The Association Between Asthma and Sleep in Urban Adolescents With Undiagnosed Asthma

Asthma prevalence rates continue to escalate among urban youth,1 with rates greater than 20% being reported.2 African-American and Latino children are disproportionately affected with greater disease prevalence compared to their non-Latino White (NLW) counterparts.3 Urban youth diagnosed with asthma experience greater asthma morbidity, including activity restriction and sleep disruption, and a number of multi-level factors – such as disease severity, poverty, acculturative stress, exposure to allergens and irritants, insurance status –are implicated.4–7 Undiagnosed Asthma among Urban Adolescents: An Understudied Group at Further Risk Research with 7 to 18 year olds indicates that 28 to 50% of those with asthma-like symptoms lack an asthma diagnosis, and therefore are underdiagnosed or undertreated.2,8–10 Undiagnosed and untreated asthma can result in significant activity limitation, loss of school days, and in cases where symptoms are more severe and dangerous, the need for emergent care.8,10–12 In fact, among those with moderate to severe persistent symptoms, diagnosed and undiagnosed youth experience equally high rates of daytime and nighttime symptoms and asthma-related activity limitation and school absences.8,11,12 Adolescents are an especially vulnerable group because many have frequent asthma-like symptoms,8–10 have greater asthma morbidity due to asthma symptoms,8,11 and inconsistently utilize health care services.10,11,13 It has also been shown that adolescents are more prone to shorter sleep duration and poor sleep habits.14,15 Focusing on adolescent youth is critical as many health-related behavioral patterns that are formed during adolescence continue in adulthood and affect adult health outcomes.15,16 Children's Sleep: An Important Avenue for Intervention in Youth with Asthma-like Symptoms Children with poorly controlled asthma-like symptoms may have difficulty initiating or maintaining sleep due to nocturnal symptoms which can make them more vulnerable to poor sleep quality.17–20 In a study including children with diagnosed asthma and healthy controls, a higher number of night wakenings has been found in children with asthma compared to those without asthma.21 Sleep disruption due to nocturnal asthma-like symptoms may also occur more often in children with persistent asthma than in those with intermittent asthma,22 because their increased severity may increase the frequency of nighttime symptoms. Frequent night wakenings in youth with diagnosed asthma can result in poor sleep quality and can affect daytime alertness,23 increased school absences,24 poorer school performance,25 increased risk for behavior problems,26 and poor quality of life.27,28 Research to date in this area has included youth either with a physician diagnosis of asthma confirmed directly or by parent report; this relationship has yet to be studied in adolescents with asthma-like symptoms who lack a diagnosis, a highly vulnerable group Stressors Relevant to Urban Youth with Asthma Urban ethnic minority children with asthma-like are more vulnerable to neighborhood and family-level stress, and this can affect their susceptibility to asthma symptoms.29 Urban stressors and low-income status are also shown to be associated with poor sleep quality in children in other disease groups.30 Understanding the extent to which perceptions of stress affect the link between asthma and sleep in vulnerable samples, such as urban adolescents with asthma-like symptoms and no diagnosis, may help to identify modifiable factors and provide important opportunities for intervention across multiple settings where students spend the majority of their time, such as at home and/or school. The Current Study This study examines the association between asthma and sleep behaviors in a group of urban adolescent students with undiagnosed asthma. Asthma-related indicators include adolescents' report of night wakenings due to breathing problems, and their perceived severity of breathing problems/asthma-like symptoms. Each of these indicators is utilized in the assessment of asthma morbidity in urban children.17 Sleep-related indicators include the youth's report of their sleep-wake behavior problems and the level of daytime sleepiness during activities. These sleep indicators have been used in several studies assessing sleep in adolescents and have been shown to correlate with indicators of daytime functioning, such as concentration.14 We hypothesized that more frequent adolescent reported night wakenings and higher levels of perceived severity of breathing problems would each be associated with reports of more sleep-wake behavior problems and daytime sleepiness. In addition, we examined whether perceived stress moderated the association between asthma-like symptoms and sleep indicators in this group. We expected that asthma-like symptoms and sleep behaviors would be more strongly associated in the context of higher levels of perceived stress.