A Comparative Study of Self Concept and Related Factors in Asthmatic and Healthy Schoolchildren

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1 Factors related to self concept of asthmatic schoolchildren ORIGINAL ARTICLE A Comparative Study of Self Concept and Related Factors in Asthmatic and Healthy Schoolchildren Shu-Chen Cheng, Yueh-Chih Chen 1, Bor-Luen Chiang 2, Yue-Cune Chang 3 School of Nursing, Tzu Chi College of Technology, Hualien, Taiwan; School of Nursing 1, National Taiwan University, Taipei, Taiwan; Department of Pediatrics 2, National Taiwan University Hospital, Taipei, Taiwan; Department of Mathematics 3, Tamkang University, Taipei, Taiwan ABSTRACT Objective: With a positive self concept, asthmatic schoolchildren are likely to accomplish self-management behaviors. The purpose of this study was, therefore, to investigate the self concept of school age children with and without asthma, and probe related factors. Materials and Methods: The subjects, 150 fourth to sixth graders of whom 50 were asthmatic and 100 were healthy, were purposively selected from a pediatric allergy outpatient clinic in a medical center in northern Taiwan. The research tools included a structured questionnaire, the Self Concept Scale and the Parenting Style Scale. Data were analyzed by descriptive and inferential statistics using SPSS for Windows/PC10.0 software and StatXact-5 statistical software. Results: There was a significant difference between the self concept of asthmatic and healthy schoolchildren. Asthmatic children s overall self concept (p<0.001), self concept family subscale (p<0.05), and self concept physical subscale (p<0.001) were lower than those of healthy children. Asthmatic children s limits in physical education class were significantly correlated with overall self concept, whereas the overall self concept was highest for children with full class attendance (p<0.05) and no shortness of breath after exercise (p<0.01). After modifying for the group effect, the parenting style and overall self concept were positively correlated (p<0.001). Conclusions: These research results can serve as guidelines for medical care professionals, parents, and teachers, in caring for and teaching asthmatic and healthy schoolchild. (Tzu Chi Med J 2005; 17: ) Key words: asthmatic schoolchild, healthy schoolchild, self concept, parenting style INTRODUCTION Asthma is a type of chronic allergic inflammatory response with polygenic inheritance. The symptomatic course can last for a significant period of time. Most childhood asthma can be cured. When the disease cannot be cured, the symptoms can be controlled, allowing a normal lifestyle. Twenty percent of childhood asthma occurs before the age of 1 year, and 80% of cases occur before the age of 5. The male to female ratio is 2:1, with a ratio of 1:1 after puberty; one in three children will have a history of asthma [1]. Asthma is a very common chronic disease among children. Almost 5%-15% of the children less than 15 years old suffer from asthma [2]. Using statistics from the 1999 American Academy of Allergy, Asthma & Immunology(AAAAI) guide, a recent government study showed a 46% increase in the prevalence of ashma between 1982 and 1993, with 80% of patients below the age of 18 [3]. In 1990 asthma treatment expenditures (including direct and indirect expenses) were approximately 62 hundred million US dollars, with 43% of the costs from emergencies, hospital admissions for treatment and deaths. Asthma is also Received: December 2, 2004, Revised: January 7, 2005, Accepted: February, 2005 Address reprint requests and correspondence to: Lecturer Shu-Chen Cheng, School of Nursing, Tzu Chi College of Technology, 880, Section 2, Chien Kuo Road, Hualien, Taiwan PPN

2 S. C. Cheng, Y. C. Chen, B. L. Chiang, et al the most common cause of school absences, averaging more than 10 days annually, and sometimes exceeding 30 days for severely asthmatic children. Hesieh reported that the incidence of asthma among 7-15-years-old children in Taipei had risen from 1.3% in 1974, 5.05% in 1985 and 5.8% in 1991, to 10.49% in 1994 [4]. The families of children suffering chronic illness often have worries and confusion about the disease. The instability of the disease, repeated hospital admissions, worry over the future of the child and unpredictability of the disease course add to their stress [5]. Research has also shown that children with chronic illnesses (such as cancer, diabetes, and especially asthma) have more psychosocial problems in adaptation. Because parents are uncertain about the child s disease, they are often overprotective and restrict their child s activities, allowing fewer opportunities for the child to participate in social and leisure activities. This contributes to adaptive emotional problems, such as anxiety, and internalizing behaviors, which can progress to lowered self esteem [6-8]. One study showed that the age of onset of asthma was related to self concept. Children who had asthma before the age of five had poorer self concepts [8]. Limiting activities because of possible asthmatic attacks during exercise especially impacts asthmatic school children. They may fear or refuse to exercise, or feel inadequate when playing sports, and subsequently form a negative self-evaluation, which impairs their physical and psychological development. Therefore, if nursing educators can appreciate and identify early, relevant factors causing negative self concepts among children with chronic asthma, they can promote normalization goals within these childrens families. Factors influencing the self concept include age, school grade, gender, rank among siblings, height, weight, number of days absent from school, overall academic performance, the family s social and financial position, the marital relationship of the parents, the age of onset of asthma, the length of illness, the severity of the disease, the progress and status of therapy, sports limitations, and parenting style. However, no studies have been conducted in Taiwan concerning self concept among pediatric asthmatic patients. Therefore, this study investigated the differences in self concept and related factors between asthmatic children in grades four to six and their peers. We hope the results of this study can be applied, in nursing education as a reference for education on asthma control. We also hope to provide a reference for medical staff, family, teachers and school nurses on the care, education and supervision of asthmatic school children and their peers. We also hope these results can be used as a reference for future studies, and can provide recommendations for future research. MATERIALS AND METHODS Targeting subjects and setting Since this research is a comparative study, we employed purposive sampling. Data was collected between December 2001 and April The subjects were selected from the registry at a pediatric allergy and immunology outpatient clinic in a medical center in Taipei. Asthmatic children in grades 4 to 6 who visited the clinic and their school peers were chosen as study subjects. An asthmatic schoolchild refers to a child in primary grade 4 to 6 who had been diagnosed with asthma by a pediatric allergy specialist with a history of disease forone year (inclusive) or more (to the date of file closure). Subjects could have no other confirmed diagnosis of major illness, or a history of psychiatric or chronic illness. A healthy school peers refers to a schoolmate of the asthmatic schoolchildren in aprimary school. For each asthmatic child, one boy and one girl peer were randomly selected using a random number table, for a total of 150 subjects, of which 50 had asthma and 100 were healthy. Healthy subjects could have no confirmed diagnosis of asthma or other major illness, psychiatric illness or chronic illness. Consents were obtained from all study subjects. Research Instruments Basic data questionnaire This included basic characteristics (such as age, grade, gender, ranking among siblings, height, weight, the total number of days absent during the previous academic year, overall academic performance during the previous semester), family characteristics ( socioeconomic status of the family, marital relationship of the parents) and disease characteristics ( age at disease onset, the duration of illness, the severity of the disease, the progress of treatment, physical limitations, and whether the patient used an inhaler/pump). Self Concept Scale for primary schoolchildren This study employed the Self Concept Scale for primary schoolchildren in grades 4 to 6 published by Wu and Ho [9]. The assessment includes a family subscale (Questions 1-17), school subscale (Questions 18-31), appearance subscale (Questions 32-40), physical subscale (Questions 41-52), and emotion subscale (Questions 53-61). Scale points are derived from these five subsections for a total of 61 questions. The family subscale examines the subject s personal awareness of the interactions and relationships between the subject PPO

3 Factors related to self concept of asthmatic schoolchildren and their parents, their family members, and their siblings. The school subscale refers to subject s personal awareness of the interactions and relationships between the subject and their teachers, friends, and classmates from school. The appearance subscale refers to the subject s personal awareness of their physical status and appearance. The physical subscale questions the subject s awareness of their performance during sports activities and their physical conditions. The emotion subscale refers to the subject s awareness of their personal daily emotional status. This scale employed the internal consistency Cronbach α value and test-retest reliability to assess the reliability of the scale. The internal consistency Cronbach α value was , and the test-retest reliability measured at 2 week intervals ranged between Overall, each subsection of the scale was more specific for individuals with low-normal and sub-normal self concepts, and it was more sensitive in detecting individuals with low self concepts. A Likert s 5 point scale was used to assess the self concept, with a higher score predicting a higher self concept. The highest possible score was 305 points, and the lowest 61 points. The reliability of the Self Concept Scale for the primary schoolchild used by our study had a calculated Cronbach α value of 0.92, showing that the measurement had considerable internal consistency. Cronbach α shows the observed correlations or covariances of items with each other. The validity assessment of the study employed the professional content validity, where the whole scale scored an average of 4.48, and the professional consistency was 0.97, revealing that this scale has considerable content validity. Parenting Style Scale Our study utilized the Parenting Style Scale compiled by Huang [10]. The scale contained aspects on parent-child interaction, academic work, friends and entertainment, and daily disciplinary regulations. The list content and the number of the questions are identical, each with 26 questions. Questions 1-14 belong to the responsiveness level, with scoring between points, and questions belong to the demands level, with scoring between points. The highest possible score is 104 points, and the lowest 26 points. The Cronbach α for the teaching and disciplinary method scale of the father was 0.92, and that of the mother was 0.93, showing that both of these scales had consistency and reliability. This scale used a Likert 4 point scoring method, with a higher score for a higher degree of response or demand perceived by the child from the teaching and disciplinary methods of their father and mother. In this study, the reliability of the Parenting Style Scale used by our study had calculated Cronbach α values of 0.93 and 0.89 respectively, showing that these measurements possess considerable internal consistency. The validity assessment of the study employed the professional content validity, where the whole scale scored an average of 4.47 and 4.45 respectively, and the professional consistency was 0.99, revealing that this scale has considerable content validity. Statistical analysis The data collected were analyzed by descriptive (splitting and distributing the number of times, percentages, means, and standard deviations) and inferential statistics (Pearson s Chi-Square, Fisher s Exact Test, Mann-Whitney U test, Kruskal-Wallis test, Spearman Correlation and multiple regression analysis) using SPSS/Window 10.0 software and the StatXact statistical program. A value of p<0.05 was taken as the level of significance. RESULTS Basic characteristics and special features of illness in the studied subjects The asthmatic group and the healthy group both had an average age of 10.5±0.9 years old. There were more boys in the asthmatic group (72%), whilst the healthy group had an equal number of boys and girls (50% each). Most of the subjects were the oldest child in their family. The number of days absent from school in the previous academic year averaged 1.6±0.6 days in the asthmatic group, and 1.3±0.4 days in the healthy group. The overall academic performance during the both groups scored most distinctions in their reports. Eighty percent of the families in both groups were upper middle class; 90% of the parents were married and lived together. There were statistically significant differences in gender and number of days absent from school between the two groups (p<0.05). Other factors showed no significant differences, which reveals great similarity between the 2 groups. The average age at first asthma attack for the asthmatic school children was 5.0±2.3 years, and the average duration of illness was 5.5±2.3 years. Formerly, the severe persistent type of asthma was most commonly seen (36%), but now, the mild intermittent type has become the most common (82%) (Table 1) [11]. The average number of asthmatic attacks in the previous year per asthmatic schoolchild was 5 times (70%). Most of the subjects not apply for school absence during their asthmatic attacks (60%). Asthmatic children experienced most of their asthmatic attacks during heavy exercise PPP

4 S. C. Cheng, Y. C. Chen, B. L. Chiang, et al (46%). Seventy percent of asthmatic schoolchildren used one (inclusive) or more asthmatic inhaler/pump. Self concept and parenting style The scores of the scales used in this study were analyzed using the Mann-Whitney U test (Table 2). The normal peer group scored higher than the asthmatic group in the whole self concept scale (p<0.001), the self concept family subscale (p<0.05) and the self concept physical subscale (p<0.001). The healthy peer group scored higher than the asthmatic group in the areas of father s teaching and disciplinary method whole scale (p<0.01), the father s responsiveness score (p<0.01), the mother s teaching and disciplinary method whole scale (p<0.01), the mother s responsiveness score (p<0.01), and the mother s demands score (p<0.05). Relationship between basic characteristics and special features of disease and self concept The results, which are divided into 2 parts (Tables 3 and 4), were statistically analyzed using the Mann- Whitney U test and the Kruskal-Wallis test. Physical education and exercise limitations were highly relevant to the overall self concept of asthmatic schoolchildren. Children who were able to complete physical education sessions (z=-2.296, p<0.05) and exercise without shortness of breath had the highest scoresin overall self concept (Chi-square=11.216, p<0.01). The other basic characteristics and special features of the disease had no significant relevance to the overall self concept. In the healthy group, children who participated in all of the physical education sessions (z=-2.250, p<0.05) and children with married parents who lived together (z=-2.013, p<0.05) had the highest scores in overall self concept. The other basic characteristics had no significant relevance to the overall self concept. The impact of parenting style on self concept The overall self concept scoring for both groups demonstrated moderately positive correlations (p<0.05) with the scores for father s teaching and disciplinary method, father s responsiveness, father s demands, Table 1. Classify Severity of Asthma Severity Categories Symptoms Frequent PEF Daytime Nighttime Predicted% Variability% Severe Persistent continuous exacerbations frequent 60 > 30 Moderate Persistent > 1 time/day 1 time/week > 30 Mild Persistent 1 time/week > 2 time/month < 1 time/day Mild Intermittent < 1 time/week 2 time/month 80 < 20 Table 2. Score Analysis of Self Concept Scale for the 150 Subjects Total (N=150) Name of the Scale Asthmatic Group Normal Peers Group Statistic Results (N=50) (N=100) Mean±SD Mean±SD The Whole Scale 227.8± ±28.6 P< 0.001** Family Subscale 68.7± ±10.0 P=0.015* School Subscale 57.3± ±7.1 P=0.300 Appearance Subscale 32.2± ±7.0 P=0.106 Physical Subscale 36.8± ±9.0 P< 0.001** Emotion Subscale 32.7± ±6.3 P=0.148 The father s teaching and disciplinary method scale 75.9± ±14.2 P=0.002** Responsiveness 37.3± ±8.8 P=0.001** Demanding 38.5± ±6.8 P=0.100 The mother s teaching and disciplinary method scale 85.9± ±9.9 P=0.002** Responsiveness 43.5± ±7.3 P=0.002** Demanding 42.4± ±4.1 P=0.028* *: p< 0.05; **: p< 0.01 PPQ

5 Factors related to self concept of asthmatic schoolchildren Table 3. Score Analysis of Self Concept Scale by Demographic Characteristics for the 150 Subjects Factor Asthmatic Group Normal Peers Group (N=50) (N=100) Statistic Results Mean±SD Mean±SD Asthmatic Group Normal Peers Group Grade Grade ± ±29.3 Chi-square=0.598 Chi-square=2.283 Grade ± ±30.8 Grade ± ±24.9 P=0.742 P=0.319 Ranking at Home Oldest 226.5± ±29.5 Chi-square=3.058 Chi-square=0.492 Second and Third 213.7± ±27.8 Youngest 235.7± ±28.2 P=0.217 P=0.782 Socioeconomic Status Lower 227.3± ±30.6 Chi-square=3.324 Chi-square=5.498 Middle 221.6± ±27.9 High 240.5± ±26.5 P=0.190 P=0.064 Parental Marital Status Married and live together 228.0± ±29.3 Z=0.000 Z= Married but live apart or divorced 225.7± ± 9.8 P=1.000 P= 0.044* School Absent Days No 232.1± ±30.8 Z= Z= Yes 224.2± ±21.7 P= P= Overall Academic Result Distinction (A+) 233.3± ±29.7 Z= Z= A and B 218.9± ±24.2 P= P= Attendance Situation for the Physical Education Attended all 232.5± ±28.2 Z= Z= Did not attended all 211.4± ±27.5 P= 0.022* P= 0.024* *: p< 0.05 Table 4. The Analysis of Special Feature of Disease and the Whole Scale amongst the Asthmatic Schoolchild (N=50) Disease characteristics Self Concept Whole scale Mean±SD Statistic Results Previous Asthma Severity Categories Mild Intermittent 231.1±34.2 Mild Persistent 234.2±23.3 Chi-square=4.539 Moderate Persistent 204.3±24.9 P=0.209 Severe Persistent 230.7±23.7 Present Asthma Severity Mild Intermittent 228.4±30.5 Mild Persistent 220.3± 6.4 Chi-square=0.264 Moderate and Severe Persistent 229.2±19.6 P=0.877 The Number of Asthmatic Attacks in the Most Recent 1 year No 235.2±26.1 Z= Yes 225.2±28.9 P= Number of School Absent Days due to Asthma Attacks in Most Recent 1 year No 228.3±29.2 Z= Yes 5 days 227.1±27.6 P= Sporting Limitation No short of breath with any exercise 244.5±25.8 Short of breath during heavy exercise 217.8±20.7 Chi-square= Short of breath during light exercise 213.0±35.9 P=0.004* *: p< 0.05 PPR

6 S. C. Cheng, Y. C. Chen, B. L. Chiang, et al mother s teaching and disciplinary method, mother s responsiveness, and mother s demands. Higher scores in these areas led to higher overall scores in self concept. Furthermore, multiple regression showed that the group category had a significant impact on the overall score for self concept (p<0.001). DISCUSSION Current situations and problems with illness Sixty percent of asthmatic schoolchildren had no school absences in the previous year. This is similar to the findings of Jiang et al who reported that 41% of asthmatic schoolchildren had school absences due to asthmatic attacks [12]. Most family members of asthmatic schoolchildren said that they allow a child who experienced asthmatic attacks during illness, fevers, or exercise to stay at home. There was a statistically significant difference (p<0.05) in the the number of school absences between groups in this study. The asthmatic schoolchildren had an average of 1.6±0.6 days absent, while the healthy schoolchildren had an average of 1.3±0.4 days absent. Goldstein and Hurd reported that children with chronic illness have higher absence rates than healthy schoolchildren. This study showed higher school absence rates did not significantly affect academic performance, similar to findings reported by Boekaerts and Roder [14]. However our results differ from those in a review by Celano and Geller, possibly because most of the children in the asthmatic group in this study had the mild intermittent type of asthma [15]. They experienced fewer symptomatic episodes than most patients in the Celano and Geller review, and the majority had achieved good symptom control. Approximately 80% of the families in this study were upper middle class, which may be another reason why academic performance remained unaffected. The self concept of the studied subjects The scores for the healthy schoolchildren were significantly higher than those of the asthmatic schoolchildren in the whole self concept scale, self concept family subscale and self concept physical subscale. Although we found no previous studies of self concept among asthmatic schoolchildren, our study results were similar to findings in research on other diseases. The self concepts of patients with insulin-dependent diabetes mellitus between primary school grade 4 and high school grade 3 are generally lower than healthy schoolchilden [16]. Children in primary school with senior grade cleft palates have lower self concepts in the physical and appearance areas than other schoolchildren [17]. However, hemophilic schoolchildren do not have significantly different self concepts from healthy schoolchildren [18]. Similar to other studies, asthmatic schoolchildren in this study were less satisfied with their family relationships, showed significantly lower self concepts and had a poorer self image reflection than healthy schoolchildren [7,8]. Schoolchildren have developed a fairly comprehensive self concept and they focus on their body image and daily activities. Therefore limits on sports participation, and poor academic performance caused by asthma, along with the sudden and recurrent nature of asthma attacks, affect children s moods, behavior and psychosocial adaptation [19]. This very likely lowers the self concept of the asthmatic schoolchildren compared with that of healthy children. For asthmatic schoolchildren the self concept for body in this study was similar to that of healthy schoolchildren, which differs from other studies [14,19]. However 16% of year-old asthmatic schoolchildren experienced increased anxiety compared to healthy schoolchildren before exercise, and they also sensed less pressure from their parents and teachers in this area. Otherwise, their motivation to complete exercise was identical to the healthy children. The reason for the differences may be differences in research subjects, sampling size or research instruments. Factors associated with self concept The asthmatic children s participation in physical education was significantly related to their self concept, school self concept, body self-concept and mood; whereas the healthy childrens participation in physical education was significantly related to their self concept, body self concept, and mood. The majority of children participated in all physical education sessions. Between the ages of 6 and 12 years, children take part in many social events and competitions which aid in developing social mutualism. If a child feels unloved by their parents, or feels belittled by their peers and teachers due to their anxiety [20], and then can not participate in physical education as a result of this anxiety, their social self development may be affected, causing adaptive problems in self evaluation and mood adjustment. Asthmatic schoolchildren may also experience this problem. Possibly, because they feel they lack endurance during sports, they notice that their peers do not seek them out during sports and games. This, along with their fears of exercising, may trigger asthma attacks. This study also revealed a significant relationship between physical limitations and self concept inasthmatic schoolchildren. The PPS

7 Factors related to self concept of asthmatic schoolchildren self concept of asthmatic childrenen who felt no shortness of breath(sob) during sports performance was higher than that of asthmatic children who experienced SOB during heavy exercise. Asthmatic children who experienced SOB during heavy exercise had higher self concepts than asthmatic children who experienced SOB during light exercise. However, the disease severity of the asthmatic schoolchild showed no significant relevance to self concept which differs from the results of the review by Celano and Geller [15]. The reasons for the difference may be that cases were only collected in clinics. In addition, due to human resource and time constraints, no stratification according to severity of disease was done during the sampling process, resulting in fewer severely asthmatic children among the study subjects. The relationship between self concept and parenting style There were much higher scores in the whole scale, responsiveness and demands areas for primary school children s parents teaching and disciplinary methods than found by Huang [10]. This could be due to the fact that families have fewer children now than they did a few years ago. Therefore both parents have shown significant increases in responsiveness and demands. The higher the scores from the parents teaching and disciplinary methods, the better the overall self concept of the children, since the most obvious methods parents use to influence their children is teaching and disciplinary activities. Therefore, if parents follow the natural development of their children, if they consider the development of the child a primary task, and if they have appropriate caring and authoritative attitudes at the right time, there will be a positive influence on the personality characteristics and life adaptation of the child s mental and physical development [21]. There were also significant differences in parental teaching and disciplinary methods and overall self concept between asthmatic and healthy schoolchildren. Following adjustment for the category effect, the parental teaching and disciplinary method still showed significant positive correlations with overall self concept. The higher the score parents achieved in their teaching and disciplinary methods, the better the overall self concept. Through comparisons between healthy and asthmatic schoolchildren we now know more about their self concepts and related factors. This can help the medical team understand these patients better and assist them in incorporating the self concept of asthmatic children into assessment and health education. A better self concept can help in self care behavior and can facilitate the asthmatic schoolchild in having a more normal life. Furthermore, the medical care team can work closely with school nurses and teachers in organizing health education on asthma, to increase the understanding of students and teachers about this condition. It is also important to allow the asthmatic schoolchild to have normal exercise, and to avoid fears by teachers and students that sports may trigger asthma attacks which could consequently reduce the opportunity for asthmatic children to exercise, and simultaneously affect the self evaluation of asthmatic schoolchild. Our study subjects were chosen from a medical center in Taipei. Research results may not be generalized to asthmatic schoolchildren and their healthy peers in the rest of Taiwan. We advise that a larger sample size, subjects from different areas, and children with asthma of different degrees of severity be chosen as subjects for future study to improve the inferential power of the research results. REFERENCES 1. Bjornson CL, Mitchell I: Gender differences in asthma in childhood and adolescence. J Gend Specif Med 2000; 3: Lemanek KL: Commentary: Childhood asthma. J Paediatr Psychol 1995; 20: American Academy of Allergy, Asthma & Immunology (AAAAI): Paediatric asthma promoting best practice: Guide for managing asthma in children. University of Rochester, Academic Services Consortium, 1999, pp Hesieh KH: Prevalence and management of childhood asthma. Acta Paediatr Taiwanica 1995; 36: Cheng TY: Adaptation of family with children chronic illness. Hu Li Za Zhi 1996; 43: Padur JS, Rapoff A, Houston BK, et al: Psychosocial adjustment and the role of functional status for children with asthma. J Asthma 1995; 32: Brook U, Tepper I: Self-image, coping and familial interaction among asthmatic children and adolescent in Israel. Patient Educ Couns 1997; 30: McNelis AM, Huster GA, Michel M, Hollingsworth J, Eigen H, Austin JK: Factors associated with self-concept in children with asthma. J Child Adolesc Psychiatr Nurs 2000; 13: Wu YY, Hou YL: The guideline booklet of self concept scale for primary school children, Taipei: Psychology Publishing, 2000, pp Huang YJ: A Study of Relationship of Type A Behavior, Parenting Style and Adjustment on Elementary Students [Dissertation]. Kaohsiung, Taiwan: Kaohsiung Normal University,1997, pp Global Initiative for Asthma (GINA): Pocket Guide for Asthma Management. NHLBI/WHO Workshop Report, PPT

8 S. C. Cheng, Y. C. Chen, B. L. Chiang, et al 12. Jiang LC, Huang JL, Chang ML: The investigation into the quality factor and the self caring behavior of the asthmatic school children; and the influence of summer camp has on them. J Nurs Res 1999; 7: Goldstein RA, Hurd S: The rising problems of asthma: Mechanisms and management. Introduction. Chest 1992; 101:355S- 356S. 14. Boekaerts M, Roder I: Stress, coping, and adjustment in child with a chronic disease: A review of the literature. Disabil Rehabil 1999; 21: Celano MP, Geller RJ: Learning, school performance, and children with asthma: How much at risk? J Learn Disabil 1993; 26: Hsiao SC, Hong LC, Jiang YJ, et al: The discussion on self concept evaluation amongst the insulin dependent diabetic youth, family caring behavior, and school life. Chin Med J 1994; 4: Lu WH: The Study of Cleft Palate Children s Social Status, Social Behavior and Self-Concept [Dissertation]. Taoyuan, Taiwan: Chung Yuan Christian University, 1998, pp Wen YC: A Comparative Study of Adjustment Problems and Coping Strategies between Hemophilic and Healthy Children [Dissertation]. Taipei,Taiwan: University of Taiwan, 2001, pp Weston AR, Macfarlane DJ, Hopkins WG: Physical activity of asthmatic and nonasthmatic children. J Asthma 1989; 26: Ruo HH: The development of self concept. Kuo Chiao Chih Sheng 1992; 26: Huang BC: The study of relationship between life adaptation of the primary school children, their parental teaching and disciplinary attitude and their personality characteristics. Psychol Test 1978; 26: PPU