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Maternal Depressive Symptoms and Emergency Department Use Among Inner-city Children With Asthma
Susan J. Bartlett, PhD;
Kenneth Kolodner, ScD;
Arlene M. Butz, ScD;
Peyton Eggleston, MD;
Floyd J. Malveaux, MD, PhD;
Cynthia S. Rand, PhD
Arch Pediatr Adolesc Med. 2001;155:347-353.
ABSTRACT
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Context Inner-city minority children with asthma use emergency departments (ED)
frequently.
Objective To examine whether maternal depressive symptoms are associated with
ED use.
Design, Setting, and Patients Baseline and 6-month surveys were administered to mothers of children
with asthma in inner-city Baltimore, Md, and Washington, DC.
Main Outcome Measures Use of the ED at 6-month follow-up was examined. Independent variables
included asthma morbidity, age, depressive symptoms, and other psychosocial
data.
Results Among mothers, nearly half reported significant levels of depressive
symptoms. There were no demographic or asthma-related differences between
the children of mothers with high and low depressive symptoms. However, in
bivariate analyses, mothers with high depressive symptoms were 40% (prevalence
ratio [PR], 1.4; 95% confidence interval [CI], 1.0-3.6; P = .04) more likely to report taking their child to the ED. Mothers
aged 30 to 35 years were more than twice as likely (PR, 2.2; 95% CI, 1.9-9.3; P = .001) to report ED use, as were children with high
morbidity (PR, 1.9; 95% CI, 1.4-7.1; P = .006). Child
age and family income were not predictive of ED use. After controlling for
asthma symptoms and mother's age, mothers with depressive symptoms were still
30% more likely to report ED use.
Conclusions Depression is common among inner-city mothers of children with asthma.
Beyond asthma morbidity, maternal age and depressive symptoms are strong predictors
of reports of ED visits. Identifying and addressing poor psychological adjustment
in mothers may reduce unnecessary ED visits and optimize asthma management
among inner-city children.
INTRODUCTION
ENSURING THE appropriate use of emergency department (ED) facilities
can play an essential role in the containment of health care resources and
costs. It is estimated that 1.7 million visits to the ED are made by children
with asthma1 at a cost exceeding $90 million.2 The high use of emergency medical care among low-income,
minority children as a primary treatment for asthma is well established.3 Although higher rates of asthma are found among African
American and other minority children,4 neither
disease severity nor age of the child (or the combination) accounts for differences
in patterns of health care use.5, 6
In a review of studies of health care use by children, Riley and colleagues7 concluded that the child's health needs explain less
than 17% of the variance of health care use. Thus, attention has turned to
the role that other factors play in a mother's decision to seek acute medical
care for her child.
A limited number of studies have examined the relationship between characteristics
of caregivers and ED use for their children. Adolescent mothers who had high
rates of social and behavioral problems when they were younger are more likely
to bring their children to the ED unnecessarily.8
Among preschoolers, Lavigne and colleagues found that parents of children
who were younger, of a minority group, and had either a psychiatric diagnosis
or history of behavioral problems were more likely to take their children
to the ED.9 Children of single parents3 and those from poorer families10
are also seen more frequently in the ED. Parents who perceive their children
as being more vulnerable also use urgent care services more frequently.11, 12
Among young inner-city children with asthma, morbidity is high and asthma
is poorly controlled and poorly managed.13
Emergency department use is common among this population and often serves
as a primary care source for asthma.13, 14
Inadequate instructions to parents regarding medication use and low adherence
were initially identified as risk factors for high ED use.15, 16
More recently, psychosocial and behavioral correlates were identified in 445
children treated for asthma in an urban ED.14
Younger children with more symptoms who had previously been hospitalized for
asthma were found to be at high risk for receiving ED care. Parental factors
such as lack of confidence in the efficacy of asthma medications and lack
of use of a criterion for deciding to go to the ED were also associated with
increased acute care use. In a multicenter trial in Australia, parental worry
and attitudes about the appraisal of asthma severity were also significantly
related to repeat ED visits.17
The psychological status of caregivers may also play a role in the decision
to use the ED. The National Cooperative Inner-City Asthma Study investigated
psychosocial factors and asthma morbidity among 1528 inner-city children (ages
4-9 years). It was found that 50% of caregivers reported clinically significant
levels of psychological distress,18 as measured
by the Brief Symptom Inventory. Caregiver (but not child) mental health was
the strongest predictor of hospitalizations for asthma; parents who scored
above the clinical cutoff for the Brief Symptom Inventory were nearly twice
as likely to have children who were hospitalized.18
Conversely, parenting style, social support, alcohol abuse, and life stress
contributed relatively little to the prediction of asthma morbidity.19
Inner-city adults,20, 21
as well as those having children with chronic health problems, including asthma,22 are at increased risk of depression. In neonates,
acute care use has been associated with emotional distress in mothers. However,
to date, no study has prospectively evaluated whether depressive symptoms
of the mother are associated with ED use (without hospital admission) for
asthma care for their children. We hypothesized that younger child age, increased
asthma morbidity, and maternal depression would be associated with ED use
among inner-city school-age children with asthma.
PATIENTS AND METHODS
STUDY SAMPLE
This study combines data from identical surveys administered at baseline
and 6 months in 2 community-based interventions designed to evaluate and improve
asthma management among inner-city children and their families. In the first
survey, 33 inner-city elementary schools from Baltimore, Md, and Washington,
DC, were contacted and invited to participate. In the second survey, 32 inner-city
Baltimore elementary schools were contacted. Schools were selected if they
met the following criteria: (1) more than 85% of students were African American,
(2) more than 350 students were enrolled in the school, and (3) administrative
consent to participate in a subsequent asthma education study was authorized.
The initial surveys were conducted between October 1996 and September 1997
and were approved by the Joint Committee on Clinical Investigation of The
Johns Hopkins University School of Medicine, Baltimore.
PARTICIPANTS
Children in kindergarten to grade 5 who had an asthma diagnosis listed
on their health records were screened for eligibility. Children were eligible
for the study if their mothers reported that they had (1) asthma diagnosed
by a physician, (2) day or night asthma symptoms, including wheezing, shortness
of breath, and/or a cough at least once a week during the past 2 weeks, and/or
(3) at least 1 visit for asthma to the ED in the previous 6 months or 1 overnight
hospitalization for asthma in the previous year. Ninety-eight percent of the
children were African American.
PROCEDURES
Parents or guardians of eligible children were mailed a consent form.
After obtaining informed written consent, telephone interviews were completed.
The child's biological mother was the interview respondent 89% of the time.
The interview, administered by trained interviewers over the telephone, queried
demographic information about the child, as well as asthma symptoms and current
management practices. Studies of pediatric populations have generally found
good agreement for medically related information when querying information
such as hospitalizations and number of visits for asthma.23, 24
Interviewers were hired through a research contract group and blinded
to the study purpose and hypotheses. Within the total sample of 338 respondents,
an expanded interview that queried mood was conducted with the last 177 mothers
enrolled in the studies; 6-month self-report data on ED use were available
for 158 of the children in the baseline sample (89%). Mothers who did not
participate in the follow-up interview were more likely to report lower levels
of asthma morbidity at baseline (mean ± SD, 6.3 ± 7.2 vs 15.7
± 11.7; P<.001, days and nights with symptoms
per month, respectively), but did not differ in age, level of depressive symptoms,
child age, or annual income. All analyses reported were performed on this
subset of children and their mothers.
MEASURES
The primary outcome measure was the number of ED visits for asthma (which
did not result in hospitalization) reported by the mother between the baseline
and 6-month follow-up interview. Participants were asked, "In the last six
months, how many times was your child treated for asthma in the emergency
room but not hospitalized?" Child measures included an index of asthma morbidity
(described below), an estimate of the amount spent for asthma-related medications
each month, the number of visits the child had with the primary care provider
(PCP) in the past year, and the length of relationship with the PCP.
An index of asthma morbidity was developed at baseline by summing the
total number of days and nights during the previous 6 months that the child
experienced asthma-related symptoms. This method has been previously shown
to have good concurrent validity with other standard measures of asthma morbidity
in children.25, 26 Respondents
were asked 2 questions: (1) "For the last six months, on average, how many
days per week did cough, wheeze, or shortness of breath limit your child's
exercise, ability to play sports or play with friends?" and (2) "For the last
six months, on the average, how many nights per week did your child wake up
at night with cough, wheeze, shortness of breath or tightness in chest?" Total
number of days and nights with symptoms in the previous month were summed.
Tertiles were calculated that reflected low (0-8 days and/or nights), moderate
(9-16 days and/or nights), and high ( 17 days and/or nights) morbidity.
Maternal measures included demographic information, an assessment of
depressive symptoms, and quality of life. Depressive symptoms were assessed
using a modified version of the Center for Epidemiological Studies Depression
(CES-D) Scale.27 The CES-D has been widely
used in clinical trials in both general and psychiatric populations and has
sound psychometric properties (ie, reliability, discriminant, and convergent
validity). To reduce the burden on participants and, because briefer versions
of the test have also been shown to have good predictive accuracy when compared
with the full-length version,28, 29
an 11-item version of the CES-D was used. Scores on each item ranged from
0 to 3 with higher scores reflecting increased dysphoria; scores of 9 or more
were judged to reflect clinically significant levels of depressive symptoms,
while scores of 8 or less were judged to reflect nonsignificant levels of
distress. Quality of life was assessed using an abbreviated 5-item version
of the Pediatric Caregiver Quality of Life Questionnaire.30
Mothers were also queried about medication use of the child.
STATISTICAL ANALYSIS
The primary objective of this study was to prospectively determine whether
baseline characteristics of inner-city children with asthma and their mothers
were associated with reports of ED use in the following 6 months. Because
the prevalence of maternal depression was so high in this sample, caregivers
were initially divided into 2 categories—low and high levels of depressive
symptoms.  2 Analyses and t tests
were used to assess differences in demographic, health care utilization patterns,
and asthma management practices. To examine characteristics of the child and
mother related to ED use, ED visits were dichotomized (no/yes), and Poisson
regression was used to estimate crude prevalence ratios (PRs). (We used PRs
rather than odds ratios because odds ratios will produce inflated estimates
of risk when the prevalence of the outcome [ED use] is high, as in this study.31) Poisson regression was also used to derive adjusted
PRs, controlling for the effects of child age, parent age, asthma morbidity,
depression, and family income. SPSS PC (version 10.0; SPSS Inc, Chicago, Ill)
and SAS (version 6.12; SAS Institute Inc, Cary, NC) software were used to
analyze the data.
RESULTS
DESCRIPTIVE DATA
Mothers had a mean ± SD age of 33.3 ± 6.7 years. Of the
140 mothers, most (ie, 70%) of the mothers had completed high school or obtained
a General Education Development certificate and reported having state-sponsored
medical assistance (56%) or private health care insurance (36%). The children
with asthma had a mean ± SD age of 7.9 ± 2.2 years and, 59%
of the sample were girls. Mothers reported that the majority (90.5%) of children
had been prescribed asthma medications in the past 6 months. More than half
(56.5%) had been prescribed a daily asthma medication. Forty-two percent of
the children had taken oral steroids for asthma in the past year and 60.1%
had a nebulizer at home. The asthma morbidity index was negatively correlated
with use of daily asthma medications (r = -0.20, P = .02) and oral steroids (r
= -18, P = .03) and positively associated with
frequency of home nebulizer use (r = 0.25, P = .02).
MATERNAL AND CHILD CHARACTERISTICS
Nearly half (ie, 47%) of the mothers reported clinically significant
levels of depression. Given this finding, we first examined differences between
families in which mothers were categorized as reporting high and low levels
of depressive symptoms. As shown in Table
1, mothers with depressive symptoms were significantly more likely
to be unemployed (P < .001), be in the lowest
income category (ie, <$10 000 per year) (P
= .004), and report a lower quality of life (P =
.001). Depressive symptoms at baseline and at 6 months were highly correlated
(r = 0.53; P<.001).
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Table 1. Comparison of Characteristics of Respondents and Children
With Asthma by Maternal Level of Depressive Symptoms*
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Few other differences emerged. There were no statistically significant
differences in age, sex, or asthma morbidity between the children of mothers
with low and high depressive symptoms. Similarly, no differences were observed
in mothers' ages or education levels. Thus, family characteristics appeared
relatively comparable between groups. There were also no significant differences
in reports of lifetime hospitalizations for asthma, the amount spent on asthma
medications each month, number of visits for routine asthma care, and length
of relationship with the PCP between mothers with low and high levels of depressive
symptoms, as shown in Table 2.
Overall, the children and their asthma-care patterns, including medication
use, appeared relatively comparable between mothers who reported low and high
levels of depressive symptoms. Also, in both groups, the estimated time from
the child's home to the PCP's office was comparable (ie, 15-30 minutes). However,
mothers with high levels of depressive symptoms were 40% (PR, 1.4; 95% confidence
interval [CI], 1.0-3.6; P = .04) more likely to report
having taken their child to the ED in the following 6 months compared with
mothers with low levels of depressive symptoms (Table 3). Mothers who reported the highest tertile of depressive
symptoms also reported the most frequent use of the ED (Mantel-Haenszel test, 21 = 6.33, P = .01).
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Table 2. Health Care and Medication Use of Children With Asthma in
Mothers With Low and High Levels of Depressive Symptoms*
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Table 3. Adjusted Prevalence Ratios for Mother and Child Characteristics
and Emergency Department (ED) Use During 6-Month Follow-up*
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Other factors were also associated with reports of ED use (Table 3). As we had anticipated, mothers
of children with the highest asthma morbidity were more likely to report taking
their child to the ED (PR, 1.9; 95% CI, 1.4-7.1; P
= .006). Mothers between the ages of 30 and 35 years were more than twice
as likely to report taking their children to the ED for asthma care (PR, 2.2;
95% CI, 1.9-9.3; P = .001) compared with those who
were younger or older. (There was a trend [P = .09]
for younger mothers to also use the ED.) Neither child age nor family income
was associated with reports of ED use.
Poisson regression was used to evaluate the independent contribution
of child age, asthma morbidity, maternal age, depression, and family income
in predicting reported ED use. Variables were selected for inclusion based
on theoretical importance, significant association in the bivariate analyses,
and findings from cross-sectional studies. Variables significantly contributing
to reports of ED use included asthma morbidity, maternal age, and depression
status (Table 3).
COMMENT
The principal finding of this study is that, in the inner city, mothers
with high levels of depressive symptoms are 30% more likely to report taking
their children to the ED for asthma care after adjusting for other factors.
Among inner-city children with asthma, the age and psychological adjustment
of the mother were the strongest predictors of ED use, independent of the
child's asthma morbidity. Mothers with depressive symptoms made frequent ED
visits, with 12.0% reporting 4 or more ED visits compared with 1.2% of visits
by mothers with low levels of depressive symptoms (Table 2).
A secondary finding was that symptoms of depression are common among
mothers of inner-city children with asthma. Nearly half (ie, 47%) reported
clinically significant levels of depression, which is more than 5 times the
national point prevalence rate of 5% to 9%.32
These results are supported by a recent study that found that 39% of inner-city
mothers with young children reported high levels of depressive symptoms,33 and a prospective study that found women with infants
who had even 1 ED visit were much more likely to be depressed (odds ratio,
3.2; 95% CI, 1.5-3.0).34 The pervasiveness
of depressive symptoms among inner-city mothers is worrisome given the well-documented
adverse consequences to both parent and child.35
As expected, mothers with depressive symptoms reported the poorest quality
of life. Though widespread, depression remains untreated in up to 90% of those
affected.36 In our sample, depressive symptoms
were highly correlated at baseline and 6 months later.
Poverty, unemployment, marital discord, child-rearing, urban dwelling,
and low socioeconomic status are potent risk factors for maternal depression.37 Depression, in turn, increases health care use. Among
adults, depression results in increased health care use, even in otherwise
healthy persons.38 A positive relationship
has also been found between the use of maternal and child health services.
Children who are high health care users are likely to continue this pattern.39 It is likely that these relationships are reciprocal
where environmental stressors and having a child with asthma impact psychological
adjustment of inner-city mothers.
There are several reasons why depressive symptoms in mothers may be
associated with reports of ED use. Maternal psychological distress diminishes
the mother's ability to cope with her child's asthma and is a marker for greater
negative impact of the child's illness on the family.40
Depressed mothers view even mild-to-moderate asthma symptoms as disruptive
and difficult to manage.40 They may have more
difficulty interpreting cues regarding their child's health status (ie, misinterpreting
the severity of their child's symptoms), may underestimate their competency
to handle the situation, and/or may feel overwhelmed by the child's immediate
needs. As anticipated, we found that ED use was highest in children experiencing
the most symptoms. However, among mothers with high levels of depressive symptoms
seen in the ED, 58% of the children were classified as having mild-to-moderate
asthma morbidity, underscoring the importance of nonasthma factors in the
mother's decision to seek urgent care. Finally, though there were no differences
in rates of prescribed daily asthma medications, oral steroids, or nebulizers,
it is possible that asthma management practices differed between mothers with
low and high depressive symptoms.
An alternate explanation for greater ED use by mothers with depressive
symptoms is that taking their child to the ED may be an attempt to signal
their own distress. Mandl et al34 note that
some women may find it less threatening or stigmatizing to contact the medical
community on behalf of their children than for their own needs. Indeed, when
we examined tertiles of CES-D scores at baseline, mothers with the most depressive
symptoms also reported the most frequent ED use.
Our finding that depressive symptoms in the caregiver are prospectively
associated with reports of ED use is consistent with recent findings from
the National Cooperative Inner-City Asthma Study19
where the caregiver's mental health had the strongest relationship to health
care utilization. However, it stands in contrast with 2 previous cross-sectional
studies. Watson and Kemper41 found that after
controlling for maternal and child age, maternal depression was not a significant
predictor of ED use in their sample of preschool children in an inner city.
However, children in their study were significantly younger (mean age, 12.2
± 15 months) and were seen in an ambulatory care setting an average
of 8.5 ± 5.2 visits per year, more than twice as often as children
in our sample were seen for regular care (3.5 ± 4.0 months). Because
the ambulatory care center routinely screened for and provided additional
case management through a special needs clinic to those identified to be at
high psychosocial risk, this may have attenuated ED use by increasing social
support and providing alternate resources for caregivers who were identified
as being at risk. Riley and colleagues7 also
found that the child's health and maternal patterns of health care use were
powerful predictors of utilization while maternal mental health was not. They
studied health care utilization of 450 children who were 5 to 11 years old
from electronic records of a health maintenance organization over a 2-year
period. However, their sample consisted of predominantly white (84%), 2-parent
families (91%) with an average household income of more than $60 000.
Thus, it is conceivable that as socioeconomic status changes, so too does
the role that depressive symptoms play in the caregiver's decision to seek
treatment for their child in an acute care setting.
The National Asthma Education Program guidelines were released in 199142 and revised and updated in 199743
to provide clinical practice and prescribing guidelines for PCPs. An anticipated
outcome of improved asthma management was that emergency facilities would
be less burdened by children who could be safely treated during an acute asthma
attack at home or in the PCP's office. The traditional view has been that
caregivers may bring children to the ED because of poorly controlled asthma
resulting from deficits in education, skills, or motivation to address the
asthma in other settings. Emerging data suggest that the psychosocial status
of the caregiver may be an important but often overlooked variable.18
This is the first study we are aware of to use a prospective design
linking reports of depressive symptoms in mothers of children with asthma
with subsequent ED use. Other strengths include the use of well-validated
psychosocial measures administered by trained clinical interviewers who were
blind to the study hypotheses. A limitation is that the caregiver's mental
health status was assessed. Children with psychiatric disorders and behavior
problems use health care more frequently and have more ED visits.6 Child psychiatric factors, either alone or in combination
with asthma symptoms, prompted some of the reports of ED use. However, this
is less likely given the findings of Weil and coworkers that the strong positive
correlation between the mother's and child's mental health eliminated the
direct relationship between child's mental health and hospitalizations.19 We used maternal reports to assess asthma morbidity
and ED use; since both reports originate from a single source, they may reflect
a shared reporting bias. Future studies would benefit by using independent
validated criteria (eg, medical records) when feasible. Finally, we did not
have data on the severity of the asthma attack that would help establish the
appropriateness of the decision to go to the ED. Some children may have been
symptomatic in the evenings or at night when access to their regular health
care provider was much more limited.
Emergency services, particularly in inner cities, are increasingly overburdened
and unable to cope adequately with the escalating demands that are placed
on them. Merely addressing the immediate medical needs of children with asthma
is becoming an increasingly difficult task. Clearly, many factors influence
asthma morbidity among children living in inner cities, including the psychological
adjustment of the caregiver. Frequent ED use may serve as a marker that nonmedical
factors contribute significantly to the decision to take a child to the ED.
Furthermore, use of the ED for treating asthma in children is unlikely to
change significantly if factors not specific to asthma (eg, mother's mental
health) remain unidentified and unaddressed.
More research is warranted to confirm these initial findings as well
as to assess asthma management practices in depressed mothers and to determine
effective intervention methods. Of great concern is the high prevalence of
depressive symptoms reported among caregivers in our sample. It is reasonable
to assume that, as in the general population, the majority of mothers with
depressive symptoms in our study remained untreated. Maternal depression has
been linked with profoundly negative short- and long-term outcomes for the
child.37 Because effective treatments for depression
exist,44 the stress for both parent and child
associated with depression may be reduced or even potentially avoided.
Recognizing and treating depression among inner-city caregivers must
become a high public health priority. The identification of depressive symptoms
among caregivers of children with chronic illness is a critical first step.
The use of CES-D or other brief screening instruments could be integrated
into the routine primary care of inner-city caregivers with chronically ill
young children. Identification of mothers at risk may present a unique opportunity
to refer and provide opportunities to enhance psychological adjustment. Improved
maternal mental health would not only directly impact quality of life but,
as this study suggests, may also reduce unnecessary visits to the ED.
AUTHOR INFORMATION
Accepted for publication October 25, 2000.
This work was supported by grants HL5201304 and HL5283303 from the National
Heart, Lung, and Blood Institute of the National Institutes of Health, Bethesda,
Md.
We thank Karen Huss, PhD, and Perla Vargas, PhD, for their helpful comments
on earlier drafts of the manuscript.
From the Departments of Medicine (Drs Bartlett, Kolodner, and Rand),
Pediatrics (Dr Butz) and Pediatric Allergy and Immunology (Dr Eggleston),
The Johns Hopkins University, Baltimore, Md; and College of Medicine, Howard
University, Washington, DC (Dr Malveaux).
Corresponding author and reprints: Susan J. Bartlett, PhD, The Johns
Hopkins Asthma and Allergy Center, 5501 Hopkins Bayview Cir, Suite 4B.32,
Baltimore, MD 21224 (e-mail: bartlett{at}jhmi.edu).
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