http://informahealthcare.com/jasISSN: 0277-0903 (print), 1532-4303 (electronic)

J Asthma, Early Online: 1–11! 2014 Informa Healthcare USA, Inc. DOI: 10.3109/02770903.2014.952437

ORIGINAL ARTICLE

The relationship between helplessness and the child’s asthmasymptoms: the role of social support

Kelly M. Conn, PhD, MPH1, Dena Swanson, PhD

1, Elizabeth McQuaid, PhD2, Kathryn Douthit, PhD

1, andSusan G. Fisher, PhD

3

1University of Rochester Warner School Rochester, New York, USA, 2Department of Psychiatry and Human Behavior, Alpert Medical School,

Brown University, Providence, RI, USA, and 3Population Research, Fox Chase Cancer Center, Temple University School of Medicine,

Philadelphia, PA, USA

Abstract

Objective: Objectives of this study were to survey parents and children independently regardingfeelings of helplessness specific to asthma and to examine the relationship betweenhelplessness and the child’s symptom-free days. Methods: Parent–child dyads (children 7–12years) from Rochester, NY were enrolled (November 2011–August 2012) from general pediatricclinics, pulmonary clinics, an Emergency Department, and area youth and asthma programs.Assessments included demographics, symptoms, ratings of helplessness related to asthma andparent social support. A multivariate linear regression was conducted to examine therelationship between feelings of helplessness and symptoms-free days: post hoc analysisassessed the moderating role of social support. Results: Overall, 107 parent–child dyads enrolled(participation rate: 72%); 104 were included in analysis. Most children were male (58%), 7–9years (58%) and White (46%). The child’s feelings of helplessness scores were positivelycorrelated with symptom-free days indicating less feelings of helplessness as symptom-freedays increased (rs¼ 0.273, p¼ 0.01). In a stratified analysis, among parents who reportedminimal social support (51 sources of support), child’s helplessness scores were positivelycorrelated with symptom-free days (rs¼ 0.335, p¼ 0.02). Conversely, among parents reporting42 supports, no relationship was found (rs¼ 0.195, p¼ 0.15). Conclusions: This study found lessfeelings of helplessness among children with asthma as symptom-free days increased. Socialsupport appears to moderate this relationship; however further studies to confirm thesefindings are needed.

Keywords

Asthma, coping, emotions, parent–child,support

History

Received 1 April 2014Revised 21 July 2014Accepted 3 August 2014Published online 2 2 2

Introduction

A variety of distinctive psychological states, such as anxiety,

depression, behavioral problems and aggression have been

associated with asthma [1–7]. In particular, these states are

associated with asthma that is more difficult to manage,

requiring higher doses of steroids, more frequent and

prolonged hospital stays, and greater functional disability

[3]. Additionally, research related to family functioning and

pediatric illness indicate an association between adverse

family functioning, such as negative family climate and

children’s asthma outcomes [2,8–10].

There is no simple model to explain the effects of emotion,

psychological states and the family climate on children with

asthma. Taylor and Repetti reviewed the role of environments

impacting chronic and acute health disorders and report that

emotions and stress are among factors that precede or

potentially trigger asthma symptoms [11]. They indicated

that negative emotions such as depression, anxiety and

hostility play a role in morbidity and mortality [11].

An additional model, constructed in 1993 by Wood et al.

the biobehavioral family model (BBFM), tested the interplay

between family environment, emotional/autonomic arousal

and asthma outcomes. This model theorizes that family

relational patterns and biobehavioral reactivity interact so

as to influence the physical and psychological health of

children [12].

Feelings of helplessness are a powerful influence on

behavior and emotion [13]. The theory of learned helpless-

ness hypothesizes that people who feel there is no connection

between their behaviors and outcomes are passive, depressed,

have increased feelings of anxiousness and fear [13].

For learned helplessness to occur, the situation is

perceived as distressing and uncontrollable [14]. Asthma is

an episodic illness with periods of exacerbation which likely

lead to feelings of helplessness and lack of control for some

people.

Correspondence: Kelly M. Conn, PhD, MPH, Warner School Counselingand Human Development, University of Rochester, Box 270425 Rm 370Rochester, NY 14627-0425, USA. Tel: +585-723-3341. Fax: +585-486-1159. E-mail: kelly_conn@urmc.rochester.edu

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Many of the same biological and autonomic mechanisms

thought to play a role in asthma are involved in the activation

and regulation of physiological responses to stress [3]. Studies

have shown that increased levels of anxiety and arousal are

associated with physiological changes in the body, including

respiration and even lung function [15–22]. Thus, individuals

with asthma who are experiencing stress or feelings of

helplessness may be at greater risk of exacerbations based on

these biological mechanisms and physiological changes.

Therefore, if parents and/or their children with asthma are

having feelings of helplessness related to the child’s asthma,

increased anxiety and heightened emotions could be asso-

ciated with increased asthma symptoms.

Among the few studies that have assessed feelings of

learned helplessness or similar concepts of illness uncertainty

related to asthma [23–25], some have indicated a connection

between feelings of helplessness, decreased psychological

adjustment and symptoms of asthma. Most studies, however,

were carried out with older children and young adults [24,25]

and only one was conducted with parents of younger children

with asthma [23]. More importantly, little has been done to

show the relationship between these feelings and asthma

morbidity. Therefore, major gaps remain in our understanding

of children’s self-report of emotions related to asthma as well

as the relationship between feelings of helplessness and

asthma morbidity.

For this study, parent and child feelings of helplessness

related to asthma were measured and the relationship between

these feelings and asthma morbidity were assessed.

Specifically, the objectives of this study were: (1) to survey

parents and children independently regarding their emotions

and feelings of helplessness specific to asthma and examine

associations between parent and child report, (2) to examine

the relationship between parent’s report of helplessness and

the child’s asthma symptoms as well as the relationship

between the child’s report of helplessness and his/her asthma

symptoms and (3) to assess the relationship between the

interaction of parent and child helplessness and asthma

symptoms.

Methods

This is a cross-sectional study of children with asthma and

their parents. Primary assessments, which were completed by

both parents and their children independently, included

learned helplessness, emotions and coping related to asthma

and asthma specific situations.

Subjects and setting

Recruitment for this study began in November 2011 and was

completed in August 2012. Subjects included parent–child

dyads from the Rochester, NY area recruited from a Rochester

area general pediatric clinic, two pulmonary clinics, an

Emergency Department (ED), an asthma coalition and area

daycares and YMCAs. A research committee or signatory

official for each of these groups reviewed the protocol and

provided permission to use the settings for research. This

study, along with all recruitment materials and protocols for

each site, were approved by the University of Rochester

Institutional Review Board.

Screening and eligibility

For each clinic, children between the ages of 7 and

12 years were identified the day prior to their appointment

and flagged so that a research assistant could arrive to greet

and enroll the parent and child. For each of the five clinic

settings used for enrollment, each required different

operational procedures, but the general process included

identification and flagging of patients with asthma that were

coming in for an appointment, followed by approach and

explanation of the study.

Enrollment in the ED required specialized procedures

using their trained research assistants. Since the asthma

status of children entering the ED is not known, all children

without significant impairment (major trauma) were

approached and screened. An additional exclusion criterion

was followed only for this setting; children with an

Emergency Severity Index (ESI) of either 1 or 2, indicating

a medical need too severe to be approached for this study,

were excluded.

Health fairs, an asthma coalition, websites and newsletters

were also used to enroll Rochester area families. Tables were

set up at two local area health fairs through the city school

district and YMCA (as approved by the directors) to help with

face-to-face recruitment. Advertisements were placed in six

daycares, five online newsletters and two Facebook pages;

parents interested in the study contacted the research team

about enrollment. Finally, staff from a Rochester asthma

coalition reached out to eligible families to obtain permission

to allow our study team to contact them regarding enrollment;

families who were interested were contacted by the research

team.

The study was introduced to the parent and if the parent

agreed to answer questions in order to assess eligibility, the

screening questionnaire was completed. For children who

were accompanied by both parents, families were asked to

choose only one to complete all study related forms and

questionnaires. Screening questions were designed to assess

asthma severity, controller medications use, age and other

eligibility criteria. If the child was not eligible, based on

enrollment criteria, the screening was concluded.

Inclusion/exclusion criteria

To be eligible, the child needed to be between the ages of

7 and 12 years and have a diagnosis of asthma. In conjunction

with the diagnosis of asthma, the parent had to have reported

the child as using a controller medication OR having

persistent asthma symptoms over the past 2 weeks. Children

with only mild intermittent symptoms and no controller

medication were considered mild and not eligible.

Parents were asked about the following for assessment of

eligibility:

(1) Relationship to the child as primary caregiver (a legal

parent or guardian officially allowed to or designated to

care for the child)

(2) Child and parent age (child must be between 7 and

12 years of age and parent must be between 19 and

88 years of age)

(3) Report of at least one controller medication OR

persistent asthma severity over the past 2 weeks based

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on the following National Heart, Lung and Blood

criteria [26]:

(a) an average of42 days/week with asthma symptoms

(b) 42 days/week with rescue medication use

(c) 42 nights/month awakened with nighttime

symptoms

(d) some limitation of activity

(e) 42 episodes of asthma during the past year that

have required systemic corticosteroids

Children were not eligible to participate if they were:

(1) mild intermittent symptoms and no controller medication

(2) unable to speak and understand English

(3) in foster care or other situations in which consent could

not be obtained from a parent or guardian. To be eligible,

a parent or legal guardian needed to be present for

immediate discussion about the study and verbal consent.

(4) parent report of the child’s diagnosed significant medical

conditions, including congenital heart disease, cys-

tic fibrosis or other chronic lung disease, that could

interfere with the assessment of asthma-related outcome

measures.

(5) already enrolled in this study and completed this

questionnaire. Although this could not be 100% verified,

this information was considered valid based on parent

report.

(6) coded in the Emergency Department as having

an Emergency Severity Index (ESI) of 1 or 2

(For Emergency Department Enrollment ONLY)

(Parents unable to read were still eligible and all

self-administered instruments were given verbally).

Survey implementation and data collection

For parents and children that met eligibility criteria and who

agreed to enroll, a consent form was completed; children

provided assent. Prior to conducting the study, parents and

children needed to agree to be briefly separated to allow for

independent completion of the survey. All survey instruments

were read aloud to the caregiver and child, and during this

time a copy of the survey was visible to follow along. Surveys

were either implemented with parents and children by two

members of the research team at the same time (if two were

available) or one research assistant doing the survey with

child first and then parent. In this case, once the research

assistant finished screening the parent and obtained written

consent, the parent was asked to step outside of the patient

room. This was done to prevent the child from being

influenced by their parent when answering questions and to

prevent the parents from hearing their child’s answers prior to

their survey. After the completion of the child’s interview, the

parent would rejoin their child in the patient room and

subsequently be interviewed by the research assistant. The

child remained in the room while the parent was interviewed.

A total of 50.4% dyads were enrolled using two research

assistants and 49.6% using one research assistant.

Primary independent variable: learned helplessness

The primary independent variable in this study is helpless-

ness, for both parent and child. A previously validated learned

helplessness scale [23] was used to capture feelings of

helplessness on a general level related to asthma; it is not

situation specific. The learned helplessness subscale is one

factor of the self-efficacy measure previously used by Grus

et al.; the other subscales that make up the self-efficacy

measure were not used in this study. The subscale consists of

nine items that reflect general feelings of helplessness as well

as helplessness in managing asthma. The subscale was used

previously in a population comprised primarily of low income

families and had good reliability with Cronbach alpha of

0.77 [23]. Questions are rated on a 4-point Likert scale with

1 representing ‘‘strongly agree’’ and 4 representing ‘‘strongly

disagree’’. Factor scores are obtained by calculating the mean

of all 9 items (each rated 1, 2, 3 or 4). Table 1 displays the

nine questions included in the Learned Helplessness subscale.

Higher scores on the learned helplessness scale indicate less

feelings of learned helplessness. Since the scale has only been

used in adults (parents of children with asthma) wording was

augmented for this study to also be used with children.

Covariates: parent and child demographics

Additional information was collected and used for descriptive

analysis and as covariates. Background information and

demographic data included whether the parent is the primary

caregiver (verification of their relationship to the child), their

education (�HS versus4HS), marital status (married/couple

versus single) and race (White versus other). Additionally, the

child’s age, gender and race (White versus other) were

collected.

Psychosocial covariates: social support anddepression

Social Support was captured by asking parents ‘‘When I need

help or support, I usually get it from (check all that apply)’’.

Parents could check any or all from a 15-item list (ex: spouse,

child’s mother and friends) and also were encouraged to write

in any other sources of support The number of supports

reported were tallied and then dichotomized into minimal

support (no support or one identified source of support) and a

lot of support (two or more identified sources of support).

Both parent and child report of depression was assessed by

using previously validated 2-item depression scales, designed

to give a quick snapshot of possible depression. These scales

were chosen based on the limited time available in clinic for

completing the surveys. For the parent, the Patient Health

Questionaire-2 (PHQ-2) was used which assesses the fre-

quency of depressed mood and anhedonia [27]. The PHQ-2

Table 1. Learned Helplessness Scale [23].

There is no way that I can solve some of the problems I haveI often feel helpless in dealing with [child’s] asthmaI have little control of my child’s asthmaThere is little I can do to change the important ways asthma affects

[child]Sometimes I feel that I’m being pushed around by the health care systemI have little control over things that happen to meThere is little I can do to change the important things in my lifeThere is really not way that I can solve some of [child’s] problems with

asthmaSometimes I feel that I’m being pushed around in life

DOI: 10.3109/02770903.2014.952437 Helplessness and asthma: the role of social support 3

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consists of two statements that ask about how the participant

has been feeling over the past 2 weeks including how often

having ‘‘little interest or pleasure in doing things’’, and

‘‘feeling down, depressed or hopeless’’. Participants answer

questions based on a validated 4-point Likert scale (0 – ‘‘not

at all’’, 1 – ‘‘several days’’, 2 – ‘‘more than half the days’’ and

3 – ‘‘nearly every day’’) [27]. Based on the prior use of this

scale, parent depression for this study was calculated by

summing both items in the scale (range 0–6); a score �3 was

considered a positive screen for depression.

For the child, the Short Mood and Feelings Questionnaire

(SMFQ) was used which is a self-report measure for rating the

severity of depression symptoms [28,29]. The questionnaire

consists of 13 sentences to which the child can respond that

the statement is ‘‘true’’, ‘‘sometimes true’’ or ‘‘not true’’.

Children are asked to answer these questions based on how

they have felt or acted in the past 2 weeks. Only the first two

of these sentences, which were previously used and validated

among 521 sixth-grade students, were included in our study

[30] (‘‘I felt miserable or unhappy’’ and ‘‘I didn’t enjoy

anything at all’’). Rhew et al. recommend using this shorter,

two-item version of the SMFQ on children when time is

limited and the primary concern of the researcher is to assure

screen sensitivity. Items for this scale were summed (max-

imum total score of 4) and a score of �1 was considered a

positive indicator of depression.

Asthma covariates: medications, smoking and pets

Asthma variables such as use of medications, smokers living

in the home and pets living in the home were also obtained

based on parent report. Medications were reported by the

parent and a picture color chart, which depicted all asthma

medications, was used in order to help parents with recall.

How often medications are taken was also reported based on

options of never, everyday, some days, only when needed/

when sick to indicate actual use (versus prescribed use).

Primary outcome: symptom-free days

The primary outcome variable for this study is symptom-free

days over the prior 2-week period (reported as a continuous

variable 0–14 days).

To capture asthma severity, asthma symptoms were

obtained over the past 14 days including the number of

symptom-free days, symptom days, symptom nights, activity

limitation and use of quick relief medications. Previous

studies have used 2- to 4-week time frames as an ideal method

for most accurately capturing asthma symptoms [31–34].

Asthma symptoms were asked only of the parent.

Analysis

The unit of analysis for this study is the parent–child dyad.

Sample size for this study was based on the primary

objectives which are the association (crude and adjusted)

between parent helplessness and symptom-free days (over

past 2 weeks) as well as the correlation between child

helplessness and symptom-free days. For estimation of the

correlation between two normally distributed variables with a

two-sided nominal significance level of 0.05, a sample size of

123 dyads (246 individuals; 123 parents and 123 children)

was required to obtain a power of at least 0.8 to detect a

correlation of 0.25 or greater. A correlation of 50.25 is

unlikely to be clinically important. This sample size would

have provided adequate power to examine �10–12 independ-

ent variables in a multivariate linear regression using the

accepted rule of 10 observations (dyads) for each variable

[35] and they met assumption of normal distribution.

Key independent variables in this analysis are parent report

of helplessness, child report of helplessness and the inter-

action of these scores. Continuous measures of helplessness

between parent and child were compared using Spearman

Correlation Coefficient. A crude association between parent’s

feelings of helplessness and the child’s asthma symptoms was

also conducted using Spearman’s Correlation. Coefficient A

linear regression (parametric) was also conducted to estimate

the slope of the line describing this relationship (Beta

Coefficient).

Multivariate linear regressions were conducted to examine

the overall relationship between parent and child feelings of

helplessness and the child’s symptom-free days. The analyses

were adjusted for confounders and all variables included were

examined to determine whether or not they meet assumptions

for normal distribution. Since symptom-free days did not

appear to be normally distributed, based on the mean, SD and

histogram, both parametric and non-parametric tests were

conducted. All data are reported using parametric statistics

since the outcomes for both approaches yielded similar

findings. T-test or analysis of variance (ANOVA) was used

when comparing helplessness to two or greater than two

level variables, respectively, and Spearman Correlation

Coefficient was used when comparing it with other continu-

ous variables. Any covariate that was associated with

helplessness with a probability of 50.10 was considered a

potential confounder.

Based on the bivariate analyses and based on the literature

regarding social support and the buffering impact on health

outcomes [36–43], further testing was conducted to under-

stand potential moderating effects of social support on the

relationship between the child’s helplessness and symptom-

free days. Therefore, post hoc subgroup analysis was

performed to assess the main effects of child helplessness

among groups with minimal social support and high levels of

social support. Linear regression analysis was conducted to

test a model that includes main effects (child helplessness and

parent helplessness) and a constructed interaction term of

parent helplessness X child helplessness. Significant

Interaction terms were retained in the model.

Statistical significance of each variable in the model was

evaluated based on a two-sided alpha level of 0.05. The

analyses were not adjusted for multiple comparisons given

the unique design and preliminary nature of this research. The

influence of the primary independent variables on symptom-

free days was also assessed by examining the magnitude of

change in symptoms based on a one unit change in

helplessness as estimated by the beta coefficient. A 10% or

greater increase in symptoms was considered important in

delineating symptom mechanisms and comparison in the beta

coefficients between models was compared in order to

understand potential mechanistic explanations for the associ-

ations under investigation.

4 K. M. Conn et al. J Asthma, Early Online: 1–11

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Results

A total of 840 children were identified for enrollment as

shown in the enrollment flow diagram (Figure 1). A total of

279 children (33.2%) were not screened for multiple reasons

(missed and ESI severity �2). The remaining 561 parent–

child pairs were screened for the study. Among those

screened, 412 (73.4%) were not eligible; the primary reasons

for ineligibility included no asthma diagnosis (292), mild

symptoms with no controller medication (42), not being of

proper age (15), having a chronic condition that would

interfere with assessment of breathing problems (19), and

already being enrolled in the study (15). Overall, 149 parent–

child dyads were eligible for participation, and 107 were

enrolled for a participation rate of 71.8% (Figure 1)

Among the 107 dyads enrolled, 62 (57.9%) came from the

clinics, 15 (14.0%) from the emergency department and 20

(18.7%) each from the asthma coalition and community

newsletters/events. Not surprisingly, the highest participation

rates were seen in the volunteer populations (asthma coalition

and community newsletters/events). The lowest participation

rates were seen among the ED population and the general

pediatric population.

Additionally, among the 107 enrolled in the study, over

half of the dyads (60%) were enrolled fully at the time of

initial contact with the remaining 40% needing a follow-up to

finish data collection. The final data set used for analyses

included 104 dyads; after enrollment 2 dyads were deter-

mined to be ineligible based on limited English ability and

understanding and an excluding chronic condition and

1 child’s parent withdrew him from the study shortly after

initiating the baseline questionnaire.

Demographic characteristics of the 104 children and their

parents included in the study are displayed in Table 2. More

children were male (57.7%), between 7 and 9 years of age

(57.7%), and White (46.2%). Among the parents, half

reported being White (50%) and being 36 years of age or

older (56.7%); two-thirds reported more than a high school

education (68.3%). Over half of the parents reported being

either married or a member of a couple (55.8%). Parent

depression was indicated in510% of the parents and over half

reporting having at least two or more identified persons as a

source of support (51.9%).

Asthma morbidity, control and environment factors

indicated symptoms that are similar to other studies among

urban children in Rochester, NY [34]. Children were reported

to have an average of 7.80 (SD 5.34) symptom-free days per

2 weeks. Additionally, they experienced �4.32 (SD 4.58)

symptom days per 2 weeks, 2.77 (SD 4.04) nights with

symptoms per 2 weeks, and used their rescue inhaler 4.48

(4.80) days per 2 weeks (data not shown). Although nearly all

parents reported that their child used a preventive asthma

medication at the time of the survey (90.4%), more than half

of the children (65.4%) had mild persistent to severe

persistent asthma based on symptom day and night based

on NHLBI criteria [44]. The child’s home environment was

also assessed; �1/3 of children (29.8%) lived with at least

1 smoker in their home and 22% of the parents completing the

surveys reported being current smokers. Additionally, over

half (56.7%) of the children lived in homes with a furry pet.

The learned helplessness scale used previously, was

implemented among a predominantly White population of

parents of children with asthma, and never with young

children. Therefore, a confirmatory factor analysis was first

Figure 1. Enrollment flow diagram.

Identified forEnrollment:

840Not screened: 279

- Missed / no one to enroll 145- No show in clinic 97- Clinic issues, unable to enroll 11- ESI index < 2 26

Screened:561 Not eligible: 412

- No asthma 292- Mild Asthma / No Controller 42- Wrong age 15- No legal guardian 10- Spanish speaking 10- Other Chronic illness 19

o Cognitive Delays, Cerebral Palsy,BPD, Heart Surgery, Down Syndrome,Sickle Cell, Pneumonia

- Unable to re-contact to complete enrollment 9- Already enrolled 15

Enrolled:107

Participation Rate: 71.8%

Eligible:149

Refused: 42

DOI: 10.3109/02770903.2014.952437 Helplessness and asthma: the role of social support 5

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conducted along with an assessment of the reliability of both

the child and parent helplessness scales. Similar to the prior

study using the helplessness scale [23], the parent helpless-

ness scale for this study had good reliability (Cronbach

alpha¼ 0.86). The child’s helplessness scale was augmented

from the parent study, and thus created specifically for this

study; therefore, based on the parent scale, reliability was not

compared to the prior study, but it was determined to be

reasonable (Cronbach alpha¼ 0.65).

Average parent helplessness scores were 2.99 (SD 0.54) on

a scale of 1 (more feelings of helplessness) to 4 (less feelings

of helplessness) and children’s scores were slightly lower

(mean 2.63, SD 0.39). Comparisons between parent helpless-

ness and child helplessness approached significance

(rs¼ 0.18, p¼ 0.06). Parent’s helplessness scores did not

differ based on any demographic or environmental factors

(Table 3); however, children’s helplessness scores differed

based on the child’s age, race, depression, parent education

and parent marital status. Younger children reported signifi-

cantly more feelings of helplessness compared to older

children (younger children, 2.55 and older children, 2.74,

p¼ 0.01). Additionally, White children reported significantly

less feelings of helplessness compared with non-White

children (2.72 versus 2.55, p¼ 0.02). Children with possible

depression were more likely to report more feelings of

helplessness compared with children without depression (2.55

versus 2.77, p¼ 0.01). Children with parents reporting less

than a high school education also reported significantly more

feelings of helplessness compared to those with a HS degree

or higher (5HS, 2.46 versus �HS 2.71, p¼ 0.04). Lastly,

children with single parents reported significantly greater

feelings of helplessness compared to children with married

parents (single 2.49 versus married 2.71, p¼ 0.01).

Demographic characteristics of parents and children, as

well as asthma morbidity and environmental factors were also

compared to the primary outcome variable of parent report of

the child’s symptom-free days (Table 4). Symptoms did not

differ on nearly all measures with the exception of the parent’s

marital status. Parents reporting being married or a member

of a couple reported nearly 2� as many symptom-free days as

compared to parents who are single (9.26 versus 5.52,

p50.001). Additionally, since asthma is known to be a

seasonal illness, the month of enrollment was compared to the

parent report of symptom-free days to determine whether

seasonality should be considered in the final models. There

were no significant differences in symptom-free days based

Table 3. Demographics and helplessness (n¼ 104).

Parenthelplessness

Childhelplessness

Mean (SD) Mean (SD)

Child and parent demographicsChild age (years)

7–9 2.92 (0.58) 2.55 (0.38)*10–12 3.09 (0.48) 2.74 (0.38)*

Child’s genderMale 2.92 (0.52) 2.59 (0.41)Female 3.10 (0.56) 2.68 (0.35)

Child’s raceWhite 2.95 (0.52) 2.72 (0.36)*Black or other 3.03 (0.56) 2.55 (0.39)*

Child depressed (n¼ 101)*Yes 2.94 (0.57) 2.55 (0.34)*No 3.05 (0.50) 2.77 (0.44)*

Parent age�35 3.00 (0.55) 2.62 (0.35)436 2.98 (0.54) 2.64 (0.42)

Parent’s raceWhite 2.93 (0.49) 2.70 (0.39)Black or other 3.05 (0.60) 2.56 (0.38)

Parent education�HS 2.85 (0.56) 2.50 (0.36)*4HS 3.06 (0.53) 2.69 (0.39)*

Parent marital statusSingle 2.88 (0.62) 2.49 (0.39)*Married/couple 3.05 (0.48) 2.71 (0.36)*

Parent depressed (n¼ 101)*Yes 3.04 (0.55) 2.59 (0.32)No 2.98 (0.51) 2.62 (0.40)

Parent supportMinimal 3.03 (0.57) 2.59 (0.38)A lot 2.96 (0.53) 2.66 (0.39)

Asthma control and environmentOn controller medication

Yes 2.80 (0.66) 2.65 (0.38)No 3.11 (0.53) 2.45 (0.41)

Smoker in the child’s homeYes 2.90 (0.62) 2.56 (0.38)No 3.03 (0.51) 2.66 (0.39)

Furry pets in the child’s homeYes 3.03 (0.49) 2.66 (0.40)No 2.95 (0.61) 2.59 (0.36)

*Indicates p50.05.

Table 2. Population demographics (n¼ 104).

n (%)

Child characteristicsChild age (years)

7–9 60 (57.7)10–12 44 (42.3)

Child’s genderMale 60 (57.7)Female 44 (42.3)

Child’s raceWhite 48 (46.2)Black or other 56 (53.8)

Child depressed (n¼ 100)a

Yes 65 (65.0)No 35 (35.0)

Parent characteristicsParent support

Minimal (none or 1 support) 49 (47.1)A lot (2 or more) 55 (52.9)

Parent age�35 45 (43.3)436 59 (56.7)

Parent’s raceWhite 52 (50.0)Black or other 52 (50.0)

Parent education�HS 33 (31.7)4HS 71 (68.3)

Parent marital statusSingle 42 (40.4)Married/couple 58 (55.8)

Parent depressed (n¼ 101)a

Yes 9 (8.9)No 92 (91.1)

aAlternate N reported due to missing data.

6 K. M. Conn et al. J Asthma, Early Online: 1–11

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on when the child and parent were enrolled and therefore the

seasonal variable was not considered in any further analyses.

Overall, parent helplessness scores were not associated

with the child’s symptom-free days (Table 5). However, the

child’s helplessness scores were positively correlated with

symptom-free days indicating less feelings of helplessness as

symptom-free days increased (rs¼ 0.273, p¼ 0.01). In further

post hoc testing, it was determined that the relationship

between the child’s helplessness and symptoms differed based

on the amount of social support identified. Among parents

who reported minimal social support (none or 1 source of

support), child’s helplessness scores were positively corre-

lated with symptom-free days (rs¼ 0.335, p¼ 0.02).

Conversely, among parents reporting two or more supports,

no relationship was found between the child’s helplessness

and symptoms (rs¼ 0.195, p¼ 0.15) indicating a potential

moderating effect of social support in the relationship

between the child’s feelings of helplessness and their

symptom-free days [45]. Based on a publication reviewing

interpretations of the magnitude of correlation coefficients in

psychosocial research, statistically significant coefficients

found in this study could be interpreted as meaningful [46].

Four models were constructed with the entire sample and

included child age, parent age, child race, child depression,

parent education greater than HS and parent marital status as

covariates. The four models differed based on parent and child

helplessness scores each entered alone, the child (Model 1)

and the parent (Model 2) and then a model with both scores

entered (Model 3) together as well as the parent and child sum

score (Model 4) (data for Models 2–4 were not statistically

significant and data are not shown). Data for Model 1 are

presented in Table 6 indicating a beta of 1.41, (p¼ 0.35). For

all models, helplessness scores were not statistically signifi-

cant after controlling for the above covariates. While not

statistically significant, and perhaps not precise, the estimate

for Model 1 suggests potentially important relationships that

should not be overlooked.

Three additional post hoc models were developed to better

understand the potential moderating effect of social support

on the relationship between child’s helplessness and symp-

tom-free days (using the same covariates). The three

additional models included: a model using a sub group of

only dyads reporting minimal support (Model 5); a model

using only families with a lot of support (Model 6); and lastly,

a full regression model with the entire sample that included an

interaction term of child’s helplessness and support. Table 6

shows the overall model including child helplessness (Model

1 from above) as well as the two models using the social

support subgroups (Models 5 and 6).

In considering the magnitude of effect, the betas between

the two subgroups of support were compared and a 5-fold

increase in betas between the subgroups was found.

Specifically, for the minimal support subgroup (Model 5),

for every one unit change in the child’s helplessness, there is a

3.265 unit change in the child’s symptom-free days. This is

compared to the subgroup with a lot of support (Model 6) that

indicates for every one unit change in the child’s helplessness

there is only 0.577 unit change in symptom-free days. A final

model using the interaction term (child helplessness X

Table 4. Demographics and symptom free days (n¼ 104).

Symptom free daysMean (SD) p Value

Child and parent demographicsChild age (years)

7–9 7.08 (5.45) 0.1110–12 8.77 (5.05)

Child’s genderMale 7.73 (5.21) 0.89Female 7.89 (5.57)

Child’s raceWhite 8.90 (5.33) 0.05Black or other 6.86 (5.21)

Child depressed (n¼ 101)Yes 7.23 (5.34) 0.24No 8.57 (5.46)

Parent age�35 6.76 (5.24) 0.08436 8.59 (5.32)

Parent’s raceWhite 8.71 (5.24) 0.08Black or other 6.88 (5.33)

Parent education�HS 7.64 (4.75) 0.834HS 7.87 (5.62)

Parent marital statusSingle 5.52 (5.32) 50.001Married/couple 9.26 (4.90)

Parent depressed (n¼ 101)Yes 6.67 (5.02) 0.66No 7.78 (5.40)

Parent supportMinimal 7.59 (5.50) 0.58A lot 8.07 (5.23)

Asthma control and the environmentOn controller medication

Yes 7.84 (4.48) 0.80No 7.40 (5.44)

Smoker in the child’s homeYes 7.65 (5.32) 0.85No 7.86 (5.38)

Furry pets in the child’s homeYes 7.85 (5.33) 0.92No 7.73 (5.40)

Table 5. Stratified unadjusted analysis: comparisons of helplessness variables and symptom free days.

Overall (n¼ 104) None or one support (n¼ 49) Two or more supports (n¼ 55)

rs p Value rs p Value rs p Value

Parent Helplessness Scale 0.106 0.28 0.118 0.42 0.105 0.45Child Helplessness Scale 0.273 0.01 0.335 0.02 0.195 0.15SUM, Parent and Child Helplessness 0.237 0.02 0.242 0.09 0.251 0.06

DOI: 10.3109/02770903.2014.952437 Helplessness and asthma: the role of social support 7

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support), and also including the primary effect of child

helplessness and support, showed the interaction term to be

not significant (p¼ 0.61).

Although not statistically significant, the findings in these

regression models provide some preliminary evidence for

support of the results of the unadjusted bivarate analysis

indicating a meaningful relationship between child’s help-

lessness and symptom-free days. For families with a lot of

support (those potentially buffered by social support), for each

one unit change in the child’s helplessness only a 0.58 unit

change in symptom free days was shown. Conversely, among

families with minimal support, those likely more vulnerable

to outside stress such as asthma, for each unit change in

children’s helplessness there was a 3.26 unit change in

symptom-free days. A 10% or greater increase in symptom-

free days was considered an important clinical indicator in

delineating symptom differences and mechanisms of action. A

prior study by the National Cooperative Inner-City Asthma

Study reports on the magnitude of effect in reducing

symptoms by a day or more over 2 weeks [47]. This

reduction, based on extrapolation over the course of 1 year

has the potential for a meaningful difference in symptom-free

days or over time.

Discussion

This study was designed to assess the relationship between

parent and child feelings of helplessness as well as to evaluate

whether or not these feelings are associated with the

children’s symptom-free days. Although there was no asso-

ciation between parent helplessness and the child’s symptoms,

there was a significant association between the child’s

feelings of helplessness and their symptom-free days.

Specifically, as the children’s feelings of helplessness

decreased their symptom-free days increased. These findings

are particularly interesting considering this study used parent

report of symptom-free days and there could be expectations

in finding significant relationships between parent report of

both symptoms and helplessness variables. Literature shows

that mothers who are under stress tend to report not only more

illness symptoms for themselves, but also for their children

[48] which might suggest a potential foundation for a

relationship. It is also worth noting that this relationship

may be bidirectional and that the child’s emotional arousal

during this time may impact the parents’ emotions and

coping [49]. The use of independent reports of children’s

feelings of helplessness in this study and parent report of

symptom-free days may provide additional strength in the

understanding of the relationship between emotions and

asthma exacerbations.

Additionally, although findings in the relationship between

the child’s feelings of helplessness and symptom-free days

were not statistically significant in the multivariate analyses,

it is important to consider the magnitude of effect shown in

this relationship, particularly only significant among families

in which the parent indicated that they had little to no support.

Compared to families who reported a lot of support (two or

more social supports reported), we draw attention to the

possibility of a buffering effect of social support, potentially

reducing the ill impact that helplessness and symptoms have

on one another (direction of relationship is unknown, but

likely bidirectional). While these findings were not statistic-

ally significant, the study was not powered for a stratified

analysis and it is likely that there was not adequate power to

fully ascertain these relationships and future studies of this

nature would be important. Literature supports this theory of

buffering from social support and its impact on health

outcomes [36–43]. Social support has been described as the

protection of others by providing tangible assistance (e.g.

financial aid), intangible assistance (emotional help) or

shielding from adverse effects of life stress [40–42,50–52].

Thus, support may serve as a buffer from the negative effects

of stressors, including feelings of helplessness. One study

found an association between social ties and fewer reports of

common cold including a dose response relationship with less

susceptibility to colds as social networks increased [53]. In

one study from the Neighborhood Asthma Coalition (NAC),

research is ongoing related to socially isolated parents (those

below the median on both support from family and friends)

and children’s asthma symptoms [54]. Additionally, lack of

social supports and social relationships has been associated

with altered immune functioning [3,55] which may play a role

specifically in asthma morbidity.

This study assessed both parent and child ratings of

helplessness among a group of children with a history of

persistent asthma. Overall, scores of helplessness among these

parents were similar to a study report using the same

validated scale among a group of non-minority parents [23].

Grus et al. measured parents’ feelings of learned helplessness

related to asthma and reported an average helplessness score

of 2.66 (+0.48); scores from parents in our study were only

slightly higher (indicating less helplessness). They did not

assess the relationship to asthma morbidity, and there was no

report of child feelings related to asthma.

Table 6. Stratified multivariate regression analysis: comparison of child’s helplessness and symptom free days.

Overall (n¼ 104) (Model 1) None or one support (n¼ 49) (Model 5) Two or more supports (n¼ 55) (Model 6)

Beta SE p Value Beta SE p Value Beta SE p Value

Parent HS education �0.78 1.19 0.51 �2.79 1.69 0.11 0.40 1.57 0.80Parent age 1.85 1.09 0.09 1.07 1.56 0.50 2.52 1.49 0.10Parent married 3.26 1.25 0.01 5.27 1.85 0.01 1.68 1.69 0.32Child depression �0.35 1.13 0.76 3.66 1.65 0.03 �3.18 1.51 0.04Child age 1.14 1.10 0.20 �0.08 1.72 0.96 1.64 1.42 0.25Child White �0.24 1.32 0.86 0.39 1.87 0.84 �0.78 1.78 0.66Child helplessness 1.41 1.51 0.35 3.26 2.44 0.19 0.58 1.91 0.76

8 K. M. Conn et al. J Asthma, Early Online: 1–11

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Nearly all of the children in this study were prescribed, and

thus presumably using, a controller medication. The screening

instrument for this study asked specifically about recent use

of controller medications, therefore, the classification of

controller medication use likely reflected families who were

currently using the medications; incorrect or underuse was

not captured. Future studies should take into consideration a

diverse sample of children using controller medications which

may allow us to also understand feelings of helplessness

related to asthma based on medication actions that parents

take to control their child’s symptoms.

The assistance and protection given to others by way of

social support can be broad and have far reaching effects,

especially to individuals [56] and this assistance can be

tangible (such as financial aid) or emotional. Among children

having family with a support network, this may serve as a

significant contributor in their chronic disease management

and illness outcomes [3]. The positive relationship between

social support and health is generally accepted in the

literature [37,56,57]. Smith et al. proposed the analogy of

attachment in children suggesting that, similar to well-

adjusted attached infants considered to have a secure base

with which to explore, adults with strong supportive relation-

ships are able to cope better with environmental stress [58].

Social support literature reports a buffering hypothesis

suggesting that individuals with a strong social support

system should be better able to cope with major life stressors

compared to those with little or no social support who may be

more vulnerable to unwanted life changes [36–43]. Cohen and

Willis [59] proposed two pathways in which social support

may play a role in health. First is the buffering hypothesis

which indicates that social support may only be beneficial for

individuals who are experiencing stressful situations; this is

different from their second main effects hypothesis suggesting

that social support is enhancing for everyone. It is possible

that the pathways in understanding the theory of learned

helplessness may be altered by either a buffering, or main

effect of social support.

Further research must distinguish between the different

types of support in order to clarify the direct and buffering

effects of social support in different situations [60]. Since

support, either tangible or emotional, could provide a crutch

or guidance for a person, allowing them to take more control

of a situation, helplessness outcomes could be altered or even

alleviated. Paving the way for interventions for families

coping with childhood chronic illness may begin with careful

understanding and assessment of not only the illness but the

family unit, their ability to utilize support systems and

resources. If feelings of helplessness are ultimately learned

based on prior experiences with asthma symptoms, it is

possible that with the proper guidance in managing symp-

toms, children and their parents may be able to regain their

feelings of control over managing this illness.

We also need to consider further assessments of how young

children feel and those implications for illness outcomes. Most

studies related to childhood asthma rely heavily on parent

report of and parent indicators related to morbidity, thus, these

investigations only capture the parent’s interpretation of the

child’s symptoms. As with this study, it is also important to

consider the child’s perspective and use independent child

report of their symptom experiences.

Implications

This study has implications for both future researchers and

clinicians. First, asthma outcomes are clearly related to

medically confirmed triggers such as smoke, exercise and

allergens, as well as medication management; however, social

and psychological factors such as stress, helplessness and

social support should be considered as additional primary

factors in the research and management of asthma.

Fortunately, outward projections of emotions and coping

during stressful illness and medical procedures are likely

modifiable factors [61]. According to Blount et al., ‘‘training

parents and children seems to be effective in reducing

distress, but there currently is no strong empirical support

for training parents and children versus only training children

(p. 102)’’. Clearly, there is a need for more research in this

area.

Additionally, although this information regarding the

potential buffering effect of social support on asthma

outcomes is still evolving, the practical implications for

clinicians are still very real. The literature confirms the

impact support systems play in how a person feels and

manages his or her environment. Thus, realizing the potential

power that social support may have on alleviating negative

asthma outcomes due to stress should be considered in

medical consultations. Social support may be a proxy for

other life situations such as poverty, discrimination or other

‘‘uncontrollable’’ or ‘‘ongoing stressful situations’’ and

should be recognized as such when family’s social support

is assessed. Clinicians may be well-positioned to ascertain the

degree of family social supports and provide recommenda-

tions for organizations and other networks.

Strengths and limitations

Strengths of this study include the use of a previously

validated scale to assess helplessness and reliability testing in

our population provided evidence that this tool is reasonable

in capturing our intended feelings of learned helplessness.

This study was designed to allow for independent ratings of

both parent and child’s feelings of helplessness. Young

children were able to report on these feelings without parent

interaction or presence strengthening our assessment and

comparisons during analysis knowing that there may be little

parent influence on the child’s answers.

Additionally, this study utilized different clinics and

settings for enrollment providing potential variability in the

population enrolled based on where they received care. Since

care from a physician, clinic or community resource could be

considered, for some families, as a source of support, this

serves as a strength of the study based on enrollment from

variety of settings. Lastly, our asthma assessments that ask

parents to reflect on the child’s symptoms over the past

2 weeks has been used in many prior studies [34,61] and is

considered an ideal method for most accurately capturing

asthma symptoms [31–34]. Similar averages in symptom days

and nights and symptom-free days were found when

DOI: 10.3109/02770903.2014.952437 Helplessness and asthma: the role of social support 9

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compared with studies using the same questions and popu-

lations [34,62]. Report from our parents related to their

child’s symptoms was indicative of other similar families, and

our subjects likely were able to understand, comprehend and

provide a reasonable report of their child’s asthma morbidity.

As with all studies, this study has some limitations. First,

data are all self-reported and no objective measures of asthma

symptoms (peak flow readings) or internal stress (such as

heart rate or cortisol) were used. This is primarily due to time

constraints as the subjects were recruited in the waiting room

of busy clinics and measurement of these parameters was not

feasible. A follow-up study adding these objective measures

should be considered.

Some measures used for this study were either augmented

from previously validated surveys, or were newly created, and

thus, provide a limitation in their reliability and validity. The

measure of social support in this study was one question that

served as an indicator of support, however a validated scale

was not used and therefore, it is unknown if the question used

is a reasonable indicator of social support. Further studies

replicating these findings using validated scales are needed.

The scale used to measure helplessness in children was

augmented from a prior validated scale used in a study of

parents of children with asthma [23]; therefore findings must

be considered in this context. However, the questions were

pilot tested for use in a group of children ages 7–12 years and

questions were assessed for understanding. We found two to

three words (such as ‘‘confident’’ and ‘‘helplessness’’) that

children sometimes needed additional clarification to under-

stand and standard definitions were provided to assure that

they had a true understanding of the meaning. Finally, for

questions that were scaled, circular diagrams were used so

that children understood the ‘‘graded’’ difference between

each answer [63].

Additionally, this study was designed with only a short

time frame in which to assess outcomes and therefore, it could

be that the limited resources and survey questions in this

study did not allow for proper statistical power, or exploration

of all factors needed to fully assess relationships. Although

some findings were not statistically significant, the estimates

suggests potential areas of importance in these relationships

that should be considered, especially in future studies.

Additionally, due to the unique design and preliminary

nature of this study, we did not adjust the p value for multiple

comparisons, however all results of this study should be

confirmed in future studies. Finally, there are other important

factors that may likely contribute to asthma management and

feelings of helplessness that should be considered in future

studies such as how long the child has had asthma or how long

the parent themselves had been dealing with their own

asthma.

Conclusions/key findings

This study found a potential moderating effect of social

support on the relationship between the child’s feelings of

helplessness and their symptom-free days. Feelings of help-

lessness may arise based on repeated asthma stress due to

exacerbations of symptoms causing a continuous cycle of

stress, helplessness and symptoms. It is possible that families

with significant social support are buffered from the effects of

helplessness and other stressors; however more understanding

is needed. Studies designed specifically to assess the

moderating effect of social support on helplessness and

other life stressors on asthma are needed.

Acknowledgements

We would like to thank Dr. Thomas O’Connor, PhD and

Dr. Mary Spagnola, PhD of the University of Rochester,

Department of Psychiatry for the contribution to pilot data in

preparation for this study. I would also like to acknowledge all

of the students who met with families and helped to collect

data for this study.

Declaration of interest

The authors report no conflicts of interest. The authors alone

are responsible for the content and writing of the article.

There was not external funding for this project, minimal funds

were provided out of pocket from the principal investigator.

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DOI: 10.3109/02770903.2014.952437 Helplessness and asthma: the role of social support 11

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