Asthma and Adolescence: Unique Opportunities for Fostering Asthma Self-Management and Asthma Control

Abstract

Asthma is a significant worldwide concern among adolescents. Adolescents experience key cognitive and psychosocial developmental changes that they must negotiate as they transition from children to adults. Several of these changes have implications for their ability to effectively manage their asthma. When health care professionals (HCPs) understand these pivotal changes and their role in asthma management, they are better able to work with adolescents and help them become effective asthma self-managers. Therefore, this article reviews the cognitive changes that render adolescents ready to care for their asthma, as well as the following psychosocial changes that may hinder or facilitate self-management: independence from caregivers, reliance on peers, identity development, the role of social media in adolescents’ lives, and risk-taking behaviors. Each developmental task is discussed in terms of asthma self-management and offers suggestions for HCPs that may help them work more effectively with adolescents with asthma.

Introduction

Asthma is the most common noncommunicable pediatric illness. The burden of asthma among adolescents worldwide is significant, affecting ∼11% of adolescents,^1,2 of whom 22%–50% have poorly controlled asthma.^1,3 Globally, after infants, adolescents have the highest rate of death due to asthma.⁴ This increased risk among adolescents may be the consequence of several factors, including inadequate asthma self-management.^5–9 For example, compared with younger children and adults, adolescents have few routine asthma-related visits to health care professionals (HCPs), poor adherence to treatment plans, and subpar trigger management.^5,6 Poor asthma control may also be the result of adolescents having insufficient access to affordable, quality health care and asthma medication, particularly in low- and middle-income countries¹⁰ or among those from low-income families in developed countries.^8,11

The health care of adolescents with asthma is complicated by the pivotal biological and psychosocial milestones that define this age group and that occur in a relatively short period of time.¹² However, these changes also present unique opportunities to support adolescents’ asthma self-management. Numerous professional health-related organizations proffer that the distinct characteristics of adolescents must be addressed to ensure their health.^13,14

Spanning ages 11–21 years, adolescence consists of three developmental stages: (1) early adolescence (11–14 years), (2) middle adolescence (15–17 years), and (3) late adolescence (18–21 years).¹⁵ During this transitional period between childhood and adulthood, adolescents become increasingly responsible for independently caring for their asthma and are transitioning to being active health consumers.¹⁶ Coping strategies evolve—adolescents rely less on avoidant coping strategies and more on problem-solving strategies.¹⁷ Thus, it is a critical time to intervene to ensure adolescents are empowered and given the requisite skills to successfully self-manage their asthma and to navigate the health care system to organize their own health care. Because support in adolescence is associated with healthy behaviors that persist into adulthood,¹⁸ fostering a preventive asthma self-management style in adolescence has the potential to continue into adulthood.

When HCPs understand the multifaceted nature of adolescence and how the developmental changes adolescents experience impact their ability to effectively self-manage their asthma, HCPs may be better positioned to assist adolescents in gaining the essential skills to manage their asthma and to form trusting relationships with them, which together may help to improve the adolescent’s asthma control. As a psychologist with expertise in human development across the lifespan, I have worked for over 25 years developing evidence-based interventions to help adolescents obtain good asthma control. To this end, I have interacted with multidisciplinary teams in middle and high school settings, as well as outpatient clinics. Drawing on these experiences, this article reviews key developmental transitions experienced by adolescents and discusses how they relate to asthma self-management. The cognitive changes that render the adolescent ready to be more effective asthma self-managers are reviewed, as are the psychosocial changes that may impact asthma self-management—separation from caregivers, importance of peer relations, identity development, the role of social media in adolescents’ lives, and increasing risk-taking behaviors. Suggestions are made that may allow HCPs to better help adolescents become effective asthma self-managers.

Cognitive Growth

The adolescent brain undergoes significant structural and functional changes that have a substantial impact on the way adolescents think and process information. The magnitude of the cognitive gains made during adolescence differs across the three phases of adolescence (ie, early, middle, and late adolescence) and continues into adulthood.¹⁵ Adolescents are now able to focus on formal operational thought, moving beyond concrete, actual experiences. They are beginning to think in logical and abstract terms.¹⁹ Their working memory improves, which allows adolescents to consider multiple factors simultaneously.¹⁵ Cognitive and decision-making skills develop rapidly, with many decision-making skills being comparable to that of adults by age 15 or 16.²⁰ Adolescents’ ability to make plans for the future and set future goals grows with age.²¹ Being able to think about the future allows them to weigh short- and long-term consequences,²⁰ which in turn allows them to engage in preventive strategies that require taking action to avoid negative consequences in the future.²¹ Metacognition—being aware of how one processes information—also develops in adolescence.¹⁵ This skill is essential to self-regulation,²² as it allows adolescents to observe and reflect on their ability to attain a goal. Cognitive abilities develop together with increased knowledge acquisition in specific domains, and effective reasoning is contingent upon an understanding of and familiarity with the content area. Domain knowledge, or knowledge about a specific area, is needed in order to apply some of the more complex skills discussed above.¹⁵

These cognitive gains render adolescents ready to care for their asthma with readiness relative to the magnitude of the gains made as they progress from early adolescence to late adolescence. Being able to think abstractly allows the youth to now envision airway inflammation, the invisible and silent hallmark of asthma. They can now link the inflammation to bronchoconstriction and understand how the different types of asthma medication work. Also, adolescents' increased understanding of biology will allow them to better understand the pathophysiology of asthma. Their ability to think about the future allows adolescents to better understand the chronic nature of asthma and the need for preventive steps to control asthma. As such, HCPs should teach about the pathophysiology of asthma and how different medications work to control their asthma, linking the use of preventive medications to avoiding future asthma exacerbations. Adolescents are better able to consider the multiple aspects of treatment plans and be able to add or remove medications as warranted by situations. HCPs can incrementally give adolescents self-management tasks to practice and ask them to reflect on how well they implemented each task and its impact on their asthma.

HCPs should be mindful that while decision-making skills grow significantly at this time, adolescents apply these skills less consistently than adults, and the context in which they make the decision impacts their decision-making abilities.²⁰ When adolescents are able to stop and make deliberate, thoughtful decisions, they do so in rational ways. However, when situations are affectively charged, they are less skilled decision-makers.²³ With respect to asthma, having current asthma symptoms, for example, may cause distress that distracts from their ability to decide to take a quick-reliever medication to alleviate the symptoms. It is also important to note that cognitive development during adolescence may evolve at different rates across cultures, in part due to differences in educational opportunities.²⁴ For example, there are cultural differences in who is able to attend school, which stimulates cognitive growth, and in beliefs regarding caregiver engagement in their child’s education.

Independence from Caregivers

During adolescence, there is a normative increase in separation from caregivers.¹⁵ It is a time when caregivers often transfer the responsibility of care to their adolescent who seeks autonomy and increased responsibility. HCPs can capitalize on this and use this growing independence as a spark for motivating adolescents to care for their asthma. Adolescents may be more open to hearing how they can now self-manage their asthma as a means of being independent and separating from their caregivers. It is important that this transfer of responsibility be done gradually and in line with the adolescents’ stage of development (eg, early adolescence versus late adolescence) as well as their asthma self-management skills. Also, because adolescents spend significantly more time away from their caregivers, the caregivers may not accurately report adolescents’ asthma symptoms or management efforts.

It is important to note that this transition to independence may differ by culture, with some cultures supporting early separation from caregivers. For example, in socioeconomic disadvantaged families, parental monitoring and guidance may be limited as caregivers spend less time with their children because they or their children are working²⁰; thus, independence is fostered at a younger age in such cultures.

Applied to asthma, it is recommended that HCPs, when permitted by caregivers, first meet with the adolescents alone to obtain information regarding symptoms they experienced and self-management strategies they have employed. After this, caregivers can be invited to join the discussion allowing HCPs to clarify adolescent–caregiver discordant reporting of the adolescents’ symptoms and asthma management efforts. HCPs might also use this as an opportunity to guide the family in transferring the responsibility of care to the adolescents in a way that ensures treatment adherence. In addition, HCPs should empower adolescents by using shared decision-making when developing a treatment plan; such involvement is essential to ensuring adolescents utilize the plan and reduce the risk of nonadherence.⁷ Shared decision-making is an active, patient-centered approach,^25,26 where HCPs and adolescents discuss treatment options, including caregivers when relevant to adherence.⁷ HCPs would communicate the best asthma practices and, considering the adolescents’ and the families’ beliefs and values, together with the adolescent formulate the treatment plan.

The transition from high school presents a specific challenge to asthma self-management, especially when it is accompanied by a move away from home. College students report lacking the skills to make this transition, including coping with new triggers, unexpected stressors that accompanied starting college, and managing asthma exacerbations safely.²⁷ It is recommended that HCPs provide anticipatory guidance to the new settings.²⁸ They may also want to help the adolescent determine if their college has a school health center on campus that routinely treats asthma or if they need to assist the adolescents in finding a local provider and pharmacy and teach them about medication expiration dates and refill plans, as well as the need to carry an inhaler at college.

For patients who attend vocational or trade schools or who enter the workforce rather than attend college, HCPs should discuss the type of jobs these youth obtain and the risk to their asthma. Adolescents may not be aware that work-related hazards may trigger their asthma, and as such, they need to understand the potential risk to asthma control as well as how ongoing exposure may lead to a decline in lung functioning.²⁹ While they can learn to control work-related asthma, they must first be able to identify and control work-related triggers. Therefore, while the treatment of work-related asthma is the same as non-work-related asthma, HCPs may want to counsel adolescents on job-specific trigger management and the need to carry their inhalers at work. These patients may also need to learn about medication expiration dates and refill plans. In addition, adolescents with work-related asthma exacerbations may also be concerned about the loss of income or losing their job if they are unable to work without having asthma symptoms.³⁰ In such situations, HCPs may need to refer patients to mental health professionals to help them cope with such fears.

It is noteworthy that adolescents’ desire for increased autonomy coincides with pressure to maintain a positive relationship with caregivers,³¹ and this has the potential to impact asthma outcomes. For example, when relationships with caregivers are characterized by warmth and closeness, adolescents have better asthma outcomes than when there is increased family conflict and chaos.^32–35 In fact, research has shown that the quality of family relationships at this time is associated with health outcomes not only in adolescence but also in young adulthood.³⁶

HCPs might consider working with caregivers to provide guidance on maintaining a warm, loving relationship during the transfer of asthma care to their adolescents. As with separation from caregivers, there may be cultural differences in what aspects of family relationships are valued. For example, some cultures place a higher value on parental control and the legitimacy of parental authority. This may impact caregivers engaging in monitoring-related behaviors and adolescents complying with rules,²⁴ including expectations regarding asthma self-care. As such, it is important for HCPs to understand the cultural values of their patients. They may want to discuss with the family the families’ expectations regarding parental control and couch recommendations to the family regarding the transfer of asthma care in a way that is consistent with these expectations.

Peer Relations

Concurrent with separating from caregivers, adolescents reliance on peers increases.³⁷ Peer groups are defined by values, attitudes, and behaviors, and as such, friends become similar to each other.¹⁵ Peer relations can hinder or facilitate successful asthma self-management and asthma control. Adolescents often feel embarrassed in front of friends when they experience symptoms or take medication,³⁸ which in turn leads to them denying having asthma⁷ and being nonadherent to medication.³⁹ However, if adolescents can associate with peer groups who do not hold negative views regarding asthma, adolescents may be more willing to discuss their disease, including needing to avoid certain triggers, and they may be more comfortable taking medication when with peers. The growing decision-making skills adolescents possess can help them negotiate situations with their peers that may negatively impact their asthma. Importantly, adolescents with asthma are subjected to more peer victimization,^40–42 and this is associated with feeling less confident to manage their asthma and with increased symptoms.^40,42 Of note, peer victimization in youth is associated with increased inflammation in adulthood,⁴³ and thus may have lasting impacts on asthma control.

HCPs are uniquely positioned to discuss peer relations and the impact of asthma on the adolescent’s social life. They can use the importance of peers to motivate adolescent patients to care for their asthma by linking asthma control to being like peers without asthma, including participating in activities with friends without limitations or needing to take medication in front of them. HCPs may need to guide adolescents in choosing a peer group that is more accepting of their having asthma. It is recommended that HCPs also screen for peer victimization, including social or covert victimization (eg, spreading rumors), because this is associated with more health problems.⁴³ When identified, HCPs should explain how the victimization impacts asthma control and discuss the adolescent’s social support at home and school, making referrals to mental health professionals when warranted.

Identity Development

One’s identity is not static, changing, and evolving throughout the course of life and is heightened during adolescence.¹⁵ Adolescents begin to examine their attitudes, interests, values, and goals with an eye on what adulthood may look like²¹; they organize these to form a coherent sense of self.^15,44 Those with asthma are faced with an additional challenge—they must consider how asthma is incorporated into their sense of self,^45,46 including experimenting with different self-management styles.²⁸ A supportive peer network is important to help the adolescent navigate a healthy sense of themselves, including that caring for their asthma is part of caring for themselves.²⁸ As such, it behooves HCPs to have an understanding of the adolescents’ asthma identity, as this will aid in communicating with and guiding the adolescent in self-management strategies. It is critical that HCPs help adolescents develop a healthy sense of self, as opposed to identifying as a sick person, as this is associated with nonadherence.⁷

Social Media

For better or worse, social media and technology are integral parts of adolescents’ lives. Platforms such as YouTube, TikTok, Snapchat, and Instagram are widely used by adolescents, with YouTube and TikTok visited daily by the majority of adolescents.⁴⁷ Adolescents ages 15–17 are more likely to be near-constant users of social media compared to younger adolescents.⁴⁷ Among US adolescents, 84% reported seeking health information online, and 34% changed their behavior because of what they found.⁴⁸ This presents a challenge to asthma management as social media often allows for misinformation regarding health, including chronic illnesses.^49,50 This often leads to confusion, fear, and mistrust,^49,51 which in turn might cause adolescents to avoid health care or make poor decisions regarding their health.^50,51

Thus, it is recommended that HCPs learn where their adolescent patients are obtaining information about their asthma, address misinformation, and assist patients in seeking accurate information online.⁵¹ Indeed, this discussion lends itself to shared decision-making,⁵¹ with HCPs assuming adolescents have utilized online platforms to learn about asthma, much of which is likely inaccurate. HCPs can discuss anticipated outcomes of advice garnered online to help adolescents understand all treatment options, guiding adolescents to make choices consistent with their and their family values. In addition, given the pervasive role of technology in the lives of adolescents, coupled with the fact that online learning is very effective for adolescents who report wanting e-health interventions,⁵² HCPs might consider offering their patients web-based asthma interventions that are evidence-based.^52,53

Risk-Taking Behaviors

Across many cultures, risk-taking behaviors increase in adolescents.^15,20,54 This may be in part due to their increased independence,⁵⁴ as well as their level of cognitive development. Relative to children, adolescents have increased sensation seeking, heightened sensitivity to rewards, and low impulse control, which in combination may lead to the adolescent engaging in risky behaviors.^20,55,56

Despite the negative impact of inhaled substances on asthma, adolescents with asthma in the United States and other countries have higher rates of inhaled substances, including cigarettes and e-cigarettes.^57–64 Use of such substances negatively impacts asthma outcomes. Adolescents with asthma who smoke or use e-cigarettes have more asthma symptoms and exacerbations^58,60–67 and are more likely to have asthma-related acute health care visits or overnight hospital stays.⁶⁸ They also have reduced lung function.^66,67,69

Alcohol is the most commonly used substance among adolescents.^70,71 In addition to being a potential trigger of asthma,⁷² use of alcohol may impair adolescents’ decision-making.⁷³ As such, adolescents may make poor decisions regarding asthma self-management strategies when drinking, placing them at risk for asthma exacerbations.

It is recommended that HCPs counsel their adolescent patients on the dangers of substance use with a focus on its impact on asthma. Given adolescents’ improved decision-making skills, HCPs can help adolescents weigh the risks and benefits of using inhaled substances relative to asthma control. Such discussions could be incorporated into the HCPs shared decision-making discussions regarding self-management.

In addition, HCPs should screen adolescents with asthma for substance use as early as age 11.⁷⁴ Using validated measures such as the CRAFFT 2.1+N (https://crafft.org),⁷⁵ asking about specific products or using pictures of products may be helpful to obtain more accurate responses from adolescents.⁷⁴ When warranted, HCPs should offer counseling or make appropriate referrals for support to assist adolescents who are using substances to quit.

Conclusion

Adolescents worldwide are at significant risk of asthma and the deleterious effects of the disease when it is poorly controlled. These youth experience dramatic cognitive growth and psychosocial changes that they must negotiate as they transition from children to adults. Several of these changes impact their ability to effectively manage their asthma. It behooves HCPs to be aware of these changes and understand how each impacts adolescents’ ability to manage their asthma for the better or the worse. This information can help HCPs tailor their discussions with not only the adolescents but also their caregivers to ensure the adolescents are fully empowered to care for their asthma in ways consistent with their development.

Footnotes

Author Disclosure Statement

J.-M.B. serves on the editorial board of Pediatric Allergy, Immunology, and Pulmonology.

Funding Information

No funding was received for this article.

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