Incorporating Family Therapy into Asthma Group

Intervention: A Randomized Waitlist-Controlled Trial

S.M. NG
ALBERT M. LI
VIVIAN W.Q. LOU
IVY F.TSO
PAULINE Y. P.WAN
DOROTHY F.Y. CHAN

Asthma psychoeducational programs have been found to be effective in terms of

symptom-related outcome. They are mostly illness-focused, and pay minimal attention
to systemic/familial factors. This study evaluated a novel asthma psychoeducation
program that adopted a parallel group design and incorporated family therapy.
A randomized waitlist-controlled crossover clinical trial design was adopted. Children
with stable asthma and their parents were recruited from a pediatric chest clinic.
Outcome measures included, for the patients: exhaled nitric oxide (eNO), spirometry,
and adjustment to asthma; and for the parents: perceived efficacy in asthma
management, Hospital Anxiety and Depression Scale anxiety subscale, Body Mind
Spirit Well-being Inventory emotion subscale, and Short Form 12 health-related
quality of life scale. Forty-six patients participated in the study. Attrition rates were
13.0% and 26.0% for the active and control groups, respectively. Repeated-measures
ANOVA revealed a significant decrease in airway inflammation, as indicated by eNO
levels, and an increase in patients adjustment to asthma and parents perceived
efficacy in asthma management. Serial trend analysis revealed that most psychosocial
measures continued to progress steadily after intervention. Significant improvements
in both symptom-related measures and mental health and relationship measures were
observed. The findings supported the value of incorporating family therapy into asthma
psychoeducation programs.
Keywords: Asthma; Psychoeducation; Family Therapy; Parallel Group
Fam Proc 47:115130, 2008

ediatric asthma is a common disorder and it tends to run a chronic course (Lai
et al., 1996; Leung et al., 1997). Apart from affecting physical well-being, chronic

Centre on Behavioral Health, University of Hong Kong, Pokfulam, Hong Kong, China

Correspondence concerning this article should be addressed to S.M. Ng, Centre on Behavioral
Health, University of Hong Kong, G/F Pauline Chan Bldg., 10 Sassoon Rd., Pokfulam, Hong Kong,
China. E-mail: ngsiuman@hku.hk
115

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asthma can have far-reaching psychosocial effects on the patients and their caretakers
(Butz et al., 1995; Fisher et al., 1993; Gustafsson, Bjorksten, & Kjellman, 1994; Rand
& Butz, 1999; Wasilewski et al., 1988). On the other hand, the emotional well-being of
the caretakers can have a significant bearing on the disease outcome, for example,
emergency room visits and school absenteeism (Butz et al., 1995; Fisher et al., 1993;
Gustafsson et al., 1994; Wasilewski et al., 1988).
Self-management has been widely recognized as a core component in the clinical
care of chronic illnesses (Lorig, 2001). In the case of asthma, psychoeducational
interventions in facilitating adaptation to the challenges of the chronic disease have
received growing recognition. These interventions can take many forms, including
simple provision of written information, single-session educational talks, structured
series of seminars, and highly elaborative group interventions for patients and their
caretakers (Gibson & Boulet, 2001; Hui et al., 2002; Klinnert & Bender, 2002; Wilson,
Mitchell, Rolnick, & Fish, 1993). The literature shows that most of these intervention
programs are driven by the theoretical frameworks of empowerment and self-efficacy
(Barlow, Wright, Shaw, Luqmani, & Wyness, 2002; Jerrett & Costello, 1996; McCathy,
Herbert, Brimacombe, & Hansen, 2002). These pediatric asthma management
programs are individual-oriented, targeting the caretakers (usually the mothers),
with the assumption that parental self-efficacy in managing the childs condition
mediates the impact of childrens ill health on both illness outcome and maternal
well-being (Rogers, Chamberlin, Ellison, & Crean, 1997; Zimmerman & Rappaport,
1998). Studies have shown that such educational approaches are effective in terms of
adherence to medical treatment, disease outcome, and self-perceived functioning
(Gibson & Boulet, 2001; Hui et al., 2002; McCathy et al., 2002), but often fail to address the psychosocial aspects (Barlow & Ellard, 2004; Brown, Bakeman, & Celano,
2002; McCathy et al., 2002; Wilson & Farber, 2003). Parents with children suffering
from chronic illness are at risk of having immense distress and a tense relationship
with the ill child (Gustafsson et al., 1994; Hyland, Ley, Fisher, & Woodward, 1995;
Klinnert, McQuaid, McCormick, Adinoff, & Bryant, 2000; Smith, Highstein, Jaffe,
Fisher, & Strunk, 2002). Relational-oriented stress is common among Chinese
mothers (Shen & Xu, 2002). In particular, mothers of children with chronic disease
often report frustration in controlling the childrens behavior and a sense of failure
(Hayman, Mahon, & Turner, 2002; Kazak, Rourke, & Crump, 2003; McCathy, 2002;
Zhu, 2002). The educational approach not only fails to address relationship issues,
but may also reinforce the parents pursuit for absolute control, amplifying their
sense of failure to control and intensifying the parent-child relationship tension
(Englund, Rydstrom, & Norberg, 2001; Wilson & Farber, 2003). This is particularly
true to Chinese families because Chinese parents tend to impose high expectations
on children, have a strong sense of obligation to be good parents, and are concerned
about whether they are seen as good parents by the others (Ho, Chan, Peng, &
Ng, 2001).
Our team has over 5 years of experience in conducting conventional asthma
educational group intervention with Chinese patients in Hong Kong and generally
shares the criticisms of the conventional psychoeducational approach discussed above.
To address these weaknesses, we revamped the program by incorporating family
therapy into the intervention and subsequently ran two pilot trials between 2002
and 2003. In doing so, special attention had been paid to some prominent features
of Chinese families. For example, it is common in Chinese families to have a close
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parent-child relationship. The label enmeshed relationship must be used with great
caution. Chinese parents tend to be very involved in the daily activities of their
children. This characteristic should be taken into account before concluding that the
parents are over-controlling. The experience of the pilot trials was encouraging,
and in light of the feedback collected, the program protocol was further revised and
became the evaluation subject of this study. Adopting a parallel group design, our
program is called We Together-We Success Parallel Group for Children with Asthma
and their Parents (WTWS). The word We in the title reflects the programs special
emphasis on the relational dimension, including both parent-child and worker-client
interactions. While embracing the empowerment and self-efficacy theoretical frameworks and the conventional educational approach, the WTWS program is characterized by two strategies of change. Firstly, it utilizes a two-stage intervention model.
Stage 1 is called the Asthma Management Part, which addresses self-management
knowledge and skills in relation to asthma. Stage 2 is called the Emotion Management
Part, which adopts a systemic/familial approach and addresses the psychosocial needs
of the patients and their caretakers, and the delicate interactions between them in
response to the disease. The rationale of such a logical sequence is two-fold. Asthma
management is a good entry point as it is the primary concern for which the parents
seek help (Klinnert et al., 2000). Emotional needs are usually less ready for sharing
(Gartland & Dery, 1999; Goodwin & Tang, 1996). It is more effective to have the more
personal, sensitive issues being dealt within the later part of the program when
a trustful working relationship is in place. Secondly, the WTWS group recognizes both
individual- and relational-oriented needs of asthma children and their parents. It
incorporates individual and familial interventions by adopting a parallel group design.
In each session, a group for patients and a group for their parents are conducted in
parallel in two nearby rooms, with intermittent joint activities in which the two
groups merge together in a single room. Parallel group design has been found to be an
effective intervention modality for children and parents confronted by various family
relationship problems (Chan & Cheung, 1998; Chan, Yeung, Chu, Tsang, & Leung,
2002; Goodwin & Tang, 1996; Yeung, Cheng, Au, & Yuon, 1999). During joint activities, relational and familial issues can be more realistically assessed and dealt with
because the therapist can have a live platform to observe, enact, and modify the
parent-child interactions. Strategies such as boundary setting, circular questioning,
and various forms of enactment are powerful intervening techniques (Liebman, Minuchin, & Baker, 1974).
The finalized WTWS protocol has 5 sessions for the Asthma Management Part and
6 sessions for the Emotion Management Part. Each session usually lasts for about
2 hours. A typical session includes three parts. The first 30 minutes is for joint activity
in which parents and children share the experience of completing the take-home tasks
agreed upon in the previous session. The second part is for the parallel groups and
lasts for about an hour. Children and parents are facilitated to work separately on a
common theme. The last part is for joint activity again in which children and parents
meet to discuss and try out ways of jointly resolving some issues related to the theme.
They will then plan to transfer the new knowledge and skills into daily life and
practice them in the coming week. Detailed session themes of the WTWS parallel
group are summarized in Table 1.
Being designed for Chinese families, the intervention program differed from similar
programs in the West in a number of ways. The most notable differences are firstly
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TABLE 1
Session Themes of the WTWS Parallel Group for Children with Asthma and their Parents

Parallel Group
Session

Parents

Asthma management part

1
Ice-breaking and team building
Basic understanding of asthmaFMyths
and facts
2

Living with asthmaFYou can, I can,

we can (attitude change)

Preventing asthma attackFKnowledge

and skills

Coping with attackFThe good practice

Traditional Chinese practice in living
with asthmaFMyths and facts
Emotion management part
6
Multidimensional aspects of
asthmaFPhysical, emotional, and
social dimensions
7
Understanding and appreciating my
child and myself
8
Relating with a child with asthma

Patients
The themes for the children group
synchronize with the parents group so
as to create synergy between the two
groups
Games are used as the primary
intervention strategy in enhancing the
childrens understanding on both why
and how
Joint activities are for enacting the parents
and patients to jointly practice and
implement the new techniques learned

4
5

9
10
11

Beyond being a parent of a child with

asthma
Allowing the child to grow up
Enhancing hope and sense of self-efficacy
Review and consolidation

Same as the parents group

Understanding and appreciating my

parents and myself
Relating with parents with a child with
asthma
Beyond being a child with asthma
Behaving to foster parents endorsement
for growing up
Same as the parents group

facilitation of self- and mutual appreciation, which is considerably emphasized in the

group. Confucianism teaches us to be humble and self-demanding. Many Chinese
parents are overly reserved in self-appreciation or appreciating their children. This is
also true for Chinese children who acquire the values in the family. Secondly, somatic
problems are frequently used as an entry point for addressing psychosocial issues.
Chinese people tend to somatize and feel much more comfortable seeking help for
somatic problems (Ustun & Sartorius, 1995, p. 285). The parents often report chronic
fatigue, sleeping problems, headache, indigestion, etc., in the group. These are good
opportunities to bring out the mind/body connection and deliberate on the underlying
psychosocial issues. Thirdly, traditional Chinese medicine (TCM) is discussed in the
group. The purpose is more than simply introducing the usage of Chinese herbal
therapy and acupuncture in asthma management. Deeply influenced by the Yin-Yang
Theory and Daoism, TCM adopts a systemic perspective of health (Cai, 1995). The key
to good health is balance, internally as well as with the environment. This concept
of balance applies in all aspects of living, and is deeply ingrained in the minds of
many Chinese individuals. Discussing TCM can bring out the issue of how to strike a
balance, say between caring for and letting go, intimacy and maintaining a boundary,
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119

and being self-driven and self-acceptance. Lastly, the group emphasizes the
importance of allowing the child to grow up. Over-compensation behavior is very
common among Chinese parents with sick children. They blame themselves and they
underestimate the ability and the growth and development of the children. They are
so caring that they unintentionally encourage regression in the children. No matter
whether the children accept or reject the excessive care, it is still an important issue
to be addressed.

PARTICIPANTS AND METHODS

A randomized waitlist-controlled clinical trial design was adopted in this study
(see Figure 1 for a graphical illustration of the procedures). Participants were children
with stable asthma recruited from the Pediatric Chest Clinic of the Prince of Wales
Hospital, Shatin, Hong Kong, in 2004. They were between 7 and 12 years of age and
able to cooperate with the tests. The diagnosis of asthma was made on standard
grounds advocated by the United States National Heart, Lung and Blood Institute
(Warner, 1992). We defined stable asthma as no asthmatic exacerbation for the
preceding 4 weeks necessitating oral prednisolone or an increased use of inhaled
corticosteroids, the use of rescue treatment no more than three times a week, and with
no clinical indication for change in treatment medication. Children who had other
concomitant nonasthmatic chronic airway diseases such as bronchiectasis; those who
used any prescription or over-the-counter medication that might affect the course of
asthma or its treatment; and those who were currently involved in any other asthma
treatment trial were excluded. Approval from the Ethics Committee of the Chinese
University of Hong Kong had been obtained for this study. Written informed consent
was obtained from the parents or guardians of the participants before the trial.

Measures
Measures for the children were:
C1: Exhaled nitric oxide (eNO) is a marker of airway inflammation. A higher eNO
level is seen in poorly controlled asthma. In this study, eNO was measured by a rapidresponse chemiluminescent method using the Sievers 280i NOA analyzer (Sievers,
Boulder, CO, USA), with a sensitivity from 1 to 200 ppb, a resolution of 1 ppb, and an
accuracy of
1 ppb, according to the American Thoracic Society guidelines (Anonymous, 1999). The participants were comfortably seated without a nose clip, and
T0 (Pretest)

Active group
Participants
recruited

T1 (Posttest)

T2 (Follow-up)

Intervention

Maintenance (no
intervention)

No intervention

Intervention

Randomization
Control group

FIGURE 1 Process of the Randomized Waitlist-Controlled Clinical Trial

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inhaled NO-free air from a reservoir and subsequently exhaled against a resistor.
The flow rate was set at 50 ml/s. This on-line measurement was taken in triplicate and
the average was recorded.
C2: Spirometry (Spirolabll, MIR, Italy) using a standard technique measured forced
expiratory volume in the first second (FEV1) and forced vital capacity (FVC). The best
of three efforts obtained was compared with local age- and sex-matched reference
values (Ip, Karlberg, Karlberg, Luk, & Leong, 2000). FEV1 and FVC are markers of
airway size. Poorly controlled asthma has more airway inflammation, which may lead
to narrowing of the airways and thus reduced FEV1 and FVC.
C3: A self-constructed 5-item scale was used to measure the patients adjustment to
asthma as rated by his/her caretaker. The five areas of adjustment were emotional and
behavioral well-being, general physical health, family, school life, and social life. High
levels of reliability were obtained for this scale. Interitem correlations ranged from .24
to .79 (mean .57) at pretest, and from .57 to .91 (mean .72) at posttest. Internal
consistency, as indicated by Cronbachs a, was .87 (pretest) and .93 (posttest).
Measures for the caretakers were:
P1: Anxiety level of the caretakers was obtained with the Anxiety Subscale of the
Chinese version Hospital Anxiety and Depression Scale (HADS) (Leung, Ho, Kan,
Hung, & Chen, 1993; Leung, Wing, Kwong, Lo, & Shum, 1999). HADS is a 14-item
self-report questionnaire that has been validated in a Chinese population in Hong
Kong. It has good internal consistency, with Cronbachs a at .81 and .74 for the anxiety
and depression subscales, respectively.
P2: The Emotion Scale of the body-mind-spirit well-being inventory (BMSWBI) was
used to measure caretakers positive and negative emotions (Ng, Yau, Chan, Chan, &
Ho, 2005). The emotion scale is a 19-item self-report questionnaire. It has good internal consistency, with Cronbachs a at .92, .88, and .92 for the whole scale, positive
emotions, and negative emotions subscales, respectively.
P3: Health-related quality of life of the caretakers was measured with the Standard
Short Form 12 (SF-12) Chinese (Hong Kong) Version 1, yielding two subscores: the
physical and mental health components (Health Assessment Lab, 1995). SF-12 is a
12-item self-report questionnaire and a Chinese version has been validated in Hong
Kong. It has been shown to have high test-retest reliability (between .86 and .89).
P4: A self-constructed 5-item scale was used to measure caretakers perceived
efficacy in the management of the childs asthma. The five areas included were
general knowledge of asthma, management of asthma attacks, use of medication and
medical equipment for asthma, prevention of asthma attacks, and general caring for
a child with asthma. High levels of reliability were obtained for this scale. Interitem
correlations ranged from .66 to .89 (mean .77) at pretest, and from .79 to .92.
(mean .86) at posttest. Cronbachs a was .94 (pretest) and .97 (posttest).

Procedures
Patients and their caretakers were recruited at the pediatric chest clinic when they
returned for scheduled follow-up consultation. Recruitment was conducted about a
month before the commencement of the intervention group. Sampling method was
100% consecutive sampling, that is, all patients meeting the inclusion criteria were
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121

invited to participate in the study. Written informed consent was obtained from each
participant. Recruited patients and their caretakers were randomly assigned to the
active or the control group: the first recruited patient/caretaker pair was assigned to
the active group, the second pair recruited to the control group, the third pair to the
active group, and so on. Effectively, each patient/caretaker pair had a 50% chance of
being in either group.
Baseline (pretest) measures of the children (measures C1C3) and their caretakers
(measures P1P4) from the two groups were obtained before commencement of
the intervention. The scheduled intervention lasted for 11 weeks and during this time
the control group did not receive any form of active psychosocial intervention or
therapy. The two groups underwent repeated assessments once the active group had
completed the intervention. The process then repeated itself, whereby the initial
control group underwent intervention and the original active group did not receive
further psychoeducational program/therapy, allowing us to assess the maintenance
effects of the intervention. The psychosocial measures (i.e. C3 on the children and
P1P4 on the parents) were taken after the second intervention period had lapsed.
The lung function measures (i.e., C1 and C2) were not performed at this time point
because of resource constraints. Because there was no control group when measuring
the maintenance effects in a randomized waitlist-controlled trial design, it was decided that the resource-consuming lung function tests would not be pursued further.
Owing to the limited size of each group (the capacity of each group was up to 10
participants), the procedure described above was repeated once more so as to achieve a
larger sample size. Mainly due to resource constraints, the target sample size of the
current study was 40, which was acceptable for early-stage efficacy evaluation of a group
psychosocial intervention. With about 20 participants in each group, the power was about
.50 if the effect size was medium, and about .85 if the effect size was large (Cohen, 1988).

Statistical Analysis
Intervention effect was evaluated by comparing the active and control groups.
Repeated-measures ANOVA with time (pretest and posttest) as the within-subjects
variable and group (active group and control group) as the between-subjects variable
was used to detect any main effects of time and group as well as Time  Group interaction of each of the outcome measures. In case of significant results, simple effect
analysis was performed to examine where the differences occurred.
Maintenance effect on the active group was examined with psychosocial measures
(i.e., C3 and P1P4). Repeated-measures ANOVA was performed, with time (pretest,
posttest, and follow-up) as the within-subjects variable. Simple and repeated
contrast methods were used to detect any differences between time points and reveal
the serial trends.

RESULTS
Figure 2 shows the flow of participants through each stage of the randomized trial.
Forty-six children with asthma were invited to participate in the study. Nine participants dropped out before the end of the study, with 3 and 6 from the active and the
control group, respectively. Attrition rates for the active and control groups were
13.0% and 26.0%, respectively. The main reason for dropping out was unavailability to
attend scheduled sessions as they clashed with school activities. The higher attrition
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FAMILY PROCESS

Assessed for
eligibility (n = 55)

Excluded (n = 9)
(5 not meeting inclusion
criteria; 4 refused to
participate)

Randomized (n = 46)

Allocated to
intervention
(n = 23)

Allocated to
control
(n = 23)

Lost to follow up (n = 3)
Key reason: clashed with
school activities

Lost to follow up (n = 6)
Key reason: clashed with
school activities

Analyzed (n = 20)

Analyzed (n = 17)

FIGURE 2 Flow of Participants Through Each Stage of the Randomized Trial

rate in the control group was largely attributed to the fact that the participants of that
group had to wait for a longer period of time for the intervention program. Attrition
analysis revealed that the dropouts had a longer duration of asthma and there were
more females, but otherwise had baseline demographic characteristics and respiratory
measures similar to the participants (Table 2). Data from the remaining 37 children,
20 in the active and 17 in the control group, were used in the final analysis. Their
mean age was 9.2 years (SD 1.5) and their mean duration of illness was 5.7 years
(SD 2.4, range: 212). Nine participants had mild persistent asthma and they were
using inhaled corticosteroids at a beclomethasone equivalent dosage of 100200 mg/day.
The remaining participants had mild intermittent asthma and were using an
inhaled bronchodilator on an as-required basis. There were no significant differences
in demography between the active and the control groups. They also had similar
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123

TABLE 2
Comparison of Demographic and Lung Function Data of Participants and Dropouts

Participants (N 37)

Demographic
Age (years)
Duration of
illness (years)
Family size
Sex (male:female)
Parents age (years)
Parents sex
(male:female)
Parents
educational level
(primary:secondary:
tertiary)
Lung function
FEV1 (l/min)
FEV1/FVC ratio
eNO (ppb)

Dropouts (N 9)

Mean (SD)

Ratio

Mean (SD)

Ratio

v2

9.24 (1.48)
5.70 (2.41)

F
F

9.89 (1.90)
7.56 (2.51)

F
F

 1.11
 2.05

F
F

.273
.046

4.03 (0.90)
F
39.86 (5.07)
F

F
25:12
F
1:36

3.67 (1.41)
F
42.22 (10.60)
F

F
2:7
F
1:8

0.96
F
 0.99
F

F
6.14
F
1.23

.343
.013
.330
.267

7:26:4

5:4:0

5.44

.066

109.58 (21.59)
79.58 (11.12)
71.02 (45.20)

F
F
F

99.67 (17.69)
79.44 (10.68)
55.30 (19.62)

F
F
F

F
F
F

.214
.975
.149

1.26
0.03
1.49

Note. eNO exhaled nitric oxide; FEV1 forced expiratory volume in the first second; FVC forced
vital capacity.

baseline lung function indices. However, participants in the active group had higher
baseline eNO levels than those in the control group (Table 3). The 20 participants in
the active group attended at least 8 out of the total 11 sessions of the group intervention (8 sessions: four pairs; 9 sessions: seven pairs; 10 sessions: six pairs; and
11 sessions: three pairs).

Intervention Effect
The pre- and postintervention respiratory and behavioral measures of the active
and control groups are summarized in Table 4. Using repeated-measures ANOVA,
significant effects were found in eNO level, patients adjustment to asthma score, and
parents perceived efficacy in asthma management score. For the eNO level, there was
a significant Time  Group interaction, F (1, 28) 5.76, p .023. Simple analysis
revealed a marginally significant decrease in eNO level at posttest in the active group,
t(15) 1.98, p .067, and an insignificant increase in the eNO level at posttest in the
control group, t(13)  1.46, p .168.
As for the patients adjustment to asthma score, the main effect of group was
significant, F(1, 31) 13.62, p .001. Further analysis showed that the two groups had
similar pretest scores, but the posttest score of the active group was significantly
higher than that of the control group, t(1, 31) 4.55, p .001. For the total patients
adjustment to asthma score, Time  Group interaction was not statistically significant, F(1, 32) 2.40, p .132. Among the five domains of child adjustment to asthma,
Time  Group interaction was marginally significant in the general physical health
subscore, F(1, 32) 3.82, p .059.
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FAMILY PROCESS

TABLE 3
Baseline Demographic, Lung Function, and Quality of Life Data of the Active and Control Groups

Active (N 20)

Demographics
Age (years)
Duration of
illness (years)
Family size
Sex (male:female)
Parents age
(years)
Parents sex
(male:female)
Parents
educational level
(primary:secondary:
tertiary)
Lung function
FEV1 (l/min)
FEV1/FVC ratio
eNO (ppb)

Control (N 17)

Mean (SD)

Ratio

Mean (SD)

Ratio

v2

9.15 (1.60)
5.55 (2.61)

F
F

9.35 (1.37)
5.88 (2.23)

F
F

 0.41
 0.41

F
F

.684
.682

4.05 (0.89)
F
40.95 (6.13)

F
12:8
F

4.00 (0.94)
F
38.59 (3.14)

F
13:4
F

0.17
F
1.43

F
1.14
F

.869
.286
.161

1:19

0:17

0.87

.350

3:13:4

4:13:0

3.93

.140

109.83 (15.96)
79.06 (12.08)
87.71 (45.97)

F
F
F

112.07 (26.20)
81.64 (8.89)
50.71 (39.88)

F
F
F

 0.30
 0.67
2.34

F
F
F

.767
.507
.027

Note. eNO exhaled nitric oxide; FEV1 forced expiratory volume in the first second; FVC forced
vital capacity.

Finally, a significant time effect, F(1, 30) 7.14, p .012, group effect,
F(1, 30) 8.41, p .007, and Time  Group interaction, F(1, 30) 8.71, p .006, were
found for parents perceived efficacy in asthma management. Simple analysis revealed
that the two groups were not statistically different at pretest, t(1, 30) 0.03, p .975.
At posttest, the active group experienced a substantial increase while the control
group remained stable, resulting in a statistically significant difference between the
two groups, t(1, 30) 4.55, po.001.

Maintenance of Intervention Effect

Table 5 summarizes the serial trend of outcome measures of the active group. Seven
out of eight of the behavioral measures at follow-up were significantly different from that
at pretest: patients adjustment to asthma; parents perceived efficacy; HADS anxiety
score; BMSWBI negative emotion score and total score; and SF-12 physical component
score and mental component score (all ps o.05). The results suggested that most intervention effects were maintained and continued to progress steadily in the 11 weeks following the intervention. There was a general trend of reducing variance in most
measures between pretest, posttest, and follow-up. The convergent trend seemed to be
partly due to bigger improvement in clients who had a lower baseline.
Using repeated-measures ANOVA to examine the serial trend, significant
results were found in five out of eight of the behavioral measures: parents perceived
efficacy in asthma management score ( p .003); HADS anxiety score ( p .003);
BMSWBI negative emotion subscore ( p .001); and total score ( p .002); and SF-12
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7.33

87.71
109.83
79.06

6.36
5.37

47.75
31.17
124.22

47.14
46.50

18

16
18
18

19
19

20
18
18

20
20

Mean

7.03
7.55

21.66
24.10
33.95

2.66
3.82

45.97
15.96
12.08

1.49

SD

45.87
46.34

53.45
36.28
128.00

8.53
5.37

60.47
110.33
81.33

7.79

Mean

Post

6.62
6.34

18.68
19.24
25.20

1.33
2.95

38.37
13.17
11.89

1.21

SD

13
13

13
10
10

13
15

14
14
14

15

44.42
45.38

43.69
28.70
124.70

5.46
6.00

50.71
112.07
81.64

6.20

Mean

Pre

8.60
7.10

17.81
18.52
28.78

2.60
3.42

39.88
26.20
8.89

1.68

SD

Control

44.20
44.27

40.92
36.10
116.30

5.35
6.80

65.84
104.64
79.21

5.81

Mean

Post

8.09
7.84

11.76
16.33
25.83

2.17
3.14

43.63
15.97
6.41

1.35

SD

.512
.712

.691
.090
.650

.012
.438

.498
.417
.969

.900

Time

.368
.408

.138
.856
.590

.007
.329

.221
.725
.941

.001

Group

.643
.781

.256
.750
.237

.006
.438

.023
.354
.234

.132

Time
 Group

Repeated-Measures
ANOVA

Note. BMSWBI body-mind-spirit well-being inventory; eNO exhaled nitric oxide; FEV1 forced expiratory volume in the first second;
FVC forced vital capacity; HADS hospital anxiety and depression scale.
n
Among the five domains of Adjustment to Asthma, general physical health subscore had marginally significant Time  Group interaction,
F(1, 32) 3.82, p .059.

Measures for patients

Adjustment to
asthma n
eNO (ppb)
FEV1 (l/min)
FEV1/FVC ratio
Measures for parents
Perceived efficacy
HADS anxiety
BMSWBI emotion
Positive
Negative
Total
SF-12
Physical health
Mental health

Pre

Active

TABLE 4
Repeated-Measures ANOVA of Pretest and Posttest Measures of the Active and Control Groups

NG ET AL.

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125

7.33
87.71
109.83
79.06
6.36
5.37

47.75
31.17
124.22

46.83
46.59

18
16
18
18

19
19

20
18
18

19
19

Mean

7.08
7.74

21.66
24.10
33.95

2.66
3.82

1.49
45.97
15.96
12.08

SD

45.63
46.37

53.45
36.28
128.00

8.53 n
5.37

7.79
60.47
110.33
81.33

Mean

6.71
6.51

9.13
19.19
24.81
5.98
3.92

57.15
16.28 nw
152.50 nw
51.01 nw
50.85 nw

0.66
2.79

8.16w
3.16 nw

1.33
2.95
18.68
19.24
25.20

0.65
F
F
F

SD

8.11w
F
F
F

Mean

Follow-Up
(T2)

1.21
38.37
13.17
11.89

SD

Posttest
(T1)

7.19
3.55

1.63
8.20
7.86

9.33
7.02

2.78
3.90
0.02
0.64

.002
.060

.210
.001
.002

.003
.003

.076
.067
.885
.435

RepeatedMeasures
ANOVA

.03
.00

.06
.06
.02

.43
.00

.09
.21
.00
.04

T0 vs. T1

.32
.25

.13
.35
.41

.29
.33

.22
F
F
F

T0 vs. T2

Effect Size
(Partial g2)

Note. BMSWBI body-mind-spirit well-being inventory; eNO exhaled nitric oxide; FEV1 forced expiratory volume in the first second;
FVC forced vital capacity; HADS hospital anxiety and depression scale.
n
Mean different from that of the preceding time-point at the .05 level.
w
Mean different from that of pretest at the .05 level.

Measures for patients

Adjustment to asthma
eNO (ppb)
FEV1 (l/min)
FEV1/FVC ratio
Measures for parents
Perceived efficacy
HADS anxiety
BMSWBI Emotion
Positive
Negative
Total
SF-12
Physical health
Mental health

Pretest
(T0)

TABLE 5
Serial Trend of Outcome Measures of the Active Group

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NG ET AL.

127

physical component score ( p .002). Medium effect size (partial Z ) was found in
these measures.

DISCUSSION
In summary, the findings from the current study provided evidence supporting the
efficacy of the WTWS program and the value of incorporating family therapy into the
asthma psychoeducational program. Analyses of immediate intervention effects and
serial trend revealed significant improvements in patients and their parents in both
symptom-related and psychosocial outcome measures.
Similar to the conventional psychoeducational approach, improvements in
symptom-related outcome measures were found. These included patients eNO levels
and adjustment to asthma, and parents perceived efficacy in asthma management. It
has to be noted that eNO is a validated marker of underlying eosinophilic airway
inflammation, which is a predictor of asthmatic exacerbation and a precursor of airway remodeling. Monitoring eNO would indeed provide better information in terms of
asthma control than simple spirometry. Therefore, despite static spirometric measures, the significant improvements in eNO levels after intervention provided highly
favorable support for the efficacy of the intervention. On top of these expected
improvements, there were significant improvements in measures of mental health and
relationships, which were the primary reason for incorporating family therapy into
the WTWS program. The adjustment to asthma scale concerned both the patients
own well-being and the relationship with his/her significant others in coping and
living with the illness. The findings seemed to support a multidimensional intervention strategy. An individual-focused psychoeducational approach and relationalfocused family therapy approach could complement each other and bring about more
comprehensive benefits for patients and their parents.
Serial trend analysis revealed an interesting pattern of progress in the parents. At
the end of intervention, improvement in perceived efficacy in asthma management
was the most prominent among all outcome measures in parents. This phenomenon
was understandable because their voluntary participation in the study suggested that
these parents were likely to be keen learners. On the other hand, the changes in parental mental health measures were not statistically significant at this time point.
Interestingly, however, at the 11-week follow-up, a statistically significant improvement emerged in nearly all (five out of six) of these measures. These included HADS
anxiety score, BMSWBI negative emotion and total emotion scores, and SF-12 physical
and mental component scores. Focus group interviews with the participants
conducted at posttest and follow-up provided some cues for understanding such
a phenomenon. Many parents were busy and found attending the program on 11
consecutive weekends a huge commitment. Emotional and behavioral issues brought
up in the sessions could lead to temporary distress. Completing between-session home
assignments could also be a source of stress as it took time and required the cooperation of the children. Nevertheless, most of the parents expressed that the effort was
worthwhile. This view was echoed by the high attendance and low attrition rate. After
completion of the program, most parents felt that the burden was much lessened.
The newly learned knowledge and skills in managing a childs asthma and living with
the child might be gradually assimilated and applied to real-life situations. This might
be a possible reason for the continuous improvement in psychosocial measures after
Fam. Proc., Vol. 47, March, 2008

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FAMILY PROCESS

intervention. It also reflected the value of organizing follow-up booster and reunion
sessions. It was also noted in the serial trend analysis of the active group that
participants became increasingly homogenous; the standard deviations of all outcome
measures decreased substantially from pretest to posttest to follow-up. This suggested
that participants with poorer baseline conditions might have benefited more from the
intervention program than those with better baseline conditions.
There were several limitations in the current study. Firstly, although there were
advantages with a waitlist-controlled trial design, the control group did not receive
any intervention during the period for comparison. Social gathering effects could not
be offset. Future studies may consider adopting a social gathering control group,
although it will require more resources. Secondly, the WTWS program consisted of
both conventional psychoeducational intervention and the additional family therapy.
The contributions of the two components to the outcome could not be differentiated
from one another. This question could be addressed in future studies by setting up a
comparison arm consisting of conventional asthma psychoeducation only. Thirdly,
lung function measures were not pursued at the follow-up due to resource constraints.
The continued improvement in psychosocial measures revealed in the current study
suggests that it is worthwhile looking at lung functions at subsequent follow-ups.
Fourthly, the sample size in the current study was only marginally adequate to detect
significant improvements in some outcome measures. Fifthly, mainly children with
mild asthma were included in this study, leaving the question as to whether the same
results will be seen in cases with more severe disease unknown. Finally, the follow-up
period in this current study was relatively short. It is unclear whether such positive
beneficial effects would persist after, say, 6, 9, or 12 months. A longer follow-up period
is suggested for future studies to examine the long-term effect.
In conclusion, the results of the current clinical trial were promising and provided
preliminary support for incorporating family therapy into asthma psychoeducational
group intervention. Furthermore, substantive studies addressing the limitations of
the current study, as discussed above, can provide more conclusive findings on the
efficacy of such an integrated approach and the value of incorporating family therapy
into the program.
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