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Article history: Background: Emotional stress triggers and exacerbates asthma in children. Reducing
Received 14 August 2008 anxiety in adults by relaxation-breathing techniques has been shown in clinical trials to
Received in revised form 12 January 2009 produce good asthma outcomes. However, more evidence is needed on using this
Accepted 24 January 2009
intervention with asthmatic children.
Objective: To evaluate the effectiveness of combined self-management and relaxation-
Keywords: breathing training for children with moderate-to-severe asthma compared to self-
Anxiety
management-only training.
Children
Design: Two-group experimental design.
Asthma
Relaxation-breathing training Setting and participants: Pediatric outpatient clinic of a medical center in central Taiwan.
Chronic illness Participants were 48 children, ages 6–14 years, with moderate-to-severe asthma and their
parents.
Methods: Participants were randomly assigned to an experimental or comparison group
and matched by gender, age, and asthma severity. Both groups participated in an asthma
self-management program. Children in the experimental group were also given 30 min of
training in a relaxation-breathing technique and a CD for home practice. Data on anxiety
levels, self-perceived health status, asthma signs/symptoms, peak expiratory flow rate,
and medication use were collected at baseline and at the end of the 12-week intervention.
Effects of group, time, and group–time interaction were analyzed using the Mixed Model
in SPSS (12.0).
Results: Anxiety (especially state anxiety) was significantly lower for children in the
experimental group than in the comparison group. Differences in the other four
physiological variables were also noted between pre- and post-intervention, but these
changes did not differ significantly between groups.
Conclusions: A combination of self-management and relaxation-breathing training can
reduce anxiety, thus improving asthmatic children’s health. These results can serve as an
evidence base for psychological nursing practice with asthmatic children.
ß 2009 Elsevier Ltd. All rights reserved.
0020-7489/$ – see front matter ß 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijnurstu.2009.01.013
1062 L.-C. Chiang et al. / International Journal of Nursing Studies 46 (2009) 1061–1070
parasympathetic nerve impulses and lead to a slower heart were recruited from patients at the asthma clinic by a well-
rate, more regular respiration, and general relaxation trained research assistant (RA). Children were included in
(Lehrer, 1998). the study if they met these criteria: (1) diagnosed with
It is important to note that the efficacy of asthma- moderate-to-severe asthma by a physician at least 6
management techniques has been measured by a sig- months before the study, (2) had >5 asthmatic episodes
nificant number of researchers using only physiological per year, with an Aas score of 2 (Aas, 1981), and (3)
indicators—that is, their results do not directly address regularly treated with asthma medication in a pediatric
psychological indicators. When studying asthma manage- clinic. Children were excluded if they had participated in
ment in children and adolescents, psychosocial interven- any other clinical trials. Potential participants were given a
tions should be emphasized (Malhi, 2001), and complete description of the study. Those who agreed to
intervention studies that address physiological, beha- participate provided written informed consent.
vioral, and psychological variables provide evidence in The Aas asthma severity score is a 5-step clinical score
support of holistic nursing approaches to this chronic that assesses the frequency and duration of asthma attacks
disease. Indeed, relaxation training of 46 school-aged during the previous year (Aas, 1981). A score of 1 (mild
children successfully reduced levels of anxiety (Lamon- asthma) indicates <5 asthma attacks, each lasting <7 days,
tagne et al., 1985). Furthermore, levels of dysphasia were and no functional limitation. A score of 2 (moderate
reduced in 17 children and adolescents (ages 8–18) who asthma) indicates <10 attacks, each lasting <7 days, and
were taught a relaxation technique based on self-induced no functional limitation. A score of 3 (moderate asthma)
hypnosis (Ran, 2001). indicates >10 attacks, each lasting <7 days, and no
Based on this background, the purpose of the present functional limitation. A score of 4 (severe asthma)
study was to examine the effectiveness of teaching a indicates >5 attacks, chronic cough, and hospitalization.
combination of self-management and relaxation-breath- A score of 5 indicates chronic malfunctioning asthma,
ing techniques to children with moderate-to-severe acute exacerbation, and the need for continuous medica-
asthma. The results from an experimental intervention tion treatment. Therefore, an asthmatic child with an Aas
(self-management plus relaxation training) were com- asthma severity score >2 has had >5 attacks in the
pared with results from the self-management-only pro- previous year.
gram currently favored by Taiwanese asthma clinics. To provide high quality care, all participating children
Outcome measures were anxiety, perceived health status, and parents received the medical center’s routine asthma
asthma signs/symptoms, peak expiratory flow rate (PEFR), self-management program and an asthma-management
and asthma medication usage. The two hypotheses tested teaching booklet. After receiving the asthma self-manage-
were as follows: ment program, children and parents in the experimental
group also received relaxation training in a separate room.
1. Changes in physiological and psychological outcome In general, matching is used to make sure that
measures between pre- and post-intervention are the participants in various research groups are equivalent on
same for both the experimental and comparison groups one or more characteristics (Polit and Beck, 2005). The
(i.e., the group time interaction is not significant). characteristics previously found to influence asthma self-
2. Physiological and psychological outcome measures do management, physical activity, and quality of life were
not change in either group from pre- to post-interven- gender (Chiang et al., 2006a,b), age (young children or pre-
tion (i.e., the self-management program does not have a adolescents) (Miles et al., 1995), and asthma severity
significant time effect). (Chiang et al., 2006a,b). Therefore, children were randomly
assigned to the experimental or comparison groups using a
2 2 3 randomized block design (2 genders, 2 age ranges
2. Methods
(6–10 and 11–14 years old), and 3 asthma severity scores (2,
2.1. Design 3, 4) (Aas, 1981)). This randomization procedure was
confidentially conducted by an administrator in the clinic.
A two-group experimental design was used to evaluate The first eligible child was assigned by a coin toss to the
the effectiveness of relaxation-breathing training com- experimental or comparison group using the block
bined with a self-management program in children with randomization scheme. If the first child was a girl, aged
asthma. Children in both the experimental and comparison 6–10 with an Aas score of 3, she would be randomly
groups received explanations of asthma disease, asthma assigned by coin toss into the experimental or comparison
medication, and monitoring with peak flow meters, but group. Then the next girl, aged 6–10 with an Aas score of 3,
only those in the experimental group received relaxation- would be assigned to the other group. The assignment
breathing training. Interventions lasted for 12 weeks per continued until all participants were assigned to each
participant, with data for five outcome indicators collected group. This procedure removed the variance due to gender,
at the beginning and end of each intervention. age, and asthma severity from the error term, increasing
the power of the study. A list of treatment assignments
2.2. Participants linked with case number was generated and kept by the
first author and the study statistician. The codes and
All asthmatic children who participated in this study treatment assignments were not released to any subjects,
were recruited from the pediatric asthma clinic of a staff, and pediatric physicians other than those mentioned
medical center in central Taiwan. Potential participants until the completion of data analysis.
1064 L.-C. Chiang et al. / International Journal of Nursing Studies 46 (2009) 1061–1070
Of the 65 families who met the inclusion criteria, 3 and SDs were obtained from a small pilot study. Placing
families refused to participate or their questionnaires were these values into the following formula (Muellner, 2002):
incomplete at pre-test. From the remaining 62 families, 29 ðz1 þ z2 Þ2 ðs21 þ s22 Þ
children were randomly assigned to the experimental nðper groupÞ ¼
ðm1 m2 Þ2
group and 33 children to the comparison group. Another
three families in the experimental group did not complete produced an overall sample size of 40, with 20 in each
the asthma self-management program and relaxation group.
training. Unfortunately, four families in the experimental The children who dropped out and participating
group and seven families in the comparison group were children were not significantly different in terms of gender
lost to the 3-month follow-up. Thus, the final sample (x2 = 0.677, p = 0.513), age (x2 = 0.250, p = 0.720), and Aas
included 22 children in the experimental group and 26 in score (x2 = 2.471, p = 0.291). Because of dropouts, it was
the comparison group (Fig. 1). necessary to check the homogeneity of the two groups in
Our power analysis, based on Cohen (1992) suggested terms of gender, age, and asthma severity. This analysis
criteria for comparing the means of two groups with a large showed no significant differences between the experi-
effect size and a = 0.05, indicated that the necessary mental and comparison groups (Table 1).
sample size was 26 for each group. Although 59 children
were recruited for the study, 11 families dropped out. The 2.3. Interventions
sample size was then re-calculated using the following
parameter values: Type I error of 5% (z1 = 1.96), power of The comparison and experimental groups received
80% (z2 = 0.842), mean values (m1 = 17.00 and m2 = 11.00), different interventions: only the routine self-management
and standard deviations (s1 = 7.0 and s2 = 6.8). The means program offered by a graduate nurse student after medical
validity of the CCAS (Tseng, 1993) the test–retest reliability medication once per week over 4 weeks received 1 point
for the CCMAS was 0.78 and for the GASCC was 0.72 for and more than twice per week 2 points, 2 use theophylline
boys and 0.76 for girls. or Singullair1 received 2 points, and use of an oral steroid
received between 3 and 5 points (3 for <3–5 days/4 weeks,
2.5.2. Self-perceived health status 4 for 6–10 days, and 5 for >10 days).
Self-perceived health status was measured by four
items adapted from the Perceived Health Status Scale 2.6. Data analysis
(Kaplan and Camacho, 1988). Responses to items were
measured on a 5-point Likert scale from 1 (very bad) to 5 All data were analyzed (descriptive and inferential
(very good). In this study, internal consistency (Cronbach’s statistics) using SPSS (12.0) for Windows. Demographic data
a) was 0.71. of the experimental and comparison groups were compared
using Chi-Square analysis. The SPSS Mixed Model was used to
2.5.3. Asthma signs/symptoms analyze scores for anxiety, self-perceived health status,
The signs/symptoms checklist used in this study was asthma signs/symptom, medication usage, and PEFR for
modified from an asthma symptom diary (Santanello et al., differences between the two groups and within each group
1999). The checklist includes four items: ability to sleep at over the 12-week intervention. To reduce problems in
night (1 item) and daytime symptoms of persistent repeated measurements, the mixed model technique is
coughing, wheezing, and dyspnea (3 items). Responses better than the General Linear Model in overcoming missing
to items were recorded by parents on a 4-point scale data in some variables at follow-up and limited availability of
according to the frequency of asthma signs/symptoms. variance–covariance structures (Chan, 2004). These types of
Lower scores indicate better control of asthma signs/ designs are called mixed-model ANOVAs, since they involve
symptoms. In this study, internal consistency (Cronbach’s a mixture of one between-groups factor and one within-
a) was 0.71. groups factor. This type of analysis is better than traditional
analysis, i.e., a two-way ANOVA, which combines one
2.5.4. Peak expiratory flow rate (PEFR) independent-sample factor and one correlated-group factor.
PEFR was measured in participating children twice each
day using Astech1 peak flow meters (Dey, L.P., Napa, CA),
3. Results
which are used in Taiwanese asthma clinics. PEFR is
recorded as the best of three trials. Results from spirometric 3.1. Participant characteristics
measures indicated a Pearson correlation r = 0.313
(p < 0.05) between PEFR and the score on the asthma In the final sample of 48 children and their parents, 22
signs/symptoms checklist used in this study and r = 0.682 were in the experimental group, and 26 were in the
(p < 0.001) between PEFR and FEV1 by Micro-Medical Super comparison group. Both groups had a majority of boys
Spiro CE120, SN1141. The children were trained in the self- (experimental: 68.2%; comparison: 57.7%), consistent with
management program to correctly use the PEF meter. the high prevalence of boys having asthma (Chiang et al.,
2007). Each group also had a majority (experimental:
2.5.5. Asthma medication usage 72.7%; comparison: 76.9%) of young children (6–10 years
Use of asthma medications was assessed by the Asthma old) and a minority (experimental: 22.7%; comparison:
Medication score, based on a treatment ladder established 15.4%) of children with emotion-induced asthma (Table 1).
according to Global Initiative for Asthma guidelines
(National Heart, Lung and Blood Institute, 2007). Higher 3.2. Outcome variables
scores indicate greater dosage and/or stronger asthma
medications. Scores for participants in this study ranged Data for each variable at the beginning and end of the
from 0 to 14, with scoring methods focused on monthly 12-week intervention are presented in Table 2. Psycholo-
drug dose. Use of a prophylactic medication in the gical indicators (total anxiety) for the experimental group
preceding month received 1 point, use of a beta-agonist decreased on average over the 12-week intervention (from
Table 2
Descriptive statistics for pre- and post-intervention outcomes for asthmatic children.
Children’s anxiety 22 31.73 (12.27) 23 29.96 (11.96) 18 26.11 (11.41) 19 32.21 (17.76)
CCMASa 22 16.64 (6.86) 23 14.74 (7.37) 18 12.67 (7.15) 19 15.77 (10.45)
GASCCb 22 15.09 (6.57) 23 15.22 (6.02) 16 13.88 (6.08) 19 16.21 (8.64)
Health status 22 15.19 (3.20) 26 15.43 (3.80) 20 18.55 (3.39) 17 17.82 (4.02)
Asthma signs/symptoms 22 9.46 (2.11) 26 10.44 (1.95) 20 6.93 (1.51) 17 7.24 (1.71)
PEFR 22 227.05 (71.69) 26 186.73 (46.80) 20 282.50 (76.72) 17 240.12 (63.62)
Asthma medication 20 5.10 (3.34) 18 4.17 (2.68) 20 2.75 (2.84) 18 1.94 (2.18)
a
CCMAS: Chinese Children’s Manifest Anxiety Scale.
b
GASCC: General Anxiety Scale for Chinese Children.
L.-C. Chiang et al. / International Journal of Nursing Studies 46 (2009) 1061–1070 1067
a score of 31.73–26.11), but increased on average for the post-intervention in the experimental group than in the
comparison group (29.96–32.21). Tendency to anxiety comparison group (by 5.62/2.25 and 3.97/1.03, respec-
(CCMAS scores) in the experimental group was decreased tively). However, trait anxiety (GASCC) scores did not differ
on average (16.64–12.67), but increased in the comparison significantly between groups. The results indicate that
group (14.74–15.77). children in the experimental group had significantly less
Physiological indicators improved for both groups total anxiety than their comparison group counterparts
over the 12-week interventions. Specifically, health status (t = 2.27, p < 0.05). Therefore, relaxation-breathing train-
improved (15.19–18.55 in the experimental group; 15.43– ing appears to have exerted a positive effect on general
17.82 in the comparison group), asthma signs/symptoms tendency to anxiety but not on trait anxiety.
were reduced (9.46–6.93 in the experimental group; Physiological indicators improved after the 12-week
10.44–7.24 in the comparison group), PEFR increased interventions in both groups (health status: t = 2.70,
(227.05–282.50 in the experimental group; 186.73–240.12 p < 0.01; asthma signs/symptoms: t = 5.84, p < 0.001;
in the comparison group), and less asthma medication was PEFR: t = 4.00, p < 0.001; asthma medication usage:
used (5.10–2.75 in the experimental group; 4.17–1.94 in t = 3.03, p < 0.01). However, the group time interaction
the comparison group). was not significant for any of the four physiological
The results from Mixed Model analyses are shown in variables (health status, asthma signs/symptoms, PEFR,
Table 3. Total anxiety and general tendency to anxiety asthma medication) although improvement over time was
(CCMAS) scores changed significantly more from pre- to evident for both groups (Table 4).
Table 3
Mixed Model evaluation of the effect of relaxation-breathing technique on anxiety.
Upper Lower
Children’s anxiety
Experimental group (comparison group) 7.44 4.33 1.72 0.091 16.10 1.22
Pre-intervention (post-intervention) 2.68 2.83 0.95 0.347 8.34 2.98
Group time interaction 9.21 4.05 2.27 0.027 1.11 17.32
CCMAS
Experimental group (comparison group) 4.07 2.52 1.62 0.111 9.10 0.97
Pre-intervention (post-intervention) 1.55 1.61 0.96 0.340 4.78 1.67
Group time interaction 5.96 2.51 2.58 0.012 1.34 10.59
GASCC
Experimental group (comparison group) 3.44 2.15 1.60 0.115 7.74 0.86
Pre-intervention (post-intervention) 1.08 1.50 0.72 0.475 4.07 1.92
Group time interaction 3.31 2.13 1.56 0.124 0.93 7.56
Table 4
Mixed Model evaluation of the effect of relaxation-breathing technique on physiological outcomes.
Upper Lower
Health status
Experimental group (comparison group) 0.52 1.18 0.45 0.657 1.83 2.88
Pre-intervention (post-intervention) 2.59 0.95 2.70 0.009 4.50 0.68
Group time interaction 0.77 1.33 0.58 0.567 3.42 1.89
Asthma signs/symptoms
Experimental group (comparison group) 0.28 0.61 0.46 0.644 1.50 0.93
Pre-intervention (post-intervention) 3.23 0.55 5.84 <0.000 2.13 4.33
Group time interaction 0.70 0.77 0.90 0.369 2.24 0.84
PEFR
Experimental group (comparison group) 39.14 20.35 1.92 0.059 1.51 79.78
Pre-intervention (post-intervention) 55.07 13.77 4.00 <0.000 82.57 27.57
Group time interaction 1.18 18.97 0.06 0.951 36.72 39.07
Asthma medication
Experimental group (comparison group) 0.81 0.91 0.88 0.381 1.02 2.63
Pre-intervention (post-intervention) 2.22 0.73 3.03 0.004 0.75 3.69
Group time interaction 0.13 1.01 0.13 0.900 1.90 2.15
and procedures must be established to ensure that the Devine, E.C., 1996. Meta-analysis of the effects of psychoeducational care
in adults with asthma. Research in Nursing & Health 19, 367–376.
intervention actually affects anxiety levels in asthmatic Erskine-Milliss, J., Schonell, M., 1981. Relaxation therapy in asthma: a
children over time. Parents or other caretakers need to be critical review. Psychosomatic Medicine 43, 365–372.
involved in the training to improve chances of success. Ernst, E., 2000. Breathing techniques: adjunctive treatment modalities for
asthma? A systematic review. The European Respiratory Journal 15,
Training programs can include (but are not limited to) the 969–972.
distribution of asthma care booklets and a CD containing Green, S., 1990. Power analysis in repeated measures analysis of var-
information on relaxation techniques for practice at iance with heterogeneity correlated trials. In: Paper presented at the
annual meeting of the American Educational Research Association,
home—a low-cost strategy for improving children’s Boston, MA.
physiological and psychological health. Further monitor- Guevara, J.P., Wolf, F.M., Grum, C.M., Clark, N.M., 2003. Effects of educa-
ing is required to measure the long-term effects of such a tional interventions for self management of asthma in children and
adolescents: systematic review and meta-analysis. British Medical
strategy.
Journal 14, 1308–1309.
Holloway, E.A., West, R.J., 2007. Integrated breathing and relaxation
training (the Pap worth method) for adults with asthma in primary
Acknowledgements care: a randomized controlled trial. Thorax 62, 1039–1042.
Huntley, A., White, A.R., Ernst, E., 2002. Relaxation therapies for asthma: a
This study was supported by grants from the National systematic review. Thorax 5 (2), 127–131.
Juniper, E.F., Guyatt, G.H., Feeny, D.H., Ferrie, P.J., Griffith, L.E., Townsend,
Science Council (No. NSC-92-2314-B039-019 and NSC-93- M., 1996. Measuring quality of life in children with asthma. Quality of
2314-B039-005) and China Medical University (No. CMU- Life Research 5, 35–46.
92-NS02), both of Taiwan, Republic of China. Kaplan, G.A., Camacho, T., 1988. Perceived health and mortality: a nine-
year follow-up of the Human Population Laboratory cohort. American
Journal of Epidemiology 117, 292–304.
Conflict of interest
Katon, W.J., Richardson, L., Lozano, P., McCauley, E., 2004. The relation-
None declared. ship of asthma and anxiety disorders. Psychosomatic Medicine 66,
349–355.
Funding Kemper, K.J., 2000. Complementary and alternative medicine for children:
This research was supported by grants from China does it work? Archives Disease in Childhood 84, 6–9.
Kern-Buell, C.L., McGrady, A.V., Conran, P.B., Nelson, L.A., 2000. Asthma
Medical University (No. CMU-92-NS02), National Science severity, psychophysiological indicators of arousal, and immune
Council (NSC-92-2314-B039-019 and NSC-93-2314-B039- function in asthma patients undergoing biofeedback-assisted relaxa-
005), Taiwan, Republic of China. tion. Applied Psychophysiology Biofeedback 25, 79–91.
Kohen, D.P., Wynne, E., 1997. Applying hypnosis in a preschool family
Ethical approval asthma education program: uses of storytelling, imagery, and relaxa-
tion. American Journal of Clinical Hypnosis 39 (3), 169–181.
This study was proved by the Institute of Review Board Kotses, H., Glaus, K.D., Bricel, S.K., Edwards, J.E., Crawford, P.L., 1978.
in China Medical University Hospital. Operant muscular relaxation and peak expiratory flow rate in asth-
matic children. Journal Psychosomatics Research 22, 17–23.
Lamontagne, L.L., Mason, K.R., Hepworth, J.T., 1985. Effects of relaxation
References on anxiety in children: implications for coping with stress. Nursing
Research 34, 289–292.
Aas, K., 1981. Heterogeneity of bronchial asthma, sub-populations- or Lehrer, P.M., 1998. Emotionally triggered asthma: a review of research
different stages of the disease. Allergy 36, 3–14. literature and some hypotheses for self-regulation therapies. Applied
Alexander, A.B., Cropp, J.A., Chai, H., 1979. Effects of relaxation training on Psychophysiology and Biofeedback 23, 13–41.
pulmonary mechanics in children with asthma. Journal of Applied Lehrer, P.M., Sargunaraj, D., Hochron, S., 1992. Psychological approaches
Behavior Analysis 12, 27–35. to the treatment of asthma. Journal of Consulting and Clinical Psy-
Castes, M., Hagel, I., Palenque, M., Canelones, P., Corao, A., Lynch, N.R., chology 60, 639–643.
1999. Immunological changes associated with clinical improvement Li, H.C., Lopez, V., 2005. Do trait anxiety and age predict state
of asthmatic children subjected to psychosocial intervention. Brain, anxiety of school-age children? Journal of Clinical Nursing 14,
Behavior, & Immunity 13 (1), 1–13. 1083–1089.
Castaneda, A., McCandless, B.R., Palermo, D.S., 1956. The children’s form of Lin, B.F., Yan, G.S., Mao, Y., Yan, Y.W., 1973. Refine the Chinese children
the manifest anxiety scale. Child Development 27 (3), 317–326. anxiety scale. In: Yan, G.S., Chang, C.X. (Eds.), The Development of
Chan, Y.H., 2004. Biostatistics 301A: repeated measurement analysis Chinese Children’s Behavior. Uniworld Publisher, Taipei, pp. 465–
(Mixed Models). Singapore Medical Journal 45, 354–369. 518.
Chiang, L.C., 2005. Exploring the health-related quality of life among Malhi, P., 2001. Psychosocial issues in the management and treatment of
children with moderate asthma. The Journal of Nursing Research children and adolescents with asthma. Indian Journal Pediatrics 68
13 (1), 31–40. (Suppl. 4), S48–S52.
Chiang, L.C., Chen, Y.H., Hsueh, K.C., Huang, J.L., 2007. Prevalence and Mathe, A.A., Knappe, P.H., 1971. Emotional and adrenal reactions to stress
severity of symptoms of asthma, allergic rhinitis, and eczema in 10- to in bronchial asthma. Psychosomatic Medicine 33, 323–340.
15-year-old schoolchildren in central Taiwan. Asian Pacific Journal of McQuaid, E.L., Nassau, J.H., 1999. Empirically supported treatments of
Allergy and Immunology 25, 1–5. disease-related symptoms in pediatric psychology: asthma, diabetes,
Chiang, L.C., Tseng, L.F., Huang, J.L., Fu, L.S., 2006a. Testing a Questionnaire and cancer. Journal Pediatrics Psychology 24, 305–328.
to measure Asthma-related quality of life among children. Journal of Miles, A., Sawyer, M., Kennedy, D., 1995. A preliminary study of factors
Nursing Scholarship 38 (4), 383–386. that influence children’s sense of competence to management their
Chiang, L.C., Huang, J.L., Fu, L.H., 2006b. Physical activity and physical self- asthma. Journal of Asthma 32 (6), 437–444.
concept: comparison between children with and without asthma. Muellner, M., 2002. Evidence-Based Medicine. Springer, Wein, New
Journal of Advanced Nursing 54 (6), 653–662. York.
Cohen, J., 1992. A power primer. Psychological Bulletin 112, 155–159. National Heart, Lung, and Blood Institute, 2007. Expert Panel Report 3:
Davis, M.H., Saunders, D.R., Creer, T.L., Chai, H., 1973. Relaxation guidelines for the diagnosis and management of asthma. Available at:
training facilitated by biofeedback apparatus as a supplemental http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf (accessed
treatment in bronchial asthma. Journal of Psychosomatic Research September 26, 2008).
17, 121–128. Norton, M., Holm, J.E., McSherry, W.C., 1997. Behavioral assessment of
Dennis, J., 2000. Alexander technique for chronic asthma. Cochrane relaxation: the validity of a behavioral rating scale. Journal of Beha-
Database of Systematic Reviews, CD000995. vioral Therapy and Experimental Psychiatry 28 (2), 129–137.
Deter, H.C., Allert, G., 1983. Group therapy for asthma patients: a concept Pagliari, C., Shuldham, C., Fleming, S., Churchill, R., 2002. Psychothera-
for the psychosomatic treatment of patients in a medical clinic—a peutic interventions for the children with asthma. The Cochrane
controlled study. Psychotherapy and Psychosomatics 40, 365–372. Database of Systematic Reviews, 3, No pagination.
1070 L.-C. Chiang et al. / International Journal of Nursing Studies 46 (2009) 1061–1070
Polit, D.F., Beck, C.T., 2005. Essentials of Nursing Research: Methods, Smith, J.R., Mugford, M., Holland, R., Candy, B., Noble, M.J., Harrison,
Appraisal, and Utilization. Lippincott Williams & Wilkins. B.D.W., Koutantji, M., Upton, C., Harvey, I., 2005. A syste-
Ran, A., 2001. Self-hypnosis for management of chronic dyspnea in matic review to examine the impact of psycho-educational inter-
pediatric patients. Pediatrics 107 (2), E21. ventions on health outcomes and costs in adults and children
Raymer, R., Poppen, R., 1985. Behavioral relaxation training with hyper- with difficult asthma. Health Technology Assessment 9 (23), 1–
active children. Journal of Behavioral Therapy and Experimental 167 iii–iv.
Psychiatry 16, 309–316. Stores, G., Ellis, A.J., Wiggs, L., Crawford, C., Thomson, A., 1997. Sleep and
Richter, R., Dahme, B., 1982. There is little evidence for the effectiveness of psychological disturbance in nocturnal asthma. Archives of Disease in
behavioral therapy and relaxation. Journal of Psychosomatics Childhood 78, 419–431.
Research 26, 533–540. Titlebaum, H., 1988. Relaxation. In: Zahourek, R.P. (Ed.), Relaxation and
Ritz, T., 2001. Relaxation therapy in adult asthma: Is there new evidence Imagery: Tools for Therapeutic Communication and Intervention.
for its effectives? Behavior Modification 25 (4), 640–666. Saunders, W.B., Philadelphia.
Rydstrom, I., Englund, A.D., Sandman, P., 1999. Being a child with asthma. Tseng, T.C., 1993. An assessment study on cognition and adaptive beha-
Pediatric Nursing 25 (6), 589–595. viors between high-anxiety and low-anxiety children. Chia I Shih
Sandberg, S., Paton, J.Y., Ahola, S., McCann, D.C., McGuinness, D., Hillary, Yuan Hsueh Pao 7, 19–76.
C.R., Oja, H., 2000. The role of acute and chronic stress in asthma Tzeng, L.F., Chiang, L.C., 2005. Developing a hospital-based asthma case
attacks in children. The Lancet 356 (16), 982–987. management program. The Journal of Nursing 52 (5), 71–76.
Santanello, N.C., Davies, G., Galant, S.P., Pedinoff, A., Sveum, R., Seltzer, J., Vazquez, I., Buceta, J., 1993a. Psychological treatment of asthma: effec-
Seidenberg, B., Knorr, B.A., 1999. Validation of an asthma symptom tiveness of self-management program with and without relaxation
diary for interventional studies. Archives of Disease in Childhood 80, training. Journal of Asthma 30, 171–183.
414–420. Vazquez, I., Buceta, J., 1993b. Relaxation therapy in the treatment of
Sarason, S.B., Davidson, K.S., Lighthall, F.F., Waite, R.R., Ruebush, B.K., bronchial asthma: effects on basal spirometric values. Psychotherapy
1960. Anxiety in Elementary School Children. Wiley, New York. & Psychosomatics 60, 106–112.
Scherr, M.S., Crawford, P.L., Sergent, C.B., Scherr, C.A., 1975. Effects of Wolf, F.M., Guevara, J.P., Grum, C.M., Clark, N.M., Cates, C.J., 2003. Educa-
biofeedback techniques on chronic asthma in a summer camp envir- tional interventions for asthma in children. Cochrane Database Sys-
onment. Annals of Allergy 35, 289–295. tematic Review, 1 (ID #CD000326).