belly breathing" that emphasise slow breathing using the diaphragm. In the training sessions, the children use biofeedback exercises to experience how their emotions can affect the body's functions and different measurements. Hayley practised tensing and relaxing muscles but she also completed an activity during which her hand temperature rose as she grew more relaxed. Watching their biofeedback can be very motivating for children and it can help to emphasise the reality of what they are being taught: e.g., that how you feel or what you are doing can make changes in your body.
Allegheny County is the setting for the study: the asthma rate among children was 10.2% in the 2003-04 school year, up from 7 percent in 1997-98. The study's medical director is Dr. David Skoner, director of allergy, asthma and immunology at Allegheny General Hospital. In an interview with the newspaper, he said, "We think there is tremendous potential benefit".
Dr. Skoner commented that asthma is particularly common among children in inner cities. He acknowledged that in children, 80% of asthma attacks are linked to colds, and allergies are a common factor. However, he is interested in studies that associate stress with a greater risk of catching a cold, and those that indicate that stress may be a trigger for asthma flare-ups.
Dr. Skoner estimates that stress may lead to asthma exacerbations in 5-10% of children with asthma, and it may contribute to symptoms suffered by many others. As part of their sessions, and to help them explore the idea that tension can lead to asthma episodes, the children work with images of a 'worked-up person'. Being 'worked-up' has the classic signs of a churning stomach, pounding heart, irregular breathing, tense muscles and clammy hands.
Dr. Anna Marsland is the study's principal investigator and an assistant professor of psychology, nursing and psychiatry. She created the I Can Cope
(ICC) program. Dr. Marsland told the newspaper that a few studies have used relaxation techniques with younger asthma patients as the primary intervention to help them to manage stress. She decided to base ICC on cognitive behaviour therapy (CBT). CBT incorporates several techniques that help people to recognise negative patterns of thinking and reacting to events: they are encouraged to replace these thoughts and actions with more constructive ones.
However, there is not much research on the effectiveness of CBT with children, particularly not for children with asthma. Nonetheless, Dr. Peter Michelson, clinical director of pulmonary medicine at Children's Hospital, is referring children to the study. Talking to the newspaper, he said that if ICC works, CBT could be a "tremendous resource," and reduce the children's need for medications, emergency room visits and other health care services.
Whatever the implications, Hayley and her mother would both recommend the program. Speaking to the newspaper, Mrs Hardcastle said that allergies, sports and stress all contributed to Hayley's asthma attacks, and she "seemed to be heading to the school nurse a lot for breathing treatments." She supported a study that would help Hayley "calm herself down". Mrs Hardcastle reported Hayley has used some of her medications less frequently since her participation in the study. Hayley also reported improvements, "I've learned what stress really is and how it affects my asthma".
ICC sounds like an interesting study and I would like to know more about it.For more information about the images used in the illustration, click on it or visit the detail on Flickr.