Asthma Care Training (ACT) for Kids

A program of the Asthma and Allergy Foundation of America, implemented in Providence 'Alaska' Medical Center, Anchorage, Alaska.

Asthma Care Training for Kids: Research Base

Introduction

The Asthma Care Training (ACT) for Kids is a major initiative of the Asthma and Allergy Foundation of America (AAFA) to teach children and their families asthma self-management skills and thereby reduce the frequency and severity of asthma episodes. ACT for Kids is designed to complement appropriate medical care and to encourage families to work in concert with their physicians to control children’s asthma. The program is clinic-based, designed by a physician-led team of researchers; it operates in a variety of pediatric clinic settings throughout the United States.

After a review of pediatric asthma self-management programs available at the time, the creators of ACT for Kids decided to base their intervention on these key principles:

• A child must be an active participant in preventing and controlling symptoms.
• child must be able to recognize initial symptoms and know appropriate actions to take.
• Children and parents should be treated as equal partners in the learning and caring process.
• Activities for children need to be focused on skills and should increase their sense of mastery.
• Parents should be taught how to create a nurturing home environment that allows children to practice such newly acquired skills as decision-making and relaxation.

In accordance with these principles, the content and materials for the children participating in ACT for Kids were designed to be developmentally appropriate for children between the ages of 7 and 12. The concept of modeling, derived from Bandura’s Social Learning Theory, was incorporated into the design of the intervention. Modeling, in conjunction with interactive learning tools such as games and role-playing, gives the child an opportunity to observe and practice a skill or task under the supervision of a knowledgeable person who can help the child master that skill or task.

In 1983, the intervention was implemented in two allergy clinics in Los Angeles, CA, to determine its effectiveness compared with weekly lectures and discussion. The following sections discuss the goals of the intervention, the educational content of the intervention, the evaluation design, important characteristics of the study population, and the results of the intervention. The discussion of the research on ACT for Kids is based on the article by CE Lewis, G Rachelefsky, MA Lewis and others titled "A randomized trial of A.C.T. (asthma care training) for kids" in the journal, Pediatrics, volume 74, pages 478-486, October 1984.

Goals of the Intervention Research

The intervention research had two primary goals. At the time the intervention research was conducted, no pediatric asthma self-management program had been evaluated utilizing a randomized control study; ACT for Kids was the first such program to test its effectiveness with the rigor of an experimental research design. The intervention sought to demonstrate the importance of addressing the emotional costs, for both parents and children, of living with asthma, and of using this understanding as a tool to teach asthma self-management skills. If children and their parents are able, in a safe environment, to express the fears, concerns, and frustrations of living with asthma, and if those feelings are acknowledged by others who have had similar experiences, and are addressed by medical professionals, then parents and children may feel more capable of taking the steps necessary to appropriately manage children’s asthma.

Intervention Research

Educational Content of the Intervention
The educational sessions were based on the simplifying paradigm that a child with asthma is in “the driver’s seat.” As a driver, the child is responsible for maintaining his or her health in much the same manner as a driver is responsible for driving safely: symptoms, medications, techniques, and steps in an asthma management plan are, like traffic light signals, identified as either green, yellow, or red. For instance, green, yellow, and red stickers are used to color code medications. Families also use this paradigm to identify the types of independent decisions children can make about their asthma management. (In this case, green identifies those decisions a child makes alone, yellow those that the child makes with his or her parents, and red those that the doctor makes with the child’s parents.)

The intervention consisted of five 1-hour weekly sessions with five to seven children and their parents. Parents and children met in separate groups but were reconvened at the end of each session to share what they had learned. The sessions for parents and children covered the same content; however, the information was presented in developmentally appropriate formats. The session topics were as follows:

Lesson 1: Information was presented about the underlying mechanisms in asthma and resultant symptoms and signs are presented. The feelings associated with having asthma were explored.

Lesson 2: The environmental control of irritants and allergens was discussed.

Lesson 3: Relaxation skills and breathing exercises were taught. Children and their parents also meet individually with the physician to review prescribed drugs. Medications were color-coded with respect to their intended use. Dosage and side effects of each drug were reviewed.

Lesson 4: Decision-making skills concerning asthma management were demonstrated.

Lesson 5: The concept of balanced living was presented. The group process enabled comparisons of similarities and differences and the recognition that one is not alone in dealing with asthma. The sharing or transfer of responsibility for care from parent to child was facilitated by the group process.

Evaluation Design
ACT for Kids was evaluated using a randomized control study. Pediatric patients and their parents from two allergy clinics in Los Angeles were chosen to participate and were randomly assigned into control and experimental groups. Patients and parents in the experimental group received the ACT for Kids intervention while families in the control group attended three 1½-hour weekly educational sessions that presented the same content in a lecture format. The educational sessions for the control group also emphasized the child’s role in asthma management but did so as part of the lecture. These lectures were given to approximately six to 12 families (12 to 25 people) compared to five to seven families for the intervention group.

To detect changes in both the children’s and the parents’ knowledge, attitudes, beliefs, and skills with respect to asthma self-management, a structured interview guide was administered by telephone prior to the first class and then 3, 6, and 12 months after the end of the classes. Children and their parents were interviewed separately. Data were collected on the following outcome measures:

• knowledge of asthma symptoms, triggers, and medications
• child and parental perception of child’s health status
• actions taken by child at the onset of an episode (did child spontaneously take medicine or ask parent for it, or did parent administer)
• location of and child’s accessibility to medication
• child’s level of panic at the onset of an episode
• child’s use of breathing and relaxation exercises

The interview guide also contained two open-ended questions that asked families if they were doing anything differently as a result of their participation and what was the most important thing they learned from the class. The responses to these questions were subsequently categorized as knowledge, communication, changes in smoking behavior, change in father-child relationships, changes in lifestyle, changes in emergency room use, and changes in decision making. In addition to the interviews, medical records from the allergy clinics were reviewed to detect any changes in numbers of doctor office visits, emergency room visits, and hospitalizations.

Recruitment and Characteristics of the Study Population
The study was conducted with pediatric patients and their parents who were clients at two allergy clinics that were part of the Los Angeles Kaiser Permanente health system. The patients were identified by a review of the medical records. After patients were assigned to either the experimental or the control group, their families were contacted by telephone. Children were eligible to participate if they a) required medication at least 25% of the days of a month b) were between the ages of 7 and 12 and c) were verbally fluent in English.

The study population consisted of 103 children, with 41 in the experimental group and 62 in the control group. Observations were collected for 28 children in the experimental group and 48 children in the control group, for a total of 76 participants. Although socioeconomic status was not reported, researchers report that the children were mainly from middle class, working families, and that all were receiving care from pediatric allergists. Seventy-seven percent of the children were male, and the average age was 10.3 years. Approximately one third of the children were African American (32.9%) and one quarter were Hispanic (23.7%). Children in both groups were classified with similar levels of severity - 3.3 and 3.1 in the experimental and control groups, respectively - based on criteria put forth by the National Health Insurance Study. Children at level 3 receive medication continuously, experience fewer than eight severe attacks a year, have more than six mild attacks a year, and experience mild symptoms and minimal functional impairment between attacks.

Research Results

The intervention was effective in increasing knowledge of triggers and in reducing perceived severity of asthma episodes in both experimental and control groups. However, there were significant increases in some self-reported compliance behaviors, such as remembering to take extra medicine when necessary and using self-care behaviors during an attack; there were also significant reductions in emergency room visits and days of hospitalization for children in the experimental group. Parents in the experimental group were also more likely to mention that there was improved communication and better father-child relationships. Furthermore, changes in parental smoking behavior resulted in less exposure for the child. Researchers estimated that, based on the reductions in hospital days and emergency room visits, and excluding the costs of developing and evaluating the intervention, there was an estimated cost savings of approximately $180 per child per year for those in the experimental group.

Research Funding

ACT for Kids intervention research was supported by grants from the National Center for Health Services Research, the UCLA Center for Interdisciplinary Research in Immunological Diseases (National Institutes of Allergy and Infectious Diseases), and The Allergy Research Foundation. The evaluation of the intervention was aided by a grant from the Southern California Permanente Medical Group, Department of Education and Research.