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What is needed now is research based on an understanding of adolescents
MJA 1996; 165: 463
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Australian data show that the prevalence of asthma among teenagers is approximately 20%. 1 Estimated conservatively, at least half a million young adolescent Australians aged 10-19 years suffer from asthma. In Australian children the prevalence of asthma has increased substantially in the past three decades, 1,2 but most children with mild asthma do not have asthma in adolescence and adulthood. 3 However, for many, their childhood asthma per sists through adolescence into adult life. 4 Identified risk factors for this persistence of asthma into adult life include female sex, onset after two years of age, more than 10 attacks throughout childhood, lower peak flow rates in childhood, and parental atopy. 3 Personal atopy is also a major determinant of outcome. 2
Objective measurement of the physiological disturbances of asthma are well accepted as part of medical care for acute asthma. In addition, various asthma management plans imply that measurement of airflow obstruction has a role in ongoing interval asthma management. Indeed, in specialist practice this is a routine component of care. In this issue of the Journal, Hewson et al. ( page 469 ) provide firm evidence to support this view in a general practice setting. They found unexpectedly low values for forced expiratory volume in one second (FE V 1 ) and/or forced mid expiratory flow (FEF 25%-75% ), both calculated as a percentage of normal values, in patients in whom clinical and personal assessment had indicated no need to change asthma treatment. This occurred at 30% of assessment opportunities in general practice in adolescents undergoing review or attending for acute exacerbation of asthma. Presumably, had these results been available to their treating doctors, drug therapy would have been altered. That measurement of airflow obstruction by spirometry in general practice has the potential to contribute to fine tuning of asthma therapy is of substantial significance.
Ambulatory monitoring of peak flow rate is promoted as assisting in diagnosing asthma, measuring its severity, assessing response to treatment and recognising any deterioration. 5 The limitations of peak flow rate monitoring are also well known, 5 and incidentally highlighted in the article by Hewson et al. While use of a peak flow monitor at home (70% of the study population) may have resulted in patients attending their general practitioner for assessment (reasons for consultation are stated only as acute deterioration or asthma management review), it did not result in appropriate medication change.
Just as there are limitations in the testing of peak flow rate, there are also limitations in the use of spirometry. Training in the performance and interpretation of spirometry, as completed by the physiotherapist who performed the tests in the study by Hewson et al., is vital to the achievement of valid and reproducible results. 6
Although measurement of disease severity is an important factor in the management of adolescents with asthma, it is becoming increasingly apparent that assessment of the broad health status of adolescents with asthma is equally important. The evidence is only just emerging that the prevalence of smoking in young people with asthma appears to be the same as their peers without asthma. 7
Adolescence is a critical period for determining future smoking behaviour -- over 90% of adult smokers begin smoking by 19 years 8 -- and achieving an effective early intervention during adolescence has the potential to have an immense impact. Moreover, what is less well understood is that smoking in young people is more than just an exacer bating factor in asthma or a major risk factor for heart d isease and cancer. It is an important symptom of, or marker for, other adolescent health problems. Specifically, symptoms of anxiety and depression are strongly associated with smoking in adolescents, 9 and heavy tobacco use is a feature of concurrent abuse of drugs such as alcohol and marijuana. 10
Monitoring the health status of the adolescent process is of itself an important component in assessing the health status of young people. 11 A young person's development involves physical, cognitive and psychosocial maturation. Medically, we are well trained to assess the physical changes of adolescence, but we receive far less training in other aspects of adolescent maturation. How independent of their parents are these young people? How personally and socially responsible is their behaviour? What are their educational and vocational goals? What activities do they enjoy?
In comparison with measuring airflow obstruction by spirometry, a suitable method of measuring adolescent developmental progress is less well defined. Frameworks have been promulgated to assist practitioners to obtain a psycho social history sensitively, 12 but it is only by placing these frameworks into the broader context of adolescent development that we can start to address adolescents' health needs. It is important that this lack of knowledge and competence in adolescent health, well recognised by general practitioners, 13 is redressed by improved training in adolescent medicine.
Specific behaviours, such as smoking, or poor adherence to medication regimens or medical review appointments, are important factors because of their detrimental effect on asthma management in adolescents. However, they are also important as potential "beacons of distress". Putting these behaviours into the context of adolescent development can be more helpful in the development of key strategies to improve asthma management than the typical medical "disease-perspective" model.
Research in asthma epidemiology has increased our understanding of the extent of asthma, and guided the development of major public health interventions for disease management. What is now needed is research based on an understanding of adolescents themselves. For adolescents with asthma, we need to define more clearly the problems they face as adolescents, not simply the problems they face because they have asthma. For example, research is required to determine the extent and nature of adherence to asthma medication regimens, and to identify young people's understanding of the effect of smoking on asthma. This may then be used to develop strategies that better engage young people in regular medical care and better target smoking. Appropriately, the recent National Asthma Week (6-12 October) targeted asthma and adolescents. We have a good understanding of the management of asthma. What we need now is an accompanying understanding of how best to care for adolescents with asthma.
Susan Sawyer
Senior Lecturer
Glenn Bowes
Professor
Centre for Adolescent Health, University of Melbourne
Royal Children's Hospital, Melbourne, VIC
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