Pediatric Asthma Clinic Research Articles

Experience-based co-design to develop innovative telehealth physiotherapy interventions and resources for children and young people with asthma and dysfunctional breathing

Introduction Healthcare requires new technologies to deliver hybrid services. Before embedding health-delivery transformations including physiotherapy in asthma clinics, it is essential to give young people and their carers a voice to facilitate co-designing of services. Objective To co-design hybrid telehealth physiotherapy services and online resources for, and in partnership with, young people with asthma and dysfunctional breathing, and their families. Methods Experience based co-design study undertaken at a specialist paediatric difficult asthma clinic, including online service user focus groups and electronic questionnaires for service providers. Eight children aged between 11 and 17 years and their families and 11 members of the multi-disciplinary team (MDT) managing children with difficult asthma were recruited purposively. Results A series of seven online videos were created, topics included: how to support a breathless child, education on how we breathe, breathing patterns, symptom differentiation, breathlessness, rescue breathing techniques, and exercise. Each video has downloadable resources. Five children and four parents wrote blogs to share their experiences. A live online 12-week physiotherapy program was developed on a web-based platform www.beamfeelgood.com called Asthma Kids. Conclusion Co-design enabled partnership working to develop hybrid telehealth physiotherapy services and prototype interventions to support home practice for children with asthma and dysfunctional breathing.

47 Association between unmet social needs and parental stress in a paediatric asthma clinic

Abstract Background There are well documented associations between unmet social needs and undesirable health outcomes, but little data exist on the association between unmet social needs and stress in families of children with asthma. Objectives To document the relationship between unmet social needs and parental stress in a Canadian paediatric asthma clinic. Design/Methods Ongoing prospective observational study to determine the association between unmet social needs and parental stress was conducted in a tertiary care paediatric asthma clinic, between September 2022 and September 2023. Participants were parents of children with a diagnosis of asthma, treated with at least one controller medication. Unmet social needs were collected by parental self-report using a questionnaire assessing 8 domains: employment, housing, ability to pay for utilities, financial resources, food security, transportation, childcare, and education. The four-item Perceived Stress Scale was used to assess how parents perceived stress and how they felt they were able to manage situations in their lives. Chi-square tests compared our independent variable, the presence vs. absence of unmet social needs, to our dependent variables; each measure of stress (control over important aspects of ones’ life, confidence in ability to overcome problems, feeling that everything was going well, ability to overcome too many accumulated difficulties). Results Of 162 participants, seventy-seven (48%) reported at least one unmet social need. Compared to participants without unmet social needs, those with unmet needs were more likely to report having no control over important aspect of their work or main activity (p< 0.001); less likely to report having confidence in their ability to overcome problems (p< 0.001); less likely to report having the feeling that everything was going well (p< 0.001); and less likely to report having the ability to overcome too many accumulated difficulties (p< 0.001). Conclusion Findings suggest significant association between unmet social needs and parental stress of asthmatic children. Parental stress and unmet needs may concomitantly increase the burden of adhering to asthma controller medication, making adherence more challenging through pathways related to the interactions between cognitive burden and precarious living situations. This ongoing Canadian study seeks to elucidate the mechanisms by which these factors make adherence to asthma medication more challenging for families, so these challenges can be addressed.

Determining Adherence to Inhaled Corticosteroids From the Epic Electronic Medical Record

OBJECTIVE Often we call the patient’s pharmacy to obtain a refill history to assess inhaled corticosteroid (ICS) adherence. The purpose of this project was to determine the accuracy of refill histories for ICS (with or without long-acting beta agonist) listed in Epic’s Medication Dispense History. METHODS We evaluated 61 patients and used data from 38 who met the following criteria: 1) under the care of the UF Pediatric Severe Asthma Clinic; 2) taking the same dose of the same ICS product for 6 months before the patient’s last clinic visit; and 3) having data available from the pharmacy where the last ICS prescription was electronically sent. We called the pharmacies to obtain a verbal report of their refill record. Then, we compared the number of refills reported to the number listed in Epic’s records using a Wilcoxon matched-pairs signed-ranks test. RESULTS Of the 293 refill dates listed in Epic, 157 were duplicates, giving a 54% error. After deleting duplicates, the mean (SD) number of refills listed in Epic was 3.6 (2.0) compared with 3.3 (2.0) in pharmacies over a period of 6 months (p < 0.0001). After removing duplicates Epic correctly reported the total number of refills for 30 of the 38 patients (78.9%). Seven of the remaining patients had more refills listed in Epic while 1 patient had more refills dispensed. CONCLUSION This study indicates that our version of Epic over-reports refills thus limiting assessment of adherence. In contrast, absence of refills in Epic is a clear indication of poor adherence.

Effects of In-Home Environmental Interventions for an Urban Multidisciplinary Pediatric Asthma Clinic in Chicago on Asthma Control

Effects of In-Home Environmental Interventions for an Urban Multidisciplinary Pediatric Asthma Clinic in Chicago on Asthma Control

Perspectives and experiences of mothers of school-age children with asthma: a qualitative study

Introduction and Aims This study aimed to explore the perspectives and experiences of mothers of school-age children with asthma in care. Methods A phenomenological study was conducted using qualitative research methods from August 2021 to November 2021. Mothers (from Sichuan, China) of school-aged children with asthma who sought outpatient care at the pediatric asthma clinic were purposively sampled based on their occupation, education level, and duration of their child’s illness. Semi-structured face-to-face interviews were conducted in consultation room A07 of the pediatric asthma clinic. The interviews were audio-recorded, transcribed verbatim, and analyzed thematically. Results 23 mothers expressed interest, but data saturation was reached after recruiting 15 mothers.Four main themes encompassing ten sub-themes emerged from the analysis: (1) Negative psychological burden, with sub-themes including anxiety shock, fear of death, guilt, and stigma. (2) Family dysfunction, with sub-themes including impaired quality of life, family emotional crisis, and heavy economic burden. (3) Difficulty in seeking medical treatment. (4) Active response, with sub-themes including emotional adjustment, family empowerment, and social support. Conclusions In this sample, the caregiving experience of mothers of school-age children with asthma is diverse and complex, reflected not only in personal psychological aspects but also in family functioning and social support. Taking into account various factors, such as addressing psychological well-being, emphasizing family and social support, and promoting the sharing of positive experiences, may result in more effective alleviation of caregiving stress for mothers of school-age children with asthma.

Implementing paediatric patient-reported outcome measures in outpatient asthma clinics: a feasibility assessment study

ObjectiveImplementation of patient-reported outcome measures (PROMs) is limited in paediatric routine clinical care. The KidsPRO programme has been codesigned to facilitate the implementation of PROMs in paediatric healthcare settings. Therefore,...

Implementation of a pediatric synchronous multidisciplinary severe asthma clinic and real-world outcomes

Implementation of a pediatric synchronous multidisciplinary severe asthma clinic and real-world outcomes

Assessment and management of anxiety and depression in a pediatric high-risk asthma clinic.

The aims of this study were to determine the prevalence of positive mental health (MH) screens in a pediatric high-risk asthma (HRA) clinic population, and to determine the success rate of engagement in MH services before and after adding a clinical psychologist to our multidisciplinary clinic. We hypothesized that the HRA population would have a higher prevalence of anxiety/depression symptoms than that previously reported for the general pediatric asthma population. We anticipated that the presence of an embedded psychologist in HRA clinic would facilitate successful connection to MH services. Pediatric patients in the HRA clinic were prospectively screened for anxiety and depression using validated screening instruments. Positive scores were referred for MH services. Time to MH service engagement was recorded before and after the addition of a clinical psychologist. A total of 186 patients were screened; 60% had a positive MH screen. Female sex was associated with higher median scores on both screening tools and higher likelihood of engagement in MH services. After addition of a clinical psychologist, new engagement in MH services increased (20% vs. 80%, p < 0.0001), and median time to engagement decreased (14.5 vs. 0.0 months, p = 0.003). There is a high prevalence of anxiety and depression in this pediatric HRA population. Success of engagement in MH services improved after a clinical psychologist joined our multidisciplinary team, suggesting access to care as a primary barrier to engagement.

Taking Control of the Breath: Prioritizing Childhood Asthma in Pakistan's Healthcare Agenda

Childhood asthma has emerged as a significant health concern in Pakistan, affecting the lives of many children and their families. Addressing this pressing issue requires prioritizing childhood asthma within the healthcare agenda of the country. This editorial aims to shed light on the importance of prioritizing childhood asthma, highlight the challenges faced, and propose strategies to enhance awareness, prevention, and management of this chronic respiratory condition. Childhood asthma imposes a substantial burden on affected children, their families, and the healthcare system in Pakistan. The prevalence of childhood asthma has risen significantly in recent years, with various factors such as environmental pollution, allergens, and urbanization contributing to its increasing incidence. Recognizing the burden and impact of childhood asthma is vital for developing targeted interventions and improving health outcomes. One of the key steps in tackling childhood asthma is raising awareness and promoting education about the condition. Empowering parents, teachers, healthcare professionals, and communities with knowledge about asthma triggers, symptoms, and proper management techniques is crucial. Public awareness campaigns, school-based initiatives, and community outreach programs can play a pivotal role in promoting asthma education and dispelling misconceptions surrounding the condition. Prevention plays a vital role in reducing the burden of childhood asthma. Implementing measures to minimize exposure to environmental triggers, such as air pollution, tobacco smoke, and indoor allergens, is essential. Collaborative efforts between the government, environmental agencies, and healthcare institutions can help establish policies and regulations aimed at reducing asthma triggers and promoting a cleaner and healthier environment for children. Access to quality healthcare services is crucial for effective management of childhood asthma. However, barriers such as limited availability of specialized care, high medication costs, and lack of trained healthcare professionals pose significant challenges. It is imperative to prioritize the development of pediatric asthma clinics, ensure the availability of affordable medications, and enhance the training of healthcare providers in asthma management. Additionally, telemedicine and digital health solutions can bridge the gap in access to care, particularly in remote areas. Collaboration among healthcare providers, researchers, policymakers, and international organizations is essential to address the complexities of childhood asthma. Robust research efforts should be encouraged to understand the epidemiology, risk factors, and genetic determinants of asthma in the Pakistani population. These research findings can guide the development of targeted interventions, personalized treatment approaches, and prevention strategies. Taking control of childhood asthma requires a multi-faceted approach that includes prioritizing awareness, prevention, and access to quality care. By incorporating childhood asthma into Pakistan's healthcare agenda, we can empower children and their families to manage the condition effectively, reduce asthma-related complications, and enhance their overall quality of life. Together, let us work towards a future where every child in Pakistan breathes easy and thrives despite the challenges posed by asthma. How to Cite This: Rai VR. Taking Control of the Breath: Prioritizing Childhood Asthma in Pakistan's Healthcare Agenda. Isra Med J. 2022; 14(4): 167. DOI: https://doi.org/10.55282/imj.ltr.34

Implementation of caregiver depression screening in an urban, community-based asthma clinic: a quality improvement project

Objective Caregiver depressive symptoms are prevalent among children with asthma and associated with greater asthma morbidity. Identifying caregivers with depression and connecting them to appropriate treatment may reduce child asthma morbidity. The goal of this project was to implement a workflow for caregiver depression screening and treatment referral in an urban, community-based, asthma clinic serving under-resourced children. Methods The Model for Improvement with weekly Plan-Do-Study-Act cycles was utilized. A two-item depression screening tool (Patient Health Questionnaire-2; PHQ-2) and an acceptability question using a 5-point Likert scale were added to an existing social needs screening checklist administered to all caregivers during the child’s clinic visit. Caregivers with a positive PHQ-2 score (≥3) received the PHQ-9. Positive screens on the PHQ-9 (≥5) received information and referrals by level of risk. PHQ-9 positive caregivers received a follow-up phone call two weeks post-visit to assess connection to support, improvement in depressive symptoms, and satisfaction with resources provided. Results The PHQ-2 was completed by 84.4% of caregivers (233/276). Caregivers had a mean age of 33.8 years (SD = 8.3; Range: 18–68) and were predominately female (86.4%), Black (80.4%), and non-Hispanic (78.4%). The majority (72.3%) found the screening acceptable (agree/strongly agree). Nearly one in six caregivers (37/233, 15.9%) reported depressive symptoms (PHQ-2 ≥ 3); 11.6% (27/233) had clinically significant symptoms (PHQ-9 score ≥ 10); and 2.1% (5/233) reported suicidal thoughts. Of those with depressive symptoms, 70.3% (26/37) participated in the follow-up phone call. While 50% (13/26) reported the resources given in clinic were “extremely helpful,” no caregivers contacted or used them. Conclusions Caregiver depression screening was successfully integrated into a pediatric asthma clinic serving under-resourced children. While caregivers found screening to be acceptable, it did not facilitate short-term connection to treatment among those with depressive symptoms.

Electronic screening for unmet social needs in a pediatric pulmonary clinic: Acceptability and associations with health outcomes.

Children with unmet basic needs experience worse health than more advantaged counterparts. There has been limited research on screening for unmet basic needs in pediatric subspecialty care. Caregivers of established patients in pediatric asthma and cystic fibrosis (CF) clinics were screened for unmet basic needs with an electronic survey, which asked about concerns and stress level (5-point Likert scale) related to food, housing, transportation, health insurance, and childcare, among others. Medical record review provided patient demographic characteristics and clinical data. A follow-up survey with the clinical providers assessed the acceptability of electronic screening for unmet needs. The sample included 214 pediatric patients (N = 105 asthma, N = 109 CF) and their caregivers. Most patients with asthma (76%) were Black, 30% in households with <$20,000 annual income. In contrast, most patients with CF (93%) were white, 12% in households with <$20,000 annual income. Reported needs included food insecurity (29% asthma and 17% CF), healthy food (75% asthma and 87% CF), financial insecurity (45% asthma and 32% CF), health insurance (15% asthma and 28% CF), smoke exposure (24% asthma and 28% CF), child's exercise (21% asthma and 28% CF), living conditions (18% asthma and 17% CF), childcare (11% asthma and 15% CF), transportation (16% asthma and 9% CF), and housing insecurity (10% asthma and 8% CF). Concerns were rated moderately to very stressful. Food insecurity, financial insecurity, and smoke exposure were significantly associated with uncontrolled asthma. In people with CF, concerns about health insurance and child exercise were significantly associated with lower lung function and increased odds of hospitalizations. Clinicians believed that screening was important and should be administered by a designated person on the clinical team. Unmet basic needs and associated stress levels are linked to adverse pediatric pulmonary outcomes. Electronic screening, without face-to-face interaction or paper trail, facilitates high response rates and is easily integrated into clinic flow. Such screenings can identify vulnerable patients for targeted interventions and referral to available community resources.

Assessment of Anxiety and Depression in a Pediatric High-Risk Asthma Clinic

The prevalence of anxiety and depression is increased in asthmatics compared to healthy controls. The aims of this study were to determine the prevalence of positive mental health (MH) screens in the pediatric high-risk asthma (HRA) clinic population, and to determine the success rate of patient engagement in MH services before and after adding a clinical psychologist to our multi-disciplinary clinic.

A mobile health intervention for improving the technique of inhaled medications among children with asthma: A pilot study.

BreatheSuite MDI is a Bluetooth-enabled inhaler attachment and mobile application which aims to improve asthma control. The objective was to compare pressurized metered dose inhaler (pMDI) technique and asthma control test (ACT) scores pre- and post-use of the device and mobile application. Secondary objectives were to assess user satisfaction and therapy adherence. Patients between the ages of 8 and 18 were recruited from several pediatric asthma clinics. Technique and ACT scores were assessed at baseline. Users were given no prompts on technique during the first month of device use. For the subsequent three months, users were given technique scores through the mobile application after each inhaler use and provided weekly performance summaries. At the end of the study, technique and ACT scores were analyzed and an exit survey was completed. Conditional logistic regression was used to examine the association between well-controlled asthma (ACT score > 19) and the intervention. 24 patients completed the study. Technique scores improved following the use of Breathesuite (44.19 vs. 62.54; P = 0.01). Well-controlled asthma did not significantly improve (OR = 1.20 [0.4-3.9], P = 0.76). 87% of study subjects agreed or strongly agreed that their asthma control improved while using BreatheSuite; 79% were satisfied with the device and mobile application; and 91% preferred using the device compared to a standard logbook to track inhaler usage. In this pilot study, the use of BreatheSuite device was associated with improved technique scores. These results need to be confirmed by a randomized controlled trial. There was high user satisfaction with the BreatheSuite device.

Quality of life assessment in children and their caregivers suffering from allergic rhinitis and/or asthma

INTRODUCTION: Asthma and allergic rhinitis (AR) are among the most prevalent diseases worldwide and they frequently persist throughout the life. These have significant effect on physical, financial, and mental wellbeing of patients and caregivers. There have been few attempts previously, assessing the quality of life (QOL) in affected families suffering from these diseases. However, the data from developing countries are scarce. QOL assessment in children and caregivers of patients suffering can help in symptomatic management and provide inputs for the better utilization of resources to achieve optimal treatment. MATERIALS AND METHODS: Patient and caregiver QOLs were ascertained using Mini Pediatric Asthma QOL Questionnaire and Pediatric Asthma Caregiver's QOL Questionnaire, respectively, in the study and correlated with disease severity and chronicity using the parametric and nonparametric statistical tools. RESULTS: There were 246 pairs of children diagnosed with asthma and/or AR and their caregivers attending the pediatric allergy and asthma clinic. Symptom score, emotional domain, and activity limitation in children did not validate a statistically significant difference in QOL in the various grades of AR/asthma/AR with asthma (P = 0.632) (P = 0.772) (P = 0.496) (P = 0.918) (P = 0.384) and (P = 0.561), respectively. In addition, there was no significant correlation between the severity of asthma and caregiver emotional disturbance (P = 0.594) or caregiver activity limitation (P = 0.446). CONCLUSIONS: QOL in children and caregivers where children are suffering from either AR or asthma, or both has not shown any significant difference as per the disease severity or chronicity in various domains. There was no significant difference in QOL noted as per the change in age group, gender of patients, or education status of caregivers.

Physical activity and quality of life in children with well-controlled asthma

Background Asthma is the most common disease in childhood. Appropriate management and programs encouraging exercise enable children to enjoy a good quality of life (QoL). Objective To assess the association between lung function, physical activity (PA), and QoL in children with well-controlled asthma. Methods Fifty-four children aged 7–14 years attending a Pediatric Asthma Clinic were included. All children underwent spirometry and completed three self-administered validated questionnaires: The Godin Leisure-Time Exercise Questionnaire (GLTEQ), the ACT (Asthma Control Test), and the DISABKIDS for QoL. Results Mean age of the study population was 11.43(±2.1), BMI, kg/m2 (20.8 ± 3.9), FVCpp (97.1% ±12.4), and FEV1pp (99.7% ±12.43), ACT (23.4 ± 3). The GLTEQ revealed that only 3% of the studied population presented satisfactory activity, while 86% were sedentary. Both FEV1pp, and PA were significantly correlated to the children’s QoL ((r2: 0.55, p:0.0001), and (r2:0.45, p:0.003), respectively). Conclusions Despite reasonable asthma control, the children exhibited low physical activity levels, which negatively correlated to their QoL. Families of asthmatic children should be educated to highlight the benefits of exercise and increase the PA of their children.

Patient-reported outcome measures in pediatric asthma care: using theoretical domains framework to explore healthcare providers’ perceptions

BackgroundPatient-reported outcome measures (PROMs) play an important role in promoting and supporting patient and family-centered care. Implementing interventions like PROMs in routine clinical care require key stakeholders to change their behavior. The aim of this study was to utilize the Theoretical Domains Framework (TDF) to identify barriers and enablers to the implementation of PROMs in pediatric outpatient asthma clinics from healthcare providers’ perspective.MethodsThis TDF-guided qualitative descriptive study is part of a larger multi-phase project to develop the KidsPRO program, an electronic platform to administer, collect, and use PROMs in pediatrics. Semi-structured qualitative interviews were conducted with 17 participants, which included pediatricians, nurses, allied health professionals and administrative staff from outpatient asthma clinics. All the interviews were transcribed, deductively coded, inductively grouped in themes, and categorized into barriers and enablers.ResultsWe identified 33 themes within 14 TDF domains, which were further categorized and tabulated into 16 barriers and 17 enablers to implementing PROMs in asthma clinics. Barriers to behavioral change were attributed to personal, clinical, non-clinical, and other system-level factors; they ranged from limited awareness of PROMs to language barriers and patient’s complex family background. Enablers ranged from a personal commitment to providing patient and family-centered care to administering PROMs electronically.ConclusionThis implementation of science-based systematic inquiry captured the complexity of PROMs implementation in pediatric outpatient clinical care for asthma. Considering the consistency in barriers and enablers to implementing PROMs across patient populations and care settings, many findings of this study will be directly applicable to other pediatric healthcare settings.

NSAID-Exacerbated Respiratory Disease in Pediatric Severe Asthmatic Population

Non-steroidal anti-inflammatory drugs-exacerbated respiratory disease (NERD) is described as the classic triad of asthma, nasal polyps, and NSAID sensitivity. Previous studies have shown variable prevalence (0.3% - 5%) in pediatric populations and different presenting symptoms compared to adults. We evaluated the prevalence of NERD in our pediatric severe asthma clinic and identified the most common presenting symptoms and associated risk factors in those diagnosed with NERD.

Assessment of airway reversibility in asthmatic children using forced oscillation technique - A single-center experience from North India.

Background:Lung function testing is recommended for the management of asthma. Due to certain limitations of conventional spirometry in vulnerable patients, forced oscillation technique (FOT) has been studied with promising results. As there is a paucity of data from developing world, we planned to conduct this study in children using FOT. To assess airway reversibility after inhaled salbutamol in asymptomatic children with suspected asthma.Settings:This study was conducted at pediatric asthma clinic of a tertiary care referral hospital in North India.Design:This was a prospective interventional study over 1-year period.Subjects and Methods:Asymptomatic children between 2 and 18 years of age, with history suggestive of asthma, were eligible for participation. Baseline and postbronchodilator pulmonary functions were assessed using FOT. Airway resistance and reactance were monitored at various frequencies. SPSS version 17 was used for statistical analysis.Results:Among the 345 enrolled children, baseline mean ± standard deviation total airway resistance (R5), central airway resistance (R19), peripheral airway resistance (R5–R19), reactance (X5), and resonant frequency (Fres) were 6.85 ± 2.60, 5.23 ± 1.93, 1.6 ± 1.16, and − 2.54 ± 1.36 cmH2O/L/s and 17.28 ± 3.06 Hz. The median (interquartile range) percentage change after inhaled salbutamol was 19.9 (11.40, 29.12), 22.86 (6.88, 38.76), 14.08 (3.40, 22.62), 39.20 (8.20, 62.39), and 15.79 (8.33, 27.27) in respective parameters. All changes were statistically significant. The studied respiratory variables were in maximum negative correlation with height, followed by body mass index.Conclusions:FOT is a simple technique for monitoring lung functions in children during asthma management.

Creation of a Novel Shared Decision-Making Tool in Pediatric High-Risk Asthma Clinic

Best practices regarding communication using shared-decision making (SDM) strategies in pediatric high-risk asthma remain unexplored. This project examines whether the addition of a written communication tool based on principles of SDM facilitates improves communication between patient families and the care team in a pediatric high-risk asthma clinic (HRA), when compared to established communication practices.

Asthma control and psychological health in pediatric severe asthma.

Psychological comorbidities have been associated with asthma in adults and children, but have not been studied in a population of children with severe asthma. The aim of this study was to test the hypothesis that symptoms of anxiety or depression are highly prevalent in pediatric severe asthma and negatively effects asthma control. Longitudinal assessments of anxiety or depression symptoms (Patient Health Questionnaire-4 [PHQ-4]), asthma control (Asthma Control Test [ACT]), and lung function were performed in a single-center pediatric severe asthma clinic. Participant data were collected during routine clinical care. Primary outcomes were ACT and forced expiratory volume in 1 s per forced vital capacity (FEV1/FVC). Among 43 subjects (with total 93 observations), 58.1% reported at least one anxious or depressive symptom and 18.6% had a PHQ-4 more than 2, the threshold for an abnormal test result. After adjusting for age, sex, race, and asthma medication step, there was a significant reduction in ACT for girls with PHQ-4 more than 2 (adjusted mean [SE] ACT for PHQ-4 > 2: 13.64 [0.59], ACT for PHQ-4 ≤ 2: 20.64 [1.25], p = .02) but not boys. Moreover, there was a significant differential effect of mental health impairment for girls than boys. ACT for girls with PHQ more than 2: 13.64 (0.59) compared with boys with PHQ-4 more than 2: 17.82 (0.95), adjusted mean difference ACT by sex = 4.18 points; 95% confidence interval, 0.63-7.73; p = .033. In adjusted models, there was no association between PHQ-4 more than 2 and FEV1/FVC. Symptoms of anxiety and depression are common. In children with severe asthma, a PHQ-4 score more than 2 is associated with worse asthma symptom control in girls, but not boys.