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Pediatrics

Bridgette Jones, MD, MSc, on Chronic Stress and Asthma Control Among Black Children

Black children are disproportionally affected by asthma compared with their white counterparts. According to the most recent Centers of Disease Control and Prevention data on asthma burden in the United States,1 12.6% of non-Hispanic black children have asthma, whereas 7.7% of non-Hispanic white children have asthma. With this higher incidence of asthma among black children comes greater disease-related morbidity and higher rates of mortality compared with white children. 

To better understand why these disparities in pediatric asthma exist, authors of a recent study2 sought to determine the association between parent-reported chronic stress exposure and pediatric asthma control among African American children aged 1 to 6 years with asthma.

Along with her colleagues, Bridgette Jones, MD, MSc—who is medical director of the Office of Equity and Diversity, a member of the Allergy/Asthma/Immunology & Pediatric Clinical Pharmacology, Toxicology, and Therapeutic Innovation division at Children’s Mercy Kansas City, and an associate professor of pediatrics at the University of Missouri-Kansas City School of Medicine—evaluated for 7 chronic stressors, including food insecurity and home instability.

It was the stressor of racism that was especially associated with lower asthma control among the children.

Dr Jones answers our questions about her study and its important findings.

PULMONOLOGY CONSULTANT: What prompted you to conduct this study?

Bridgette Jones: Asthma disproportionately affects African American children who have increased asthma prevalence, morbidity, and mortality rates compared with white children. Despite copious amounts of asthma research, we still do not understand why this disparity exists, and attempts to reduce this disparity have failed. I see the real-life experience of this disparity daily in my clinical practice.

Previous work has described the association of chronic stress exposure with asthma. African Americans experience unique chronic stress exposure, with its foundations based in the legacy of explicit, implicit, and institutional racism that only exists in the United States. Previous studies of the association between chronic/toxic stressors and asthma have not considered the unique types of chronic stress that African Americans face. We also wanted to investigate how chronic stress exposure impacts young children, as interventions may be introduced during this developmental period that could potentially modify long-term disease outcomes. 

PULM CON: Regarding treating asthma and improving a child’s long-term health outcomes, why is it key that a clinician be aware of and address adverse childhood experiences?

BJ: As asthma is a known heterogeneous disease with differences in underlying pathophysiology/phenotype, it is important for clinicians to consider the potential unique underlying drivers of the disease. Just as clinicians consider environmental exposures, such as allergens and air pollution, they should assess chronic stressors that may also lead to inflammatory changes and be related to disease risk and outcomes.

PULM CON: Of the 7 stressors you analyzed, is there any one or any combination of stressors for which a clinician should be especially vigilant? If so, why? And how can he or she successfully do this?

BJ: I really think that each patient is unique and that when thinking about asthma, different factors should be considered for each patient. However, I do think racism—as a personal and institutional factor—is not currently routinely considered by clinicians, and it should be. The American Academy of Pediatrics published a policy statement3 that describes racism as a social determinant of health that should be addressed by clinicians; the organization also provides instruction on how this can be done in the clinical setting. This landmark policy statement is a great resource for clinicians.

PULM CON: When treating an African American child who has asthma, how should a clinician approach the conversation about potential chronic stressors with the child’s parents?

BJ: One method of assessing chronic stressors in a busy clinical practice is to use validated questionnaires similar to how we often used asthma control questionnaires. Questionnaires exist that allow clinicians to assess adverse childhood events (ACE Questionnaire) and specific stressors such as racism and the emotional impact of racism. 

PULM CON: What do you hope will be the clinical impact of these findings?

BJ: As this study was a small pilot study, these findings should be reevaluated in a larger group, as well as in an older age group, to be applied directly to clinical practice. However, clinicians should start to consider the impact of chronic stressors on asthma in their practices as well as how they can work with patients and families to mitigate these effects.   

As I previously mentioned, our current scientific knowledge has not allowed us to understand the current asthma disparities experienced by African American children, and we are currently failing these children. There is currently little research conducted that is specific to understanding the unique risk factors, disease pathology, outcomes, and effective interventions for African American patients. African Americans are often excluded from clinical and translational research studies of asthma. More research that focuses on the unique lived experiences, environment, and institutional barriers that impact African American children with asthma needs to be conducted.

References:

  1. Most recent national asthma data. Centers for Disease Control and Prevention. https://www.cdc.gov/asthma/most_recent_national_asthma_data.htm. Updated May 2019. Reviewed May 2018. Accessed November 21, 2019.
  2. Jones BL, Staggs V, Woods-Jaeger B. Chronic stress exposure among young African American children with asthma. Ann Allergy Asthma Immunol. 2019;123(5):507-508. https://doi.org/10.1016/j.anai.2019.08.023. 
  3. Trent M, Dooley DG, Dougé J; AAP Section on Adolescent Health, AAP Council on Community Pediatrics, AAP Committee on Adolescence. The impact of racism on child and adolescent health. Pediatrics. 2019;144(2):e20191765. https://doi.org/10.1542/peds.2019-1765.