tion may be perceived as distal from the noncompliant action. Most patients miss occasional doses without any noticeable consequence, although failure to take a prophylactic medication may increase the likelihood of their experiencing an acute attack that requires hospital care ( Canny et al., 1989).
A major problem with medication compliance in childhood asthma occurs with respect to the management of attacks. As was noted earlier, the management of an attack involves a number of steps by the patient beginning with symptom detection and ending with the termination of the episode. There are a number of compliant behaviors that can be observed during an attack (e.g., the child taking an inhaled medication). In addition, it is possible to assess treatment outcomes of the child's behavior (e.g., a diminuition of symptoms, improved performance in respiratory testing, etc.). It is in the area of cognitive patient skills that uncertainty occurs, because knowledge regarding information processing and evaluation, decision making, and self-reaction can be obtained only through self-reports of the patient. At the present time, not enough patients know these self-management skills and are able to communicate their actions to others. As a result, patients encounter difficulties when they could be avoided. For example, FitzGerald and Hargreave ( 1989) recently proclaimed that "Most emergency visits, hospital admissions and life-threatening exacerbations are preventable because severe asthma usually develops over days and there is time to increase treatment to reverse them before they become severe" (p. 892). For various and sundry reasons, patients, including children, do not process information about what is occurring to their breathing, make management decisions based on this information, and communicate their needs to medical personnel. The matter becomes even more serious with respect to asthma mortality. A number of reports, including those that investigated mortality in children (e.g., Carswell, 1985), have found that deaths often result from severe asthma that is inadequately assessed and treated by the child and the medical staff alike. Future efforts must be directed towards teaching self-management skills to children with asthma; along with increased knowledge, effective ways to assess cognitive self-management skills, public only through self-report, must be developed. Increased performance of these self-management skills is ultimately the key to medication compliance and, in turn, to the successful control of childhood asthma.
Preparation of this chapter was supported, in part, by Grant No. HL 32538 from the National Heart, Lung, & Blood Institute. I am indebted to Raymond E. Tobey, MD and John A Winder, MD for their advice, and to Harry Kotses, PhD for his comments concerning the manuscript.