Related factors associated with the occurrence of depressive disorders in children with asthma

Abstract

BACKGROUND

Pediatric asthma is a prevalent chronic respiratory disease with a rising global incidence. Beyond physical symptoms, its persistent nature significantly disrupts children’s daily life and social activities. Most patients may exhibit anxiety and depression, reducing treatment adherence and worsening disease control. While the bidirectional relationship between psychological factors and asthma is established, Chinese research has primarily focused on parental emotions, leaving children’s psychological state, particularly depression, underexplored. We hypothesize that identifying key risk factors for depression is crucial for early screening and targeted intervention to improve overall pediatric health outcomes.

AIM

To explore the related factors of asthmatic children with comorbid depression.

METHODS

A retrospective analysis was conducted, selecting 60 children with asthma and depression admitted from January 2023 to June 2025 as the comorbid depression group, and 60 children with asthma without depression during the same period as the non-depression group. Univariate and multivariate logistic regression analyses were performed to identify the related factors for asthmatic children with comorbid depression, and receiver operating characteristic curves were used to assess the correlation strength between each factor and depression.

RESULTS

Univariate and multivariate logistic regression analyses showed that the primary caregiver’s educational level (high school or below), the primary caregiver’s negative emotions (yes), family history of asthma (yes), parents’ awareness of asthma (poor), medication adherence (poor), and asthma control (poor) were all independent related factors for asthmatic children with comorbid depression. Receiver operating characteristic curve analysis showed that each factor had a certain ability to distinguish whether asthma children were complicated with depression, but the prediction efficiency was medium and low.

CONCLUSION

Asthmatic children’s depression risk factors include family environment, disease awareness, and management quality.

Key Words: Asthma; Depressive disorder; Children; Psychological; Emotional

Core Tip: This analysis identifies key factors associated with depression in children with asthma, including primary caregivers’ lower education level and negative emotions, poor parental asthma knowledge, medication non-adherence, poor asthma control, and a family history of asthma. While these factors show moderate predictive value individually, they serve as crucial clinical warning signals. Recognizing these multifaceted risks enables early screening and targeted psychological interventions for at-risk children and their families, ultimately improving comprehensive asthma management and pediatric mental health outcomes.

INTRODUCTION

Bronchial asthma (hereinafter referred to as asthma) is a common chronic respiratory disease in children, characterized by chronic airway inflammation. Its onset is related to genetics, immune disorders, environmental factors and respiratory infections[1]. The main symptoms of children are paroxysmal wheezing and coughing. The symptoms have a diurnal rhythm, and are more likely to occur or worsen in the early morning and at night, and are relieved during the day. Before an attack, there are often prodromal symptoms such as runny nose and chest tightness[2,3]. In recent years, the incidence of childhood asthma has been increasing year by year worldwide[4]. The disease has a long course, recurrent attacks and is difficult to control. It not only seriously affects the lung function and physical health of children, but also interferes with their daily life and social life, becoming an important public health problem for children.

Numerous studies have confirmed that psychological factors are closely related to the occurrence, development and prognosis of asthma, and the two interact with each other. On the one hand, the chronic course and recurrent symptoms of asthma can easily trigger negative emotions in children; on the other hand, poor psychological state may aggravate airway inflammation through the neuro-endocrine-immune regulatory axis, further worsening the condition[5]. In this field, developed countries such as Europe and the United States have carried out more in-depth research. In addition to systematically exploring the mutual influence between the psychological state and disease process of children with asthma, they have also attached great importance to the application value of psychological intervention and clarified the positive role of psychological intervention in improving the level of asthma control and optimizing the prognosis[6]. China’s related research started late, and the focus was mostly on the relationship between the emotions of the parents of children with asthma and the condition, with insufficient attention paid to the psychological state of the children themselves, especially depression. Depression is a common psychological disorder in children. When children with asthma have depression, it will reduce treatment compliance, aggravate the fluctuation of the condition, and seriously affect growth and development and quality of life[7]. At present, domestic research lacks in-depth analysis of the risk factors of comorbid depression in children with asthma. Based on this, this study aims to explore the relevant risk factors for depressive disorders in children with asthma, in order to provide empirical evidence for early identification, psychological intervention and comprehensive management.

MATERIALS AND METHODS

Research object

This study employed a retrospective analysis. Sixty children with asthma and depression who received treatment at Hunan Children’s Hospital from January 2023 to June 2025 were selected as the depression group, and 60 children with asthma without depression during the same period were selected as the non-depression group.

Exclusion and inclusion criteria

Inclusion criteria: (1) Meeting the relevant diagnostic criteria for asthma[8]; (2) Asthma history > 2 years; (3) Age > 8 years and < 16 years; (4) No intellectual problems or cognitive impairment; and (5) Informed consent from the child and parents, and able to read and complete all the contents of the questionnaire on their own.

Exclusion criteria: (1) Children in the acute exacerbation phase of asthma; and (2) Children with other chronic diseases or serious acute diseases. This study has been approved by the Ethics Committee of Hunan Children’s Hospital.

Observation indicators

General information questionnaire: Based on the child’s medical records, collect the following information about the child’s condition: (1) Age; (2) Course of illness; (3) Gender (male/female); (4) Place of residence ( rural/county town /rural); (5) Only child (yes/no); (6) Primary caregiver’s education level (high school or below/college or above); (7) Family history (yes/no); (8) Primary caregiver’s negative emotions (yes/no); (9) Primary caregiver’s understanding of asthma (good/poor); (10) Medication adherence (good/poor); and (11) Asthma control status (good/poor).

Assessment of asthma with depression: The Depression Self-Rating Scale for Children (DSRSC)[9] was used. It includes 18 items and uses a 3-level Likert scale. 0 points are given for not having it, 1 point for sometimes having it, and 2 points for often having it. Items 1, 2, 4, 7, 8, 9, 11, 12, 13, and 16 are scored in reverse order. The ≥ 15 points indicates the presence of a depressive disorder, 20-24 points indicates moderate depression, and ≥ 25 points indicates severe depression. At the same time, we conducted semi-structured clinical interviews with children with positive screening (DSRSC ≥ 15) and their primary caregivers using the Chinese version of the school age affective disorder and schizophrenia questionnaire (Kiddie-Schedule for Affective Disorders and Schizophrenia)[10]. The interview was jointly conducted by two experienced pediatric psychologists, and the final diagnosis was made after synthesizing the information of both sides. The children in the “depression group” finally reported in this study were all cases that met the DSRSC screening positive criteria and were confirmed by Kiddie-Schedule for Affective Disorders and Schizophrenia interview.

Asthma control assessment: This study used a standardized scale to assess asthma control levels based on the age of the children. Among them, the Childhood Asthma Control Test (C-ACT) was used to assess children aged 5-11 years[11]. The scale has 7 items and a total score of 0-27 points. It was completed by the children and their parents under guidance. The Asthma Control Test (ACT) was used to assess children aged ≥ 12 years[12]. The scale has 5 items and a total score of 5-25 points. It was completed by the children themselves. According to the clinical application guidelines of ACT in children, the C-ACT and ACT scales have verified cut-off values[11,12]. In this study, C-ACT score ≥ 20 and ACT score ≥ 20 were defined as “good control”, and total score < 20 was defined as “poor control”.

Assessment of negative emotions of primary caregivers: The Hospital Anxiety and Depression Scale (HADS) was used to assess the negative emotions of primary caregivers[13]. The scale consists of two subscales: Anxiety (HADS-A) and depression (HADS-D), each with 7 items, for a total of 14 items. A 0-3 scale was used for scoring, and the total score for each subscale ranged from 0 to 21. According to the Chinese version of the norms, a score ≥ 8 on any subscale indicates significant anxiety or depression symptoms. In this study, a score ≥ 8 on any subscale was defined as negative emotions in the caregiver.

Statistical analysis

Data processing was performed using SPSS 22.0 software. Quantitative data were expressed as mean ± SD, and independent samples t tests were used for comparisons between groups. Categorical data were expressed as n (%), and χ² tests were used for comparisons between groups. Statistically significant variables from the univariate analysis were included in logistic regression analysis to identify independent risk factors for asthma with comorbid depression. Receiver operating characteristic (ROC) curves were plotted for the independent risk factors identified by logistic regression analysis, and the area under the curves was calculated to assess the predictive power of each factor for comorbid depression in children with asthma. A P value < 0.05 was considered statistically significant.

RESULTS

Depression scores of children with asthma and depressive disorder

Among the 60 children in the observation group, 20 had mild depression, accounting for 33.33%, 24 had moderate depression, accounting for 40%, and 16 had severe depression, accounting for 26.67%.

Univariate analysis of basic information of the two groups of children

Univariate analysis showed no statistically significant differences between the two groups in general characteristics such as age, disease duration, gender, place of residence, and whether they were only children (P > 0.05). Statistically significant differences were found between the two groups in terms of the primary caregiver’s education level, negative emotions of the primary caregiver, family history of asthma, parents’ understanding of asthma, medication adherence, and asthma control (P < 0.05; Table 1).

Table 1 Univariate analysis of basic information of the two groups of children, n (%)/mean ± SD.

Factor		Non-depression group (n = 60)	Group with depression (n = 60)	t value	P value
Age		9.35 ± 0.633	9.58 ± 0.70	1.921	0.057
Course of disease		2.34 ± 0.42	2.40 ± 0.35	0.708	0.480
Gender	Male	35 (58.33)	32 (53.33)	0.304	0.581
	Female	25 (41.67)	28 (46.67)
Place of residence	Urban area	32 (53.33)	29 (48.33)	0.635	0.782
	County seat	16 (26.67)	20 (33.33)
	Rural areas	12 (20.00)	11 (18.33)
Only children	Yes	24 (40.00)	26 (43.33)	0.137	0.711
	No	36 (60.00)	34 (56.67)
Education level of primary caregivers	High school and below	20 (33.33)	32 (53.33)	4.887	0.027
	College degree or above	40 (66.67)	28 (46.66)
Negative emotions of primary caregivers	Have	23 (38.33)	36 (60.00)	5.635	0.018
	None	37 (61.67)	24 (40.00)
Family history of asthma	Yes	23 (38.33)	35 (58.33)	4.805	0.028
	No	37 (61.67)	25 (41.67)
Parents’ level of understanding of asthma	Better	41 (68.33)	27 (45.00)	6.652	0.010
	Poor	19 (31.67)	33 (55.00)
Medication use guidelines	Better	40 (66.67)	29 (48.33)	4.126	0.042
	Poor	20 (33.33)	31 (51.67)
Asthma control	Better	37 (61.67)	24 (40.00)	5.635	0.018
	Poor	23 (38.33)	36 (60.00)

Logistic regression analysis of asthmatic children with comorbid depressive disorders

Factors showing differences in univariate analysis were included as independent variables in multivariate logistic regression analysis, with asthmatic children’s comorbid depression as the dependent variable. Variable assignment information is shown in Table 2. Multivariate logistic regression analysis showed that the primary caregiver’s educational level (high school or below), primary caregiver’s negative emotions (yes), family history of asthma (yes), parents’ understanding of asthma (poor), medication adherence (poor), and asthma control (poor) were all independent risk factors for asthmatic children’s comorbid depression, as shown in Tables 2 and 3.

Table 2 Variable assignment information.

Factor	Assignment
Depression in children with asthma	No depression group = 0; with depression group = 1
Education level of primary caregivers	College degree or above = 0; high school diploma or below = 1
Negative emotions of primary caregivers	No = 0; yes = 1
Family history of asthma	No = 0; yes = 1
Parents’ level of understanding of asthma	Better = 0; poor = 1
Medication use guidelines	Better = 0; poor = 1
Asthma control	Better = 0; poor = 1

Table 3 Logistic regression analysis of asthmatic children with comorbid depression.

Factor	β	SE	Wald χ²	P value	Odds ratio (95%CI)
Education level of primary caregivers	0.926	0.447	4.294	0.038	2.523 (1.051-6.055)
Negative emotions of primary caregivers	1.351	0.465	8.437	0.004	3.826 (1.552-9.612)
Family history of asthma	0.966	0.444	4.734	0.030	2.628 (1.101-6.273)
Parents’ level of understanding of asthma	1.332	0.470	8.017	0.005	3.787 (1.507-9.520)
Medication use guidelines	1.067	0.454	5.520	0.019	2.908 (1.194-7.083)
Asthma control	1.386	0.455	9.260	0.002	3.997 (1.637-9.758)

ROC analysis of asthmatic children with comorbid depressive disorder

ROC curve analysis showed that the primary caregiver’s educational level (high school or below = 1), primary caregiver’s negative emotions (yes = 1), family history of asthma (yes = 1), parents’ asthma awareness (poor = 1), medication adherence (poor = 1), and asthma control (poor = 1) all had statistically significant discriminatory value for the development of depressive disorders in children with asthma [area under the curve (AUC) > 0.5, P < 0.05]. The discriminatory power for asthma control was the highest (AUC = 0.625, 95%CI: 0.532-0.712; Table 4).

Table 4 Receiver operating characteristic analysis of asthmatic children with comorbid depression.

Factor	Area under the curve	Specificity	Sensitivity	Youden index	95%CI	P value
Education level of primary caregivers	0.600	66.67	53.33	0.200	0.507-0.688	0.025
Negative emotions of primary caregivers	0.608	61.67	60.00	0.217	0.515-0.696	0.015
Family history of asthma	0.600	61.67	58.33	0.200	0.513-0.720	0.026
Parents’ level of understanding of asthma	0.617	68.33	55.00	0.233	0.524-0.704	0.008
Medication use guidelines	0.592	66.67	51.67	0.183	0.498-0.680	0.040
Asthma control	0.625	61.67	63.33	0.250	0.532-0.712	0.005

DISCUSSION

the most common chronic diseases in childhood, asthma is increasingly associated with mental disorders, with depression being particularly prominent[14,15]. A systematic analysis of the related factors for depression in children with asthma and identification of which children with asthma belong to the high-risk group can help achieve early identification and accurate warning, and provide a certain reference for the development of targeted early psychological intervention and comprehensive management strategies. The results of this study showed that the primary caregiver’s educational level (high school or below), the primary caregiver’s negative emotions (yes), family history of asthma (yes), parents’ awareness of asthma (poor), medication adherence (poor), and asthma control (poor) were all independent related factors for depressive disorders in children with asthma.

First, from the perspective of society and family, the low level of education of the main caregivers and the existence of negative emotions of caregivers are important remote risk factors for depression in children. The data of this study showed that the risk of depression in children with low education level of caregivers was 2.5 times higher than that in the control group [odds ratio (OR) = 2.523]. This phenomenon can be explained more profoundly through the family stress model. This kind of external pressure does not directly affect children, but indirectly affects them by gradually eroding the emotional environment within the family. The caregiver’s lower education level may limit their ability to acquire, understand, and use complex medical information, making it difficult to accurately identify the child’s asthma attack precursors and emotional abnormality signals. At the same time, the lack of targeted psychological counseling can easily trigger the child’s depressive mood[16]. Pinot de Moira et al[17] showed that low education level is often associated with low family economic level, which not only directly exacerbates the care pressure of children with asthma, but may also have a significant negative impact on disease control by limiting access to medical resources and increasing the family burden. In addition, the risk ratio of caregivers’ negative emotions in this study was as high as 3.8 (OR = 3.826), suggesting that caregivers may play a key mediating role in the process of pressure transmission. The caregiver’s own anxiety, depression, and other negative emotions will directly create a high-pressure and uneasy family emotional atmosphere, which will directly affect the occurrence of depressive disorders in children. As a chronic disease, asthma requires a lot of time and energy for long-term care, which can easily cause caregivers to experience negative emotions such as anxiety and depression. Children’s emotional regulation ability is not yet mature, and they are highly sensitive to the emotional state of caregivers. The negative emotions of caregivers can be directly transmitted to children through daily interactions[18,19]. At the same time, negative emotions may lead to insufficient emotional response from caregivers to children, decreased caregiving patience, damage to parent-child attachment, weakening of children’s psychological security, and ultimately increasing the risk of depressive disorders. This is consistent with the previous research conclusion that “the emotional state of caregivers is an important influencing factor of psychological problems in children with chronic diseases”[20,21]. A family history of asthma is a complex factor. It may indicate the superposition of genetic susceptibility, and often means the specific pattern or potential burden formed by the family’s long-term coping with chronic diseases[22]. The synergistic effect of these factors constitutes a significant related factor for asthmatic children with depressive disorders.

Secondly, at the psychological and behavioral level, parents’ disease cognition level and medication compliance constitute the key mediating behavior path to link the family environment risk with the disease outcome of children. The pressure load accumulated in the family system ultimately needs to affect the health status of children through specific disease management behavior. Parents’ insufficient awareness of asthma (OR = 3.787) and poor medication compliance (OR = 2.908) are the specific manifestations of this kind of family stress at the behavioral level. On the one hand, parents with limited cognitive level may not be able to accurately identify the early signals of children’s disease changes, or experience the loss of control and helplessness in the process of disease management decision-making. This negative cognitive emotional experience may penetrate into the daily interaction mode between parents and children; on the other hand, poor medication compliance directly leads to the decline of asthma control level, which makes children repeatedly exposed to physiological pain such as wheezing and chest tightness. The persistent physical discomfort not only interfere with the children’s sleep rhythm, academic performance and peer communication, but also may lead to the children’s gradually accumulated sense of helplessness and frustration about their own diseases. Long term exposure to this negative experience is likely to lead to depression[23,24]. These factors are the core objectives of intervention, because they transform abstract family background risks into specific and harmful health behaviors.

Finally, from the biological point of view, the family history of asthma and poor asthma control are two factors, which further suggests that there may be a common biological basis between asthma and depression. Among them, the existence of family history of asthma (OR = 2.628) may reflect the genetic susceptibility of the body to specific inflammatory reactions, while poor asthma control (OR = 3.997) may continue to strengthen and maintain this pathological state, thereby increasing the related physiological and psychological burden. At the same time, poorly controlled asthma itself constitutes a continuous and intense source of psychological trauma, greatly increasing the risk of developing depressive disorders[25]. In addition, asthma is a chronic inflammatory disease, and its characteristic airway inflammation can lead to the increase of systemic pro-inflammatory cytokines such as interleukin-6 (IL-6) and C-reactive protein[26]. Both basic and clinical studies have confirmed that elevated IL-6 can directly act on the brain through the blood-brain barrier, affect the metabolism of neurotransmitters such as 5-hydroxytryptamine, and activate microglia in the brain area responsible for emotion regulation, thereby inducing depressive symptoms[27]. In this study, poor asthma control, the most closely related factor, may directly form the biological basis of emotional disorders in children through the persistent systemic inflammatory load. At the same time, the negative emotions of the primary caregivers, as a chronic psychological stressor, may further amplify the inflammatory reaction in the body by activating the hypothalamus pituitary adrenal axis of the child. Therefore, the relevant factors found in this study may not only be early warning signals at the psychosocial level, but also form a biological bridge from asthma to depression through the interaction with systemic inflammation.

ROC curve analysis showed that the AUC values corresponding to the above six factors ranged from 0.592 to 0.625. Although the lower limit of the 95%CI was greater than 0.5, it was statistically significant, indicating that these factors had a certain ability in distinguishing whether children were complicated with depression, but the overall prediction efficiency was low. The highest AUC value of asthma control was only 0.625. This suggests that the value of using these factors as independent predictive tools for accurate diagnosis at the individual level is limited. The clinical significance of this study is mainly reflected in the level of risk identification, suggesting that the above factors can be used as psychological early warning signals that need to be highly concerned in clinical practice. Based on these indicators, combined with in-depth interviews and behavior observation, clinical workers can carry out systematic psychological state assessment for high-risk children, rather than simply relying on the scale score to predict the risk of depression. Therefore, the results of this study provide the basis for the construction of a preliminary screening framework, help to optimize the allocation of resources, and more accurately invest the limited medical intervention resources to children with high psychological risk and their families.

This study also has some limitations. First of all, in terms of causal inference, this study uses a cross-sectional design, which can only reveal the correlation between each factor and depression in children with asthma, and cannot confirm its causal relationship. The factors identified in this study, such as caregivers’ negative emotions, asthma control and other related factors, may interact with children’s depression, forming a complex feedback loop, rather than a simple one-way causal relationship. For example, poor asthma control may induce depression, and depression may in turn reduce medication compliance and further aggravate asthma symptoms. Future studies should adopt a prospective cohort design, through multi-point follow-up, to track the dynamic change process and time sequence of each factor and children’s depressive symptoms, so as to clarify its causal path and interaction mechanism more clearly. Secondly, in the depth of mechanism discussion, this study mainly focused on the observable factors at the level of social demography and disease management, and failed to include the corresponding biological indicators for verification. The relevant factors found in this study may not only be early warning signals at the psychosocial level, but also form a biological bridge from asthma to depression through the interaction with systemic inflammation. Future research should include the laboratory detection of inflammatory markers such as IL-6 and C-reactive protein, combined with the perspective of neuroimmunology, to more accurately reveal the complex mechanism of comorbid depression in children with asthma from the social psychological biological multidimensional level. Finally, in terms of sample representativeness, the samples of this study are all from the same hospital, and the sample size is relatively limited, there may be selection bias, and the extrapolation of the research conclusion is limited. The follow-up study should carry out a multi-center, large sample survey, and include children in different regions and different levels of medical institutions, so as to verify the stability of the conclusion of this study, and provide more evidence-based basis for the development of more universal clinical intervention strategies.

CONCLUSION

In conclusion, the development of depressive disorders in children with asthma is the result of multiple factors, including genetics, environment, disease management, and psychological interaction. In clinical practice, targeted interventions are needed, such as strengthening health education and psychological support for caregivers with lower levels of education, enhancing parents’ asthma knowledge and medication guidance, and emphasizing psychological screening for children with a family history of asthma. By improving disease control and the quality of family care, the risk of depressive disorders can be reduced, thus protecting the physical and mental health of children.