Stressful Life Events, Caregiver Depressive Symptoms, and Child Asthma Symptom-Free Days

Background: Asthma prevalence and morbidity disproportionately affect low-income, Black children. Accumulating evidence suggests that complex and interconnected risk factors at multiple social-ecological levels drive these disparities. Life stress and depression are prevalent among caregivers of these children and may be risk factors for asthma symptom burden. The objective of this longitudinal analysis was to evaluate the direct and indirect relationships among these variables.

Methods: This analysis used data from a single-blind, randomized clinical trial assessing the efficacy of a six-month parental stress management intervention for urban, publicly insured, Black children aged 4-12 years with persistent asthma (N=217). Repeated measures Poisson regression was used to examine the relationships among stressful life events, caregiver depressive symptoms, and number of child asthma symptom-free days (SFDs) in the prior 14 days by caregiver report. Stressful life events were measured using the 10-item Rochester Youth Development Stressful (RYDS) Life Events Scale (Range: 10-20), with higher scores indicating more stressful life events. A score ≥ 11 on the 10-item Center for Epidemiologic Studies Depression scale indicated clinically significant symptoms of depression. A symptom-free day was defined as a 24-hour period with no wheezing, coughing, tightness in chest or shortness of breath. Covariates included child age, sex, and baseline asthma severity; caregiver age and sex; group status (intervention vs. comparison); and time.

Results: 36.9% of caregivers (92% female) had clinically significant depressive symptoms at baseline. The mean baseline RYDS score was 10.78 (SD=1.11). Caregivers reported 160 instances of death of a family member and 114 instances of serious family accident or illness over the course of the study. In the three multivariate models, overall child SFDs increased over time, but caregiver depression predicted fewer child SFDs. In Model 1, which used the stressful life events scale score, there was no association with SFDs; however, in Model 2, which specified each stressful life event separately, a serious family accident or illness was predictive of fewer SFDs (IRR: 0.91, 95% CI: 0.85-0.98). In Model 3, the interaction between depression status and accident/illness was statistically significant. Post-hoc analysis showed that accident/illness was only significantly associated with SFDs when the caregiver was depressed. Depression was significantly associated with SFDs irrespective of accident/illness, but the effect of depression on SFDs was much stronger among those who reported an accident/illness. The model predicted 8.26 child SFDs (95% CI: 7.08-9.44) among depressed caregivers with accident/illness, and 10.56 (95% CI: 10.04-11.09) among depressed caregivers without accident/illness. Non-depressed caregivers without accident/illness had the highest number of predicted SFDs (11.20, 95% CI: 10.82-11.57).

Conclusions: Caregiver depressive symptoms were negatively associated with SFDs, and serious accident or illness in a family member intensified this effect in a sample of low-income, urban, Black children with asthma. These results emphasize the impact of social factors on asthma morbidity. As members of an interdisciplinary healthcare team, social workers are well-positioned to monitor and assess caregiver depressive symptoms and other life stressors and to provide targeted, evidence-based interventions to reduce health disparities among low-income, urban, Black children with asthma and their caregivers.