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New Study Links Violence-Related Stress and Decreased Lung Function and Quality of Life In Children With Asthma

November 12, 2021

A new study1 led by UPMC Children’s Hospital of Pittsburgh Division of Pediatric Pulmonary Medicine researchers has uncovered an association between chronic stress as a result of witnessing or experiencing violence and decreased lung function and lower quality of life in children with asthma

Division fellow Kristina Gaietto, MD, and Division faculty, Yueh-Ying Han, PhD, were the lead authors of the study. Division chief Juan C. Celedón, MD, DrPH, ATSF, was the senior author of the investigation.

The study was published in September in the European Respiratory Journal and represents the first prospective investigation to assess lung function in children with asthma in the setting of violence-related stress. The study is also the first prospective research to analyze low-dose corticosteroid treatment data related to lung function and the experience of violence-induced stress.

Research Highlights and Clinical Implications

The first part of the examination was a secondary analysis of data from the Vitamin D Kids Asthma Study (VDKA) randomized trial.2 In brief, the participants in the VDKA all had mild persistent asthma and represented a racially and ethnically diverse U.S. cohort. Results from this secondary analysis were then replicated in the “Prospective Study of Puerto Rican Youth and Asthma Study” (PROPRA), which followed a cohort of 232 children with and without asthma who reside in Puerto Rico.

Measures of violence-related stress were captured and scored using the Checklist of Children's Distress Symptoms.

Not only did violence-related stress lead to decreases in lung function and quality of life in the participants, but those individuals being treated for asthma with low-dose corticosteroid therapy also experienced decreases in lung function and quality of life of a similar nature.

Data from the prospective study in Puerto Ricans corroborated the findings of the secondary analysis of the VDKA data in that for every 1 point increase in the CCDS score, participants were found to have an associated 3.27% decrease in forced expiratory volume1 (FEV1) and a 2.65% decrease in forced vital capacity.

The analysis also found that even individuals being treated with a low-dose corticosteroid for their asthma experienced decreased lung function and lower quality of life related to violence-associated stress. The mechanisms for this reduced sensitivity to corticosteroids could be a result of "dysregulation of the HPA and sympathetic-adrenal-medullary (SAM) system," and that other factors, such as epigenetic changes, may also contribute to the reduced sensitivity, but the exact nature of this interplay is unknown and yet to be studied.

“Violence-related stress can negatively affect lung function and quality of life for individuals with asthma. It can do so over time, and our findings suggest that this stress may reduce an individual’s sensitivity to low-dose corticosteroid therapy, making it less effective for treating and managing asthma,” says Dr. Gaietto. “As we study a range of social determinants of health, stress, and other outside influences on the health and quality of life of individuals with asthma, it is becoming increasingly clear just how important these factors are to the physical well-being and disease state of the individual.” 

As the research team concludes, reducing the experience of violence and its accompanying stress, apart from its broader sociologic implications and effects on the individual, may present a modifiable factor in improving lung function and maintaining the efficacy of steroid therapy in children with asthma.

Learn more about the study and its findings at the reference below.


1. Gaietto K, Han Y-Y, Forno E, et al. Violence-related Distress and Lung Function in Two Longitudinal Studies of Youth. Eur Respir J. 2021 Sep 29: 2102329. Online ahead of print.

2. Forno E, Bacharier LB, Phipatanakul W, Guilbert TW, Cabana MD, Ross K, Covar R, Gern JE, Rosser FJ, Blatter J, Durrani S, Han YY, Wisniewski SR, Celedón JC. Effect of Vitamin D3 Supplementation on Severe Asthma Exacerbations in Children With Asthma and Low Vitamin D Levels: The VDKA Randomized Clinical Trial. JAMA. 2020 Aug 25; 324(8): 752-760.