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Examining the associations of respiratory problems with psychological functioning and the moderating role of engagement in pleasurable activities during late adolescence
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Content
Examining the Associations of Respiratory Problems with Psychological Functioning and the
Moderating Role of Engagement in Pleasurable Activities During Late Adolescence
by
Annemarie R. Kelleghan
A Dissertation Presented to the
FACULTY OF THE USC GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(PSYCHOLOGY)
August 2021
Copyright 2021 Annemarie R. Kelleghan
ii
Acknowledgements
This dissertation and the additional training requirements towards the completion of my
PhD would not have been possible without the mentors, family, friends, and communities who
have supported me along the way. I am extremely appreciative of my graduate advisor, Dr.
David Schwartz, who accepted me into the USC Clinical Science program five years ago and
who has provided guidance, while also allowing me to pursue my own research interests. I am
forever grateful to my incredible mentor, Dr. Jessica Barrington-Trimis, who welcomed me into
her lab and who has been an unwavering source of encouragement, insight, and statistical
expertise. Thank you for having confidence in me. I extend gratitude to my dissertation
committee members who have stood by me and provided support over the course of a few years
and many changes due to the nature of school-based data collection and an unexpected global
pandemic. Drs. Gayla Margolin, Adam Leventhal, and Frank Manis – your guidance and wisdom
have extended far beyond the role of dissertation committee members and have influenced my
broader research, clinical work, and professional development.
I feel so fortunate to have been surrounded by wonderful colleagues. My fabulous cohort
– Mariel Bello, Shubir Dutt, Nina Jhaveri, and Crystal Wang – has been with me from the start
of this journey, and I wouldn’t want to be on this path with anyone else. I’m lucky to have
worked with many incredible labmates across multiple labs. A special thank you to Drs. Sarah
Malamut and Luiza Mali, Mariel Bello, Yana Ryjova, and Hannah Fitz who have helped me
form research ideas, edit manuscripts, and enjoy the research process along the way. I would like
to acknowledge the support of the USC HEAL Lab and extend my appreciation to the members
of the Population Core who have been involved in data collection and to the students who
participated in the Happiness and Health Study.
iii
Finally, I would not be here without the love, support, and ongoing encouragement from
my family and friends who have been by my side throughout this entire process. Mom, Dad,
Catalina, Michael, and Andrew, thank you for always believing in me, reminding me that there is
a life outside of grad school, and supporting me in a myriad of ways. I’m grateful to my extended
family, including The Stums – thank you for feeding me after long clinical days and encouraging
me on this journey. A special thank you to my dear friend, mentor, and role model, Maria
Celocruz, who constantly reminds me of my priorities, shares in my successes, and helps me
problem-solve when faced with challenges. Alex, Cristina, and Valerie, thanks for indulging me
in many conversations about grad school and for working alongside me in coffee shops over the
years. This dissertation is in loving memory of the three women who taught me the importance
of education but were not able to see me reach this milestone – Grandma, Aunt Betty, and Aunt
Marilyn.
iv
Table of Contents
Acknowledgements ............................................................................................................................... ii
List of Tables ........................................................................................................................................ vi
List of Figures ...................................................................................................................................... vii
Abstract ............................................................................................................................................... viii
Introduction ............................................................................................................................................ 1
Respiratory Problems and Psychological Functioning ....................................................................... 3
Extant Cross-sectional and Longitudinal Findings .......................................................................... 4
Significance of Specific Respiratory Problems ............................................................................... 5
Specific Respiratory Problems and Psychological Functioning ...................................................... 7
Possible Underlying Mechanisms .................................................................................................... 7
Engagement in Pleasurable Activities................................................................................................. 9
In-person Pleasurable Activities ...................................................................................................... 9
Digital/Online Pleasurable Activities............................................................................................. 13
Consideration of Covariates .............................................................................................................. 14
The Current Study ............................................................................................................................. 18
Methods ................................................................................................................................................ 19
Analytic Sample ................................................................................................................................ 19
Measures ........................................................................................................................................... 21
Statistical Analyses ........................................................................................................................... 27
Results .................................................................................................................................................. 29
Respiratory Problems and Psychological Functioning ..................................................................... 30
Moderation by Engagement in Pleasurable Activities ...................................................................... 33
Discussion ............................................................................................................................................ 36
Conclusion ........................................................................................................................................ 46
References ............................................................................................................................................ 48
v
Tables ................................................................................................................................................... 73
Figures.................................................................................................................................................. 83
Appendices ........................................................................................................................................... 88
Appendix A: Respiratory Measures .................................................................................................. 88
Appendix B: Engagement in Pleasurable Activities ......................................................................... 89
Appendix C: Psychological Functioning Measures .......................................................................... 91
Appendix D: Respiratory Problems and Depressive Symptoms Models ......................................... 93
Appendix E: Respiratory Problems and Anxiety Symptoms Models ............................................... 99
Appendix F: Depressive Symptoms Models Examining Moderation by In-Person Activity ......... 105
Appendix G: Depressive Symptoms Models Examining Moderation by Digital/Online Activity. 112
Appendix H: Anxiety Symptoms Models Examining Moderation by In-Person Activity ............. 120
Appendix I: Anxiety Symptoms Models Examining Moderation by Digital/Online Activity ....... 127
vi
List of Tables
Table 1. Demographic Characteristics of Analytic Sample ..........................................................73
Table 2. Pearson Correlation Matrix .............................................................................................75
Table 3. Associations of Respiratory Health Problems with Depressive Symptoms ....................76
Table 4. Associations of Respiratory Health Problems with Anxiety Symptoms .........................77
Supplemental Table 1. Demographic and Key Study Variables among Youth with and without
Follow-up Data ..............................................................................................................................78
Supplemental Table 2. Linear Regression Associations between Respiratory Problems and
Symptoms of Depression and Anxiety while Co-adjusted ............................................................80
Supplemental Table 3. Association of Respiratory Health Problems with Clinically-elevated
Depressive Symptoms ....................................................................................................................81
Supplemental Table 4. Association of Respiratory Health Problems with Clinically-elevated
Anxiety Symptoms.........................................................................................................................82
vii
List of Figures
Figure 1. Conceptual Framework of Research Questions .............................................................83
Figure 2. Moderation by In-person Pleasurable Activities on the Association between Total
Number of Respiratory Problems and Symptoms of Depression and Anxiety .............................84
Figure 3. Moderation by Digital/Online Pleasurable Activities on the Association between
Bronchitis and Symptoms of Depression and Anxiety ..................................................................85
Supplemental Figure 1. Consort Flow ...........................................................................................86
Supplemental Figure 2. Moderation by Digital/Online Pleasurable Activities on the Association
between Any Respiratory Problems and Depressive Symptoms ...................................................87
viii
Abstract
Background
Respiratory problems often manifest in childhood and are one of the most common health
problems among youth. Respiratory problems have been shown to contribute to poor
psychosocial functioning, including detriments to academic achievement, sleep, social and peer
relationships, and mental health. While common, respiratory problems are often unpredictable
and can thus substantively, adversely impact youths’ daily lives. Respiratory problems can
contribute to adolescents’ stress, fear of symptoms flares, and impairments in routine activities,
all of which can exacerbate problems with adolescent functioning and mental health. Yet, little is
known about whether respiratory problems and symptoms of depression and anxiety co-occur, or
if there is a prospective association of respiratory health with adverse psychological functioning
over time that may indicate a causal relation. The current study aims to investigate this
prospective association and to identify whether the association may weaken (leading to better
mental health outcomes) for youth who are able to engage in pleasurable activities.
Methods
A total of 1,923 adolescents (59.7% female) with a mean age of 17.4 years (SD=0.4) at baseline,
completed surveys on respiratory problems, psychological functioning, engagement in
pleasurable activities, and demographic data during the fall of 2016 (12
th
grade) and again in
2018-2019, following graduation from high school. Linear regression models were used to
examine the association between past 12 month respiratory problems (i.e., shortness of breath,
wheeze, bronchitis, any respiratory problem, total number of symptoms) at baseline with anxiety
and depressive symptoms at follow-up (continuous), adjusting for baseline characteristics and
variables hypothesized to confound the association. We assessed moderation by pleasurable in-
person and digital/online activities on the association between respiratory problems and
psychological functioning by inclusion of multiplicative interaction terms in linear regression
models. In sensitivity analyses, we used logistic regression models to evaluate the association of
each respiratory symptom with the odds of any clinically significant depression or anxiety
(yes/no, in separate models).
Results
Having any (vs. no) respiratory problem at baseline was associated with mean levels of
depression and anxiety symptoms more than two years later, even after accounting for initial
levels of depression or anxiety. These effects held when analyses examined specific respiratory
problems (i.e., bronchitic symptoms, shortness of breath, wheeze). In sensitivity analyses,
logistic regression analyses also showed that each specific respiratory symptom was associated
with about 1.43-1.98 times greater odds of report of clinically significant depression or anxiety
(ps<0.05), with the exception of wheeze, which was not significantly associated with depression
(OR=1.36; p=0.064). Each additional respiratory symptom increased the odds of report of any
clinically significant depression or anxiety.
In-person pleasurable activities moderated the association of one total respiratory problem with
symptoms of depression (p=0.02) and anxiety (p=0.009). Report of 1 (vs. 0) respiratory problem
ix
was associated with both depression and anxiety symptoms, an association which lessened with
increasing engagement in pleasurable in-person activities; the association of the report of 2 or 3
respiratory problems (vs. 0 problems) with mean depression and anxiety symptoms did not differ
by level of engagement with pleasurable in-person activities. A significant two-way interaction
was found between pleasurable digital/online activity and bronchitis with both mean depression
(p=0.003) and anxiety (p=0.005) symptoms. The association of bronchitis with subsequent
symptoms of depression and anxiety lessened with increasing engagement in pleasurable
digital/online activities.
Conclusions
A considerable proportion of adolescents reported experiencing respiratory problems including
bronchitic symptoms, wheeze, and shortness of breath, and these problems were prospectively
associated with both depression and anxiety in early adulthood. These findings warrant
consideration of screening for depression and anxiety when an adolescent patient presents with
respiratory problems and in follow-up assessments. Consideration of co-location of physicians
and psychologists in adolescent pulmonary and allergy clinics and pediatricians’ offices may be
useful to ensure that both physical and mental health can be addressed and treated
simultaneously. Earlier identification and treatment of mental health problems among youth with
respiratory problems may reduce the severity of mental health outcomes and related sequelae.
Moreover, additional study is needed to identify optimal intervention strategies for youth with
respiratory problems to reduce risk of development of depression and anxiety. Engagement in
pleasurable activities may be an easy target for brief intervention, but additional intervention
strategies need to be identified.
Keywords: respiratory problems, anxiety, depression, pleasurable activities, late adolescence
1
In 2019, diagnoses of depression, anxiety disorders, and asthma, a common respiratory
problem, ranked among the ten leading causes of morbidity among youth 15-19 years old in the
United States (World Health Organization, 2020). These conditions all often emerge in
childhood or adolescence, interfere with daily functioning, and can persist through adulthood.
Respiratory problems more broadly comprise of any symptoms that manifest due to impairments
in the chemical, mechanical, or physical processes necessary for breathing. Respiratory problems
can include trouble breathing (e.g., difficulty breathing while walking, rapid or shallow
breathing, absence of breathing), wheeze (i.e., whistling or rattling sound in the chest), chronic
cough, and cough with phlegm (Singh, 2020). Respiratory problems are common among youth.
Approximately 15.9-25.2% of adolescents report past-year wheeze, 12.3-14.0% report long-
standing cough or cough without a cold, 9.4% endorse shortness of breath, and 16.4% experience
sputum production; however these prevalence estimates vary by geographic location and age of
youth (Barreto et al., 2014; Lukrafka et al., 2010; Wennergren et al., 2010). Concerningly, recent
epidemiological research in Scandinavia has suggested an increase in the prevalence of a variety
of respiratory problems (e.g., wheeze, shortness of breath), particularly among adolescents and
young adults (Borna et al., 2019). Youth with respiratory problems often experience
unpredictable symptoms that cause stress, impact daily life, and affect activities of typical
development (Collins et al., 2008; Milton et al., 2004; Röder et al., 2003).
Similarly, diagnoses of depression and anxiety can also contribute to impairment in
functioning and daily life (Cairns et al., 2014; Jaycox et al., 2009), academic attainment (Jaycox
et al., 2009), social relationships (Jaycox et al., 2009; Siegel et al., 2009), and overall quality of
life (Raknes et al., 2017). Previous research has shown a link between asthma and poor
psychological functioning among adolescents, primarily in cross-sectional studies (Lu et al.,
2
2012). However, it is unclear whether these symptoms co-occur or if respiratory problems may
be associated with increased levels of depression and anxiety symptoms over time. The current
study aims to extend and expand extant research by examining specific respiratory problems
among late adolescents and assessing their longitudinal impact on depression and anxiety. If
respiratory problems are longitudinally associated with depression and anxiety, interventions can
be tailored to reduce the prevalence of symptomatic respiratory conditions, to address onset and
exacerbation of these symptoms, and to better address overall adolescent health. Simultaneously,
screening, prevention, and treatment for depression and anxiety following symptomatic
respiratory problems could prevent the onset or exacerbation of mental health symptoms, thus
reducing the morbidity of these problems among late adolescents.
The overarching aim of this study is to understand the link between respiratory, anxiety,
and depressive symptoms to ultimately inform intervention and prevention efforts aimed at
reducing the impact of these health conditions among adolescents. Therefore, the secondary goal
of this project seeks to identify possible moderators of the association between respiratory
problems and psychological functioning. Few studies have considered the role of moderating
variables in mitigating associations between respiratory problems and psychopathology.
However, identifying possible modifiable moderators of these associations is crucial in order to
develop appropriate and successful prevention and intervention efforts. To this end, a secondary
aim of the current project is to examine pleasurable leisure-time activities (i.e., both in-person
and digital/online) as moderators of the associations between respiratory problems and
subsequent symptoms of depression and anxiety.
Notably, this study examines physical and mental health symptoms among late
adolescents during the transition to early adulthood. Late adolescence is a time of developing
3
mastery, identity, and autonomy for oneself (Zarrett & Eccles, 2006). Experiences during this
period of development often set the stage for their ongoing development as adults. Youth begin
to take on increasing responsibilities and independence in their lives and in managing their health
decisions (Albert & Steinberg, 2011; Zarrett & Eccles, 2006). At the same time, parents and
guardians can no longer access youths’ health information without their explicit consent. Thus,
as youth navigate transitions from pediatric to adult medical care, they often receive insufficient
scaffolding from family or medical providers (Vaks et al., 2016; Wong et al., 2010) which
contributes to an increased likelihood that they do not receive the medical care they need (Rand
et al., 2007). While these transitions are taking place, youth are also more likely to have
increased environmental exposures to smoke or occupational exposure to gas, dust, or other
particulate compared to younger children (Wennergren et al., 2010) which can cause or
exacerbate respiratory problems. Youth in this age group have also been identified to be at
increased risk for respiratory problems (Borna et al., 2019), depression, and anxiety (Costello et
al., 2011). Therefore, it is especially important to study youth in this age group to better
understand how respiratory problems may impact mental health outcomes at this crucial time and
to identify ways to support the health of late adolescents as they transition to early adulthood.
Respiratory Problems and Psychological Functioning
Understanding how respiratory problems affect youth is particularly important given that
respiratory problems are associated with poor concurrent adjustment, including school
absenteeism (Milton et al., 2004), sleep disruption (Desager et al., 2005; Meltzer et al., 2015),
and psychosocial challenges such as being unhappy at school, reporting poor overall health, and
being less likely to have friends with whom to play (Collins et al., 2008). While research
suggests that respiratory problems profoundly impact children’s development, understanding
4
why this is the case has been more difficult to identify (Collins et al., 2008; Dell et al., 2007).
Researchers have suggested a few possible explanations for these associations. One
consideration is that respiratory problems are a constant stressor with unpredictable symptoms
which exacerbates feelings of stress and helplessness and impacts youth’s functioning (Röder et
al., 2003). Additionally, respiratory problems can directly impact youth’s academic and social
lives. Youth who have respiratory problems at times engage in limited physical and social
activities which can impact their daily functioning and can contribute to difficulties with social
competence and mental health problems (Röder et al., 2003; Zbikowski & Cohen, 1998).
Extant Cross-sectional and Longitudinal Findings
Respiratory problems have also been associated specifically with symptoms of depression
and anxiety. Extant literature has largely focused on cross-sectional studies of respiratory
problems on psychological outcomes. This research has identified that individuals with asthma
are more likely to endorse symptoms of anxiety than individuals without asthma (Delmas et al.,
2011; Goodwin et al., 2003; Ortega et al., 2002; Ortega et al., 2004). Similarly, youth with
asthma or a history of asthma attacks were more likely to endorse symptoms of depression than
those without a history of asthma (Ortega et al., 2004). Adolescents with poorly controlled
asthma experienced the greatest difficulties, reporting greater levels of depressive symptoms
compared to healthy adolescents and youth with well-controlled asthma (Delmas et al., 2011; Lu
et al., 2014).
Longitudinal studies can elucidate the temporal nature of the cross-sectional associations
between respiratory problems and psychological functioning. One such study found an
association between asthma reported at age 18 and subsequent anxiety symptoms at age 21.
However, this association was no longer significant after adjusting for confounders including
5
childhood adversity (Goodwin et al., 2004). Similarly, in another study, Puerto Rican 5-18 year-
olds with a history of asthma attacks had greater odds of experiencing internalizing symptoms
one year later, however, the association did not persist when internalizing symptoms at baseline
were included in the analyses (Feldman et al., 2006). These studies indicate that confounding
variables and baseline characteristics may account for some of the longitudinal effects of
respiratory problems on mental health outcomes.
Other research supports the contention that respiratory problems are positively associated
with psychological functioning longitudinally. For example, Alati et al. (2005) found that youth
with asthma and bronchitis at age 5 were at greater risk for internalizing difficulties at age 14,
considering internalizing symptoms at baseline (Alati et al., 2005). Another study found asthma
to be associated with depressive symptoms at age 14, but not at age 21, suggesting that the link
between asthma and psychological functioning may be especially salient during adolescence
(Ferro et al., 2016). Taken together, these data indicate associations between some features of
respiratory problems (e.g., asthma attack, asthma diagnosis) and internalizing problems, and they
highlight the importance of developmental considerations in studying these problems.
Significance of Specific Respiratory Problems
To date, research on respiratory problems and associated sequelae, including
psychological functioning, among adolescents has been narrowly focused on the study of asthma.
(Lu et al., 2012). However, respiratory problems extend beyond asthma diagnoses and can have
serious implications for youth regardless of a specific medical diagnosis. There are many other
diagnoses and symptom presentations that manifest as respiratory problems including chronic
obstructive pulmonary disease, vocal cord or laryngeal dysfunction, sleep apnea, and pulmonary
edema (Smoller et al., 1996; Tilles, 2010). Clearly respiratory problems extend beyond the role
6
they play in asthma diagnoses. The current study focuses on examining associations of specific
respiratory problems with psychological functioning, rather than relying solely on a reported
diagnosis of asthma. Furthermore, it is crucial to study specific symptoms, instead of relying on
an asthma diagnosis, given that individuals are frequently either over- or under-diagnosed with
asthma, that improper diagnosis is linked with a variety of risk factors and maladaptive outcomes
(Aaron et al., 2018), and that respiratory problems that are not part of an asthma diagnosis can
also impact adolescent functioning.
Underdiagnosis of asthma was identified among some patients including those who
underreported symptoms, received a diagnosis via spirometry which lacks sensitivity, are female,
and have a lower socioeconomic status (SES; Aaron et al., 2018; Gonzalez-Garcia et al., 2015).
Overdiagnosis of asthma occurs when objective tests of lung functioning and airflow are not
administered (Aaron et al., 2017), when child-onset asthma goes into remission, which happens
in approximately 68% of early-onset asthma diagnoses (De Marco et al., 2002), and possibly
when patients are obese (however there are mixed findings regarding obesity and asthma
diagnosis; Aaron et al., 2008; Scott et al., 2012; van Huisstede et al., 2013). Furthermore, and
relevant to the current analyses, youth who receive an asthma diagnosis and treatment are more
likely to have access to health care (Freeman et al., 2003), which is also correlated with
diagnosis and treatment of psychological disorders (Kataoka et al., 2002). It is therefore crucial
to examine specific respiratory problems regardless of reported physician diagnosis as this will
include more individuals who may experience a variety of respiratory problems but who were
not formally diagnosed or who have been diagnosed with related respiratory conditions.
7
Specific Respiratory Problems and Psychological Functioning
A few studies based on the European Community Respiratory Health Study (ECRHS)
have taken this symptom-specific approach to examine respiratory problems among adults. One
cross-sectional study found higher levels of specific respiratory problems including wheezing,
nightly respiratory problems, and breathlessness, among participants with depression and anxiety
(Leander et al., 2014). However, directionality of this association could not be identified due to
study design. A longitudinal study using ECRHS data focusing on dyspnea (i.e., shortness of
breath) found that new onset of depression and anxiety symptoms was related to new-onset
dyspnea, but no significant association was found predicting depression and anxiety from new-
onset dyspnea (Neuman et al., 2006). It is unclear whether these associations extend to other
respiratory problems or to adolescents and young adults. Furthermore, this study examined new-
onset symptomology and does not address links between persistent respiratory, anxiety, or
depressive symptoms.
Possible Underlying Mechanisms
There are a few reasons why respiratory problems may be associated with depression and
anxiety. Cognitive, biological, and behavioral factors may contribute to this link, however, no
one explanation fully elucidates the association between respiratory problems and psychosocial
functioning. More investigation is warranted to understand why respiratory problems have such a
strong impact on youth’s functioning (Collins et al., 2008; Dell et al., 2007), as understanding
underlying mechanism is crucial to reducing the incidence of these conditions. The link between
respiratory problems and symptoms of depression and anxiety has been attributed to a variety of
factors including cognitions and emotions such as stress (McEwen, 1998; Monroe & Simons,
1991) and fear of symptoms (Bruzzese et al., 2016), overlapping biological pathways (Van
8
Lieshout et al., 2009), and shared behaviors including poor management of symptoms (Letitre et
al., 2014) and limited participation in activities and peer engagement (Cui et al., 2015; Ferro et
al., 2016; Rhee et al., 2007).
Cognitions involved with monitoring respiratory problems and associated vigilance
(Bruzzese et al., 2016; Feldman et al., 2009) or with catastrophic beliefs and attentional biases
towards symptomatology (Dudeney et al., 2017; Katon et al., 2004) may be associated with
increased recognition of anxious and depressive symptoms. Biological mechanisms have also
been suggested, including neural circuitry responses in the amygdala and locus coeruleus that are
associated with both respiratory problems and psychological disorders (Gorman et al., 2001;
Katon et al., 2004). Behaviorally, youth with respiratory problems may experience less
enjoyment in activities that are typically positively reinforcing (e.g., playing with friends,
exercising) which could be associated with symptoms of depression and anxiety (Lewinsohn &
Graf, 1973; Lewinsohn & Libet, 1972; Rosen & Schulkin, 1998). Despite the ambiguity
regarding the underlying mechanism linking these symptoms, it is crucial to continue
investigating associations between respiratory problems, depression, and anxiety in order to
understand the progression of these symptoms among late adolescents and to inform preventive
and treatment interventions.
The present study examined longitudinal associations of respiratory problems (i.e.,
chronic bronchitis, wheeze, shortness of breath) with psychological functioning (depression and
anxiety) among late adolescents in southern California from 2016 to 2019. It is hypothesized that
experiences of respiratory problems will be positively associated with symptoms of depression
and anxiety.
9
Engagement in Pleasurable Activities
The secondary aim of this study was to assess whether the association between
respiratory problems and psychological functioning differs by the extent to which youth engage
in pleasurable activities either in-person or digitally/online. Understanding factors that mitigate
or exacerbate the link between respiratory problems and psychopathology can inform treatment
intervention and recommendations. A conceptual framework of these research aims is illustrated
in Figure 1.
In-Person Pleasurable Activities
Engagement in pleasurable in-person activities is hypothesized to be a protective factor
for youth who experience respiratory distress. Participation in pleasurable, in-person activities is
likely a marker of a wide set of adaptive processes that support adolescent development and
well-being in the face of respiratory problems. Specifically, we contend that youth who engage
in pleasurable in-person activities would experience or develop adaptive cognitions, positive
alternative reinforcement (e.g., fun/enjoyment, opportunities to learn new skills, etc.), and
engagement with peers, role models, and mentors that might mitigate the impact of respiratory
problems on subsequent psychological functioning.
Engaging in pleasurable in-person activities may be correlated with adaptive cognitions,
as youth who remain engaged in activities would be less likely to ruminate over negative
cognitions (e.g., concerns around exacerbations of respiratory problems or attacks, worry about
the implications of a diagnosis, fear of missing out) or to let these concerns lead to maladaptive
behavioral avoidance (e.g., avoiding strenuous activity, staying home from social events).
Furthermore, these activities can provide opportunities for youth to have fun and to develop or
10
hone skills and relationships, all of which can also increase youths’ self-efficacy and self-
perceptions. These affordances might be especially important for adolescents struggling with
respiratory problems.
The benefits of in-person pleasurable activities may be especially important for
adolescents who experience respiratory problems. A sample of youth with asthma reported that
the worst aspects about their respiratory problems included difficulties playing sports or
engaging in physical activities and asthma-related bullying (Wildhaber et al., 2012). This finding
suggests that youth with respiratory problems may experience and be concerned by difficulties
engaging in activities with peers for reasons that extend beyond traditional peer relations and are
specific to (or attributed to) their respiratory problems. Therefore, engagement in pleasurable in-
person activities may be particularly beneficial for youth with respiratory problems. The
association between respiratory problems and internalized distress would be attenuated for youth
who engage in high levels of in-person pleasurable activities. Engagement in pleasurable
activities is one modifiable factor that has been linked to a variety of psychosocial and health
outcomes among adolescents and adults (Pressman et al., 2009). However, it has not been
considered in the link between respiratory problems and psychological adjustment.
The effect of pleasurable leisure-time activities on adolescent health has garnered
attention in research, with scientists exploring the impact of leisure-time physical activity, social
activity, sedentary activity, and social media use on health outcomes. Youth who participate in
activities during their leisure-time can gain specific skills, build social support through
engagement with peers and supportive adults, and develop character and self-esteem (Eccles et
al., 2003; Fredricks & Eccles, 2006; Schmalz et al., 2007; Umberson et al., 2010). Much of the
existing research has explored the main effect of leisure-time activities on adolescent well-being,
11
including links with academic achievement (Badura et al., 2016), reduced substance use (Sharp
et al., 2011), decreases in school dropout (Mahoney & Cairns, 1997), and reduced levels of
depression and anxiety (Birkeland et al., 2009; Kremer et al., 2014). These studies indicate a
strong association between engagement in pleasurable activities and adaptive psychological,
social, behavioral, and academic outcomes.
Research on pleasurable activities largely focuses on participation in physical activities.
Engagement in physical activities is associated with a variety of positive health factors including
promotion of perceived health (Piko & Keresztes, 2007; Pikó & Noémi, 2006), physiological
regulation of stress (Nguyen-Michel et al., 2006), reductions in depression and anxiety (Hallal et
al., 2006; Salmon, 2001), and improvements in self-esteem (Schmalz et al., 2007). A few
existing studies have specifically explored physical activity among youth with asthma, and have
found that exercise has been associated with quality of life improvements among youth (Basaran
et al., 2006; Fanelli et al., 2007; Flapper et al., 2008). Given the positive outcomes associated
with physical activity engagement, researchers have also examined physical activity as a
moderator between stress and psychological functioning. Various stressors have been identified
as predictors of poor psychological outcomes (Goldenson et al., 2021; McMahon et al., 2003).
However, the association between stress and poor psychological functioning is weaker among
youth who engage in physical activities compared to those who do not engage in physical
activities, in most (Carmack et al., 1999; Haugland et al., 2003), but not all studies (Gerber &
Pühse, 2008; Moksnes et al., 2010). These findings indicate that while leisure-time physical
activity may partially moderate associations between stress or adverse experiences and
psychosocial functioning, other forms of pleasurable activities may also provide a protective role
and warrant consideration.
12
In addition to physical activities, other kinds of pleasurable activities also contribute to
adolescent health outcomes. Participation in achievement-oriented leisure activities (i.e.,
activities that “involve a challenge” or place demands on youth; e.g., structured extracurricular
activities) was found to increase youth’s self-efficacy, competence, and self-worth. The
development of competency, in particular, had a direct, negative association with mental health
problems (Passmore, 2003). Similarly, pleasurable activities oriented towards social engagement
and connection were associated with perceived competencies, which in turn were negatively
associated with mental health problems (Passmore, 2003). Another study found that youth who
were highly involved in a wide range of activities including school-based activities and clubs
were more likely to report positive adjustment in academic performance, problem behavior, and
psychological functioning. However, youth who were uninvolved in activities ranging from
“reading for pleasure” to “school clubs” had poor academic performance, high self-reported
problem-behaviors, and high levels of parent-reported internalizing and externalizing symptoms
(Bartko & Eccles, 2003). Taken together, these findings suggest that involvement in a
constellation of pleasurable activities is associated with adaptive adolescent adjustment.
There are a variety of reasons why engagement in pleasurable in-person activities may
play a protective role in adolescent development. Participation in pleasurable activities can
provide youth with opportunities to acquire specific skills and experiences that may increase
their competency, self-efficacy, and self-esteem, which is linked with a reduction in negative
cognitions and improved adolescent development (Passmore, 2003). Youth who engage in
activities are more likely to develop strong, meaningful relationships with peers and supportive
adults, and this social support has been identified as an important protective factor for health and
well-being throughout the life course (Gariépy et al., 2016; Umberson et al., 2010). Participation
13
in pleasurable in-person activities can also provide youth with opportunities to have fun which
can bring positivity and enjoyment into their lives (King et al., 2014). Depression is often
associated with decreases in positively reinforcing activities (Lewinsohn & Graf, 1973;
Lewinsohn & Libet, 1972). Thus, high engagement in pleasurable activities may buffer youth
from the development of these symptoms. If our hypotheses are supported, in-person pleasurable
activities can be integrated into intervention development to help mitigate depression and anxiety
among youth with respiratory problems.
Digital/Online Pleasurable Activities
We also examined the extent to which associations between respiratory problems and
symptoms of depression and anxiety might differ by levels of engagement in pleasurable
digital/online activities. When considering the role of pleasurable digital/online activities, there
are two competing hypotheses of how online engagement may strengthen or mitigate
associations between respiratory problems and symptoms of depression and anxiety. Digital
media use is omnipresent in the lives of adolescents (Anderson & Jiang, 2018) and provides
opportunities for youth to engage in a variety of activities (e.g., watching shows, listening to
music, messaging friends) through digital platforms. One hypothesis particularly prevalent in
research among pediatric populations is that engaging with peers online may provide connections
to similar peers and opportunities for camaraderie, negotiation of identity, and support that they
do not experience in the in-person peer environment (Daniels et al., 2021). Similarly, youth with
chronic health conditions often report looking for peers with the same diagnosis on social media
platforms and the desire to share their experience of health problems with friends online (De
Nardi et al., 2020). Youth with chronic health conditions also seek out medical information
online (De Nardi et al., 2020; Frey et al., 2020; Hausmann et al., 2017), and there is some
14
evidence that youth with uncontrolled asthma who seek online medical information are more
proactive in managing their symptoms (Frey et al., 2020). Considering this, we could expect
youth with respiratory problems who engage in high levels of pleasurable online activities to be
less likely to experience symptoms of psychopathology at follow-up compared to those who
engage in fewer pleasurable online activities.
However, a competing hypothesis suggests that engagement in online activities may not
confer a protective advantage, particularly among youth with respiratory problems. Youth who
spend more time engaging in pleasurable digital/online activities are likely more sedentary and
less likely to participate in leisure time activities in-person (Costigan et al., 2013; Kremer et al.,
2014) which may contribute to symptoms of depression and anxiety. In fact, some studies
provide support for engagement with digital/online activities being positively associated with
depression and anxiety among youth (Keles et al., 2020). Additional research has identified use
of digital/online media to be associated with fear of missing out and feelings of depression and
anxiety (Elhai et al., 2020). Fears of missing out may be particularly salient among youth with
respiratory problems, to the extent which they already feel unable to participate in activities with
peers (Wildhaber et al., 2012). Thus, engagement in online activities could confer risk of
depression and anxiety symptoms particularly among youth with respiratory problems.
Therefore, we will evaluate evidence for hypotheses in both directions.
Consideration of Covariates
To increase precision in our longitudinal models, the current study will consider
covariates that may confound the main associations. Specifically, gender, ethnicity, SES (i.e.,
eligibility for subsidized lunch, highest parental education), body mass index (BMI), exposure to
second-hand smoke in the home, baseline depression or anxiety, asthma diagnosis, and youths’
15
use of cannabis, cigarettes, and e-cigarettes will be included in models. Adjusting for these
potential confounding variables will limit the extent to which these extraneous variables appear
to obscure or alter the actual relation between respiratory problems and symptoms of depression
and anxiety.
Covariates included in the current study were specifically selected given extant research
that has identified associations between each covariate variable and the study variables of
interest: respiratory problems and symptoms of depression and anxiety. Gender was included in
analyses, as it has been found to be associated with respiratory problems, such that females
report higher prevalence of diagnosed asthma, shortness of breath, and other respiratory
problems compared to their male counterparts (Chhabra & Chhabra, 2011; Vrijlandt et al., 2005),
particularly among adolescents (Osman et al., 2007). Similarly, there is a well-documented link
between gender and symptoms of anxiety and depression, with females reporting elevated
symptoms of these mental health disorders compared to males – a finding that arises during
adolescence (Cyranowski et al., 2000). Ethnicity has been identified as a correlate of respiratory
problems, with a body of research highlighting poorer lung functioning among some
racial/ethnic minority groups (Asthma and Allergy Foundation of America, 2020; Moorman et
al., 2011; Whitrow & Harding, 2008). Additionally, there is consistent evidence that an
individual’s self-report of depressive and anxious symptoms, as well as their diagnosis and
treatment by a medical professional vary by race and ethnicity. Ethnic minority youth, and
specifically individuals who identify as Hispanic, African-American, and multiracial, report
higher rates of depressive and anxious symptoms compared to their non-Hispanic white peers
(Anderson & Mayes, 2010; Cummings & Druss, 2011; McLaughlin et al., 2007). Furthermore,
Black, Hispanic, and Asian adolescents are less likely to receive treatment for mental health
16
disorders (Cummings & Druss, 2011) which can further exacerbate differences in adolescent
mental health functioning by ethnicity.
Socioeconomic status (SES) is a critical covariate that has been evaluated in the study of
respiratory problems, anxiety, and depressive symptoms. SES is the social standing of an
individual, family, or group. It is often operationalized by measuring income levels, occupational
status, or educational attainment. Rates and severity of respiratory problems are higher among
individuals with disadvantaged SES, compared to those with high SES (Ellison-Loschmann et
al., 2007; Forno & Celedon, 2009; Gold & Wright, 2005). It is believed that while SES itself
may be partially responsible for this association, it is also a marker of other underlying constructs
such as community violence, insurance status, air pollution, and other variables that likely
contribute to respiratory problems (Forno & Celedon, 2009; Gold & Wright, 2005). Similarly, a
negative association has been found between SES and symptoms of anxiety and depression, such
that youth with lower SES experience increased symptoms of depression and anxiety compared
to their peers with higher SES (Goodman et al., 2003; Lemstra et al., 2008).
In addition to these common, aforementioned, demographic covariates, there are a variety
of other variables that have been speculated to confound associations between respiratory
problems and symptoms of depression and anxiety. However, few studies have been able to
control for these variables, and we are not aware of any other studies that have controlled for
these important covariates simultaneously. Body mass index (BMI), a crude assessment of an
individual’s excess body fat, has been linked to respiratory problems, with overweight
individuals more likely to experience common respiratory problems and poorer lung functioning
compared to individuals with lower BMIs (Davidson et al., 2014; Xanthopoulos & Tapia, 2017).
In studies of adolescent depression and anxiety, there is some evidence that youth with a larger
17
body sizes may experience elevated symptoms of depression and anxiety compared to their
smaller-sized peers (Anderson et al., 2007; Mühlig et al., 2016; Quek et al., 2017). Asthma
diagnosis was also included as a covariate, given that the primary aim of the current study was to
assess specific symptoms of respiratory distress, regardless of diagnostic history. Youth who
have received a medical diagnosis of asthma would likely experience elevated respiratory
problems, and would also be more likely to receive additional mental health diagnoses given
their engagement with the healthcare system and would likely monitor symptoms differently than
non-diagnosed youth (Freeman et al., 2003; Kataoka et al., 2002).
Another important consideration not often addressed in other studies of respiratory
problems and symptoms of depression and anxiety is the evaluation of exposure to substances as
a potential confounding variable. While many studies do not have the data to control for these
variables, a strength of the current study includes a robust assessment of exposure to substances,
both through second-hand exposure and adolescent substance use. Exposure to second-hand
substance use in the home has been associated with respiratory problems and exacerbation of
symptoms (Lai et al., 2009; Merianos et al., 2018; Tyc et al., 2008), anxiety, and depression in
extant literature (Bandiera et al., 2011; Wellman et al., 2020).
Furthermore, it is important to consider adolescent substance use in the longitudinal
associations between respiratory problems and psychopathology. There is a robust body of
evidence supporting the association between cigarette use with elevated levels of respiratory
problems (Hedman et al., 2011; McLeish & Zvolensky, 2010; Vázquez-Nava et al., 2017). More
recent research has similarly identified possible links between vaping of cannabis and nicotine
products and respiratory problems among adolescent and young adult populations (Braymiller et
al., 2020; Clapp & Jaspers, 2017; McConnell et al., 2017). Substance use is also correlated with
18
psychopathology. Findings regarding the link between cigarette smoking and symptoms of
depression and anxiety largely conclude that there is a positive association among these variables
(Chaiton et al., 2009; Leventhal & Zvolensky, 2015), although these findings are not consistent
across all studies (Fluharty et al., 2017). Researchers have also identified associations between
youths’ use of electronic cigarettes and cannabis products with symptoms of depression and
anxiety (Dierker et al., 2015; Gobbi et al., 2019; Leventhal et al., 2016). Taken together, this
information warrants consideration of exposure to cigarettes, e-cigarettes, and cannabis as
possible confounders in the association between respiratory problems and symptoms of
depression and anxiety.
Finally, to assess change in mean depression and anxiety over time, baseline depression
and anxiety scores were included in the current analyses. This study aimed to assess the
longitudinal nature of the association between respiratory problems on subsequent symptoms of
depression and anxiety. Earlier endorsement of depressive and anxious symptoms at baseline is
highly correlated with subsequent reports of these symptoms at follow-up (Waszczuk et al.,
2016). The current study extends previous literature by considering the change in psychological
functioning over time.
The Current Study
The main objectives of the present study are (1) to examine the association of respiratory
problems with depressive and anxiety symptoms among older adolescents in a longitudinal
analysis while considering key covariates, and (2) to examine the moderating role of pleasurable
activities on the association between respiratory and psychological symptoms. We hypothesize
that youth who report respiratory problems will experience more elevated symptoms of
depression and anxiety at follow-up compared to youth who do not report respiratory problems.
19
We also hypothesize that in-person pleasurable activities will moderate the association between
respiratory problems and psychological functioning such that the association of respiratory
problems with depression and anxiety will be weaker for those who report more (vs. less)
engagement in pleasurable activities. We will further explore competing hypotheses of
moderation in the association between respiratory problems and psychological functioning by
engagement in pleasurable digital/online activities. The present study extends existing research
by focusing on longitudinal associations between respiratory and psychological functioning
among older adolescents, examining specific respiratory problems, including important
covariates, and considering moderation by modifiable behaviors (i.e., engagement in pleasurable
activities).
Methods
Analytic Sample
The current study was conducted in the context of a larger project, the Happiness &
Health Study, a prospective cohort study of adolescents (Leventhal, Strong, et al., 2015).
Roughly 40 public high schools in the greater Los Angeles area were selected due to their
geographic location and diversity of student bodies. Each school was contacted and invited to
participate in the longitudinal data collection. A total of 10 high schools agreed to participate in
the study. Ninth grade students were invited to participate in the study. Written or verbal consent
from parents and child assent were required for study participation. Once youth were 18 years
old (i.e., during the long-term follow-up period), they were invited to provide consent for their
continued participation in the study.
20
Data collection occurred in classrooms each semester from 9
th
to 12
th
grade (2013-2017).
Youth completed paper-and-pencil surveys throughout high school. If a student was not present
on the day of data collection, they were invited to complete an abbreviated survey by phone or
online. Youth completed an additional follow-up survey approximately one to two years
following high school graduation (2018-2019). The research team contacted participants by
phone and email to remind them of their participation in the study and to invite them to complete
the online survey. The current analyses include data obtained at two time points embedded in the
longitudinal study, beginning in Fall 2016 when participants were in 12
th
grade (hereafter
referred to as baseline) with follow-up in Fall 2018-2019, approximately 2-3 years after baseline.
These time points were selected based on availability of exposure and outcome data in the
surveys, as the surveys were modified for each wave of data collection. This study was approved
by the University of Southern California Institutional Review Board.
Across all schools, there were 4100 students eligible to participate in the larger Happiness
& Health Study. Of these youth, 3396 received positive parental consent and student assent in 9
th
grade. Supplemental Figure 1 displays the flow diagram for participation in the current analyses.
A total of 2488 students provided valid data of key study variables at baseline in the fall of 12
th
grade. The final analytic sample for the current analyses included 1923 of these students who
also provided follow-up data in young adulthood (1-2 years post-high school). Compared to
students included in the analytic sample, youth who did not provide follow-up data for study
variables (n=565) were more likely to be older (Mage=17.5 vs 17.4 years; p =0.001), to be male
(60.5% vs. 40.3%; p <0.001), to receive free lunch (38.2% vs. 34.0%; p=0.015), and to report
ever use (but no past 6 month use) of e-cigarettes (31.7% vs. 27.6%; p=0.028), cigarettes (29.6%
vs. 25.6%; p=0.011), and cannabis (21.6% vs. 15.1%; p <0.001). They were less likely to be
21
Asian (17.7% vs. 23.5%; p =0.006) and reported lower baseline anxiety (M=1.07 vs. 1.21; p
<0.001) and depression (M=0.67 vs. 0.74; p=0.032) mean scores and lower engagement in online
pleasurable activities (M=31.6 vs. 34.6; p <0.001). Youth without follow-up data were less likely
to report wheeze at baseline (8.3% vs. 11.4%; p=0.039), but no other differences in respiratory
problems were noted (Supplemental Table 1).
Measures
Exposure Variables: Respiratory Problems
Consistent with prior research (McConnell et al., 2017), we considered respiratory
problems based on participant report of respiratory functioning throughout the previous year. We
identified three distinct respiratory problems (1) bronchitis, (2) wheeze, and (3) shortness of
breath (see Appendix A). We also considered the effects of any respiratory problem and number
of respiratory problems on the outcomes of interest.
Bronchitic symptoms. Youth were identified as having bronchitic symptoms (bronchitis)
if they endorsed one or more symptoms including cough, congestion, or phlegm not linked to a
cold over the past 12 months, or bronchitis (McConnell et al., 2003). Participants responded
[yes/no] to the questions:
(1) “During the last 12 months, have you had a couth first thing in the morning that lasted
for as much as 3 months in a row?”
(2) “During the last 12 months, have you had a cough at any other times of the day that
lasted for as much as 3 months in a row?”
22
(3) “Other than with colds, do you usually feel congested in your chest or cough up
mucus or phlegm?”
(4) “During the past 12 months, have you had bronchitis?”
Any bronchitic symptom was coded 0=responded no to all four questions above or 1=responded
yes to one or more of the four questions above.
Wheeze. Wheeze was identified when participants reported that they had ever
experienced wheeze, and they endorsed one or more symptoms in the past 12 months, including
wheezing attacks, sleep disruption or limited speech due to wheeze, or wheeze with exercise
(Asher et al., 1995). Specifically, participants responded to the umbrella question:
“Have you ever had wheezing or whistling at any time in the past?” [yes in the past 12
months; yes, but not in the last 12 months; no]
If a participant reported symptoms in the past 12 months, they were asked four additional
questions:
(1) “How many attacks of wheezing have you had in the last 12 months?” [none, 1-3, 4-
12, 12+]
(2) “In the last 12 months, how often, on average, has your sleep been disturbed due to
wheezing?” [never awakened with wheezing; less than one night per week; one or more
nights per week]
(3) “In the last 12 months, has wheezing ever been severe enough to limit your speech to
only one or two words at a time between breaths?” [yes/no]
23
(4) “In the last 12 months, has your chest sounded wheezy during or after exercise?”
[yes/no]
Wheeze was coded dichotomously such that 0=responded “no” or “yes, but not in the last 12
months” to the umbrella question regarding ever wheeze or whistling in the chest, or responded
“yes, in the last 12 months” but did not report any additional symptoms in the four follow-up
questions, and 1=responded “yes, in the last 12 months” to the umbrella question and endorsed
one or more symptom in the four above questions.
Shortness of Breath. Youth were identified as experiencing shortness of breath if they
reported shortness of breath when hurrying on level ground or a slight incline and endorsed an
additional indicator of severity. Specifically, all participants were asked:
“Are you troubled by shortness of breath when hurrying on level ground or walking up a
slight hill?” [yes/no].
Those who reported “yes” were asked to respond [yes/no] to three additional items:
(1) “Do you have to talk slower than people of your age on level ground because of
shortness of breath?”
(2) “Do you ever have to stop for breath when walking at your pace on level ground?”
(3) “Do you ever have to stop for breath when walking about 100 yards (or after a few
minutes) on level ground?”
Shortness of breath was coded 0=responded “no” to the umbrella question or responded “yes” to
the umbrella question but did not report any additional symptoms, 1=responded “yes” to the
24
umbrella question and responded “yes” to one or more of the additional symptoms in the three
questions above.
Any Respiratory Problem. A dichotomous variable was created based on reported
bronchitic symptoms, shortness of breath, and wheeze. Individuals reporting one or more of
these three respiratory problems were identified as having “any respiratory problem” (dummy
coded 1=any problem), and individuals who reported no to the symptoms associated with
bronchitis, shortness of breath, and wheeze were categorized as having no respiratory problems
(0= no reported symptoms).
Total Number of Respiratory Problems. A count variable was created to represent each
participant’s total number of respiratory problems reported. Scores ranged from 0 (no reported
problems) to 3 (all three respiratory problems endorsed). Models considered total number of
respiratory problems as a categorical and continuous variable in separate models.
Covariates
Covariates in these analyses include self-reported gender (male/female); race/ethnicity
(Hispanic, Asian, white, other); two proxies for family SES (1) eligibility for subsidized lunch
(free lunch, reduced cost, no subsidized lunch, don’t know or missing) and (2) parental education
(some high school or less, high school graduate, some college, college graduate, advanced
degree); BMI; exposure to second-hand smoke in the home (none, any reported); baseline
psychological functioning (i.e., baseline mean depression scores for depression models and
baseline mean anxiety score for anxiety models; assessment of psychological functioning
described below), and youth’s use of cannabis, cigarette, and e-cigarette products (never-use, any
lifetime use, past 6 month use, past 30 day use). These covariates have been previously identified
25
as associated with respiratory problems or psychological functioning and therefore may
confound the hypothesized associations (Chhabra & Chhabra, 2011; Forno & Celedon, 2009;
Forno et al., 2018).
Moderator: Pleasurable In-Person and Online Activities
A modified version of the Pleasant Events Schedule (MacPhillamy & Lewinsohn, 1974)
for adolescents, which we have used in prior studies (Audrain-McGovern et al., 2011; Leventhal,
Bello, et al., 2015), assessed engagement and level of pleasure in leisure-time activities. Students
reported on the frequency (never; 1-6 times/month; 7+ times/month) of 44 different in-person
activities such as “getting assistance from others”, “playing team sports”, and “doing arts and
crafts”. Participants also reported on the extent to which they received pleasure from the activity
(not pleasurable, somewhat pleasurable, very pleasurable). A composite score of engagement in
pleasurable in-person activities was created by multiplying the frequency of participation x level
of pleasure for each item and then summing the total scores for all 44 activities (range=0-176).
Students also reported on their leisure-time digital media/online activities using a
measure developed for our data collection (Ra et al., 2018), which we have used in prior studies
(Kelleghan et al., 2020). Youth were asked how often (never; 1-2 times/week; 1-2 times/day;
many times per day) they engaged in 14 different digital media activities, including “checking
social media sites”, “playing games by yourself on a console, computer, or smartphone”, and
“posting own photographs, images, videos, status updates, or blogs”. Similar to the construction
of the in-person activity score, participants also reported on the extent to which they received
pleasure from the activity (not pleasurable, somewhat pleasurable, very pleasurable). A
composite score of engagement in pleasurable digital/online activities was created by
26
multiplying the frequency of participation x level of pleasure for each item and then summing
the total scores for all 14 activities (range=0-84).
Outcomes: Psychological Functioning
The Center for Epidemiologic Studies Depression Scale (CES-D) is a 20-item measure of
depression symptomology administered at baseline to calculate mean depression score (Radloff,
1977). Participants reported on their depressive symptoms using a 4-point Likert scale (0=Rarely
or none of the time, 3=Most or all of the time). When participants were adults at follow-up, the
10-item Center for Epidemiologic Studies Depression Scale (CES-D-10) was used to measure
depression (Andresen et al., 1994). This scale is a subset of items from the full scale explained
above. Depression scores at each timepoint were averaged across all items to calculate a mean
depression score (range=0-3) at baseline (covariate) and follow-up (outcome variable) for main
linear regression analyses.
For sensitivity analyses described below, cut-off scores were used to identify clinically-
significant depression. When the CES-D was administered at baseline, the total score on the
scale was dichotomized based on the publisher’s recommendation, using a clinical cut-off of 16
to correspond with clinical elevations in depressive symptoms (Radloff, 1991). When
participants completed the CES-D-10 at follow-up, the clinically significant cut-off was
determined based on previous literature using a sum score greater or equal to 10 to indicate
clinically-elevated depressive symptoms (Björgvinsson et al., 2013).
Symptoms of anxiety were assessed using two self-report measures. At baseline, the
Revised Children’s Anxiety and Depression Scale (RCADS), 6-item subscale for generalized
anxiety (GAD) was used to evaluate mean anxiety level (Chorpita et al., 2000). At follow-up,
27
when participants were adults, the 7-item Generalized Anxiety Disorder Scale (GAD-7) was
used to assess for mean number of anxiety symptoms. On both surveys, respondents endorsed
symptoms on a 4-point Likert scale (0=Not at all, 3=Nearly every day). Reports of anxiety
symptoms were averaged at each time point to calculate a mean anxiety score (range=0-3) for the
primary linear regression analyses.
For sensitivity analyses, cut-off scores were used to identify clinically-significant anxiety.
At baseline when the RCADS was administered, raw sum scores of six items were standardized
by sex and age norms, and T-scores were used to determine clinical cutoff for generalized
anxiety (Chorpita et al., 2005). At follow-up when the GAD-7 was administered, summed scores
were dichotomized, such that participants with a score greater or equal to 10 were identified as
having clinically-significant symptoms of anxiety (Spitzer et al., 2006). All measures used to
assess psychological functioning are provided in Appendix C.
Statistical Analyses
A series of linear regression models were used to examine the association between
respiratory problems at baseline with reported mean depression and anxiety scores (as
continuous variables) at follow-up. Three specific respiratory problems (i.e., shortness of breath,
wheeze, bronchitis) were assessed as exposure variables in separate models, as was presence of
any respiratory problem (dichotomous) and total number of respiratory problems (modeled
categorically and continuously). These six models were initially minimally adjusted for basic
demographics including ethnicity, gender, subsidized lunch (a proxy for SES), and baseline
psychological functioning (i.e., either mean depression or anxiety score consistent with outcome
variable). Fully adjusted models were additionally adjusted for parental education (a secondary
proxy for SES), history of cannabis, electronic cigarettes, and combustible cigarette use, BMI,
28
diagnosed asthma, exposure to second-hand substance use in the home, and baseline
psychological functioning. Prior to including gender and ethnicity as covariates, these variables
were considered as possible effect modifiers to ensure that inclusion as covariates did not
obscure meaningful group differences by gender or ethnicity. No statistically significant
interactions by gender or ethnicity were found, thus these variables were included as covariates.
As a supplemental sensitivity analysis, models described above were also run using logistic
regression with dichotomous outcome variables for depression and anxiety using clinically-
significant cutoff scores. Odds ratios and 95% confidence intervals are reported in supplemental
tables.
Moderation of the association of respiratory problems with psychological functioning
was assessed using hierarchical linear regression. Two continuous moderator variables were
assessed: (1) total engagement and pleasure of in-person activities (2) total engagement and
pleasure in digital/online activities. In separate models, we entered the main effects for the
exposure variables (i.e., specific respiratory problems, any respiratory problem, total number of
problems), covariates, and hypothesized moderator on Step 1. The interaction term (i.e., any
respiratory problem x in-person activity or any respiratory problem x digital activity) was added
on Step 2. The interaction terms between total number of respiratory problems (a categorical
variable; k=4) and pleasurable activity levels (continuous variables) were represented by the
products of the continuous variable with k-1 dichotomous variables that represented the
categorical variable. Interaction terms were calculated using mean centered values (Aiken &
West, 1991). Variables were entered into each step simultaneously, and each step was entered
sequentially. Statistically significant interactions were decomposed by algebraically fixing
29
engagement in pleasurable activities at high (one standard deviation above the mean), medium
(mean), and low (one standard deviation below the mean) cutoffs (Aiken & West, 1991).
Missing data for covariates and proposed moderators were managed with multiple
imputation; all covariate and exposure data were used to estimate and impute values for missing
observations in 5 imputed data sets. Multiple data sets were created with missing values imputed,
and the estimates from models tested in each imputed dataset were pooled and a single summary
estimate was presented (Rubin, 2004). Outcome psychological functioning data and respiratory
symptom variables were not imputed and were handled with listwise deletion. Regression
coefficients, standard errors, and p-values were reported, and p<0.05 was established as
statistically significant. In supplemental analyses, odds ratios and 95% confidence intervals were
reported. Benjamini-Hochberg method was applied to correct for multiple tests, as this method
adjusts the false discovery rates due to multiple hypothesis testing (Benjamini & Hochberg,
1995). As the current study evaluates multiple inferences and considers a variety of approaches
to understanding the link between respiratory problems and psychological functioning, it is
important to consider that a proportion of the statistically significant results could be false
positives. To address this concern, the Benjamini-Hochberg procedure was used to control the
false discovery rate at 0.05. STATA 15 was used to perform all analyses.
Results
Among the 1923 participants included in the total analytic sample, 1147 were female
(59.7%), and the mean age was 17.4 (SD=0.4) years at baseline (Table 1). The sample was
racially/ethnically diverse, with a majority of the participants identifying as Hispanic (835
[43.4%]), Asian (452 [23.5%]), or Caucasian (300 [15.6%]), and 298 (15.5%) reporting other or
mixed-race ethnicities. A wide range of SES was represented, with 851 (44.2%) receiving free or
30
reduced lunches, and 450 (23.4%) reporting parents’ highest education was high school
completion or less. Mean (SD) BMI for the sample was 23.3 (4.7). Most participants reported
never smoking cigarettes (1227 [63.8%]), cannabis (1153 [60.0%]), or e-cigarettes (1164
[60.5%]) at baseline. A minority of participants endorsed exposure to substance use in the home
(527 [27.4%]). A total of 442 participants (23.0%) reported asthma diagnosis. Correlations
between dichotomous and continuous study variables are presented in Table 2. Having any
respiratory problem was positively correlated with being female, receiving subsidized lunch,
exposure to second-hand smoke in the home, BMI, asthma diagnosis, cigarette and cannabis use,
and scores of mean depression and anxiety at baseline and follow-up.
Respiratory Problems and Psychological Functioning
Overall, 632 participants (32.9%) reported one or more respiratory problems.
Specifically, 448 (24.5%) reported bronchitic symptoms, 219 (11.5%) reported wheeze, and 187
(10.0%) reported experiencing shortness of breath over the past 12 months. Among these
participants, 451 (23.5%) reported 1 respiratory symptom, 140 (7.3%) reported 2 respiratory
problems, and 41 (2.1%) reported all three respiratory problems at baseline.
Among the full analytic sample, youth reported an average mean depression score at
follow-up of 1.0 (SD=0.6) with a range from 0 to 3. The average mean anxiety score for the
sample was 0.9 (SD=0.8) with a range from 0 to 3. Considering categorical thresholds for
clinically-significant symptom presentation, these scores correspond to 865 (45.1%) participants
indicating clinically significant levels of depression and 430 participants (22.5%) reporting
clinically significant symptoms of anxiety at follow-up. A total of 64 (3.3%) participants
endorsed only clinically elevated anxiety, 499 (25.9%) reported elevations in depressive
symptoms alone, and 366 (19.0%) endorsed both depression and anxiety symptoms at or above
31
the clinically significant level. Data on mean depression and anxiety scores by respiratory
problems are reported in Tables 3 and 4, respectively. Data on clinically significant levels of
depression and anxiety by respiratory problems are reported in Supplemental Tables 3 and 4,
respectively.
Associations of Respiratory Problems with Depressive Symptoms
Table 3 reports regression coefficients from the analyses examining the associations of
respiratory problems on subsequent depression outcomes. Complete regression models can be
viewed in Appendix D.
In individual regression models when adjusting for all covariates (i.e., fully adjusted
models), chronic bronchitis (β=0.06, p=0.005), shortness of breath (β =0.06, p=0.009), and
wheeze (β =0.05, p=0.012), were each positively associated with mean depression score at
follow-up. Taken together, having any respiratory problem was associated with elevated
depressive symptoms (β =0.07, p=0.001) compared to having no respiratory problems. There
was also an association between number of respiratory problems and mean depression score (β
=0.09, p<0.001). Minimally adjusted models (Table 3) provided similar results with slightly
larger effects, and models additionally co-adjusting for anxiety symptoms at baseline
(Supplemental Table 2) provided similar results, though with slightly weaker effects. Nearly all
associations remained significant after Benjamini-Hochberg corrections were applied.
Bronchitis, shortness of breath, and composite respiratory variables were also
significantly associated with odds of clinically elevated depression in models considering
depression as a dichotomous outcome (Supplemental Table 3). When adjusting for all covariates
(i.e., fully adjusted models), chronic bronchitis (aOR=1.43, 95% CI=1.13-1.80, p=0.003) and
32
shortness of breath (aOR=1.62, 95% CI=1.15-2.30, p=0.006) were associated with increased
odds of clinically-elevated depression. Taken together, having any respiratory problem was
associated with 1.45 times greater odds (95% CI=1.17-1.80, p=0.001) of clinically-elevated
depression compared to participants reporting no respiratory problems. There was a dose-
response association between number of respiratory problems and depression, such that each
additional respiratory symptom was associated with 1.32 times greater odds of endorsing
clinically-significant depression (aOR=1.32, 95% CI= 1.14-1.53, p<0.001). Wheeze was not
significantly associated with clinically-elevated depression in the fully adjusted model.
Minimally adjusted models provided similar results with slightly larger effects. Associations
between respiratory problems and depressive symptoms did not differ significantly by gender,
ethnicity, or SES (i.e., receiving free or reduced-fee lunch).
Associations of Respiratory Problems with Anxiety Symptoms
Table 4 reports regression coefficients for the associations of respiratory problems with
subsequent anxiety outcomes. Complete regression models can be viewed in Appendix E.
In individual regression models when adjusting for all covariates (i.e., fully adjusted
models), chronic bronchitis (β =0.08, p<0.001), shortness of breath (β =0.10, p<0.001), and
wheeze (β =0.06, p=0.009) were each positively associated with mean anxiety symptoms. Taken
together, having any respiratory problem was associated with higher mean anxiety scores (β
=0.10, p<0.001), compared to reporting no respiratory problems. There was also an association
between total number of respiratory problems and mean anxiety level (β =0.12, p<0.001).
Minimally adjusted models (Table 4) and models co-adjusting for baseline depressive symptoms
(Supplemental Table 2) did not differ appreciably. Nearly all associations remained significant
after Benjamini-Hochberg corrections were applied.
33
Bronchitis, shortness of breath, wheeze, and composite respiratory variables were also
significantly associated with odds of clinically elevated anxiety in models considering anxiety as
a dichotomous outcome (Supplemental Table 4). When adjusting for all covariates (i.e., fully
adjusted models), chronic bronchitis (aOR=1.82, 95% CI=1.41-2.36, p<0.001) was associated
with increased odds of anxiety, as was shortness of breath (aOR=1.98, 95% CI=1.39-2.82,
p<0.001), and wheeze (aOR=1.56, 95% CI=1.11-2.19, p=0.011). Taken together, having any
respiratory problem (vs. no respiratory problem) was associated with 1.54 times greater odds
(95% CI=1.32-1.79, p<0.001) of clinically-elevated anxiety. There was a dose-response
association between number of respiratory problems and anxiety, such that each additional
respiratory symptom was associated with 1.73 times greater odds of endorsing clinically-
significant anxiety (95% CI= 1.36-2.21, p<0.001). Minimally adjusted models provided similar
results with slightly larger effects for all exposure variables.
Moderation by Engagement in Pleasurable Activities
We examined the role of two separate moderators, (1) engagement in pleasurable in-person
activities and (2) engagement in pleasurable digital/online activities, on the associations of
respiratory problems with subsequent psychological functioning.
Moderation by Engagement in In-Person Pleasurable Activities
The association of total number of respiratory problems with depression was moderated
by engagement in pleasurable in-person activities. The association of report of 1 (vs. 0)
respiratory problems with mean depression symptoms lessened for youth who engaged in more
pleasurable in-person activities (interaction: β =-0.05, p=0.02). For example, among youth who
reported 1 standard deviation (SD) below the mean number of in-person activities, having 1 (vs.
34
0) respiratory symptoms was associated with greater mean depression symptoms (β =0.14,
SE=0.05, p=0.002); for youth reporting 1SD above the mean number of in-person pleasurable
activities, there was no association of respiratory symptoms (1 vs. 0) and depressive symptoms
(β =-0.01, SE=0.04, p=0.85; see Figure 2A). However, those with 2 or 3 respiratory problems
(vs. no respiratory problems) experienced greater depression symptoms regardless of
engagement with in-person pleasurable activities [i.e., the association of 2 (vs. 0) and 3 (vs. 0)
respiratory problems with depression symptoms was not moderated by in-person pleasurable
activities; p-interaction=0.43-0.96]. Figure 2A illustrates the decomposition of the significant
interaction. All other moderation analyses between pleasurable in-person activities and each of
three specific respiratory problems (i.e., bronchitis, wheeze, and shortness of breath; p-
interaction=0.15-0.67) as well as any respiratory problem (p-interaction=0.05) were not
statistically significant. Significant interaction terms did not maintain significance after
Benjamini-Hochberg corrections were applied. Complete regression models can be viewed in
Appendix F.
Similarly, in models evaluating the association of respiratory problems with anxiety, a
statistically significant interaction was identified with total number of symptoms. Figure 2B
depicts the decomposed interaction. The association of report of 1 (vs. 0) respiratory problems
with mean anxiety symptoms similarly lessened for youth who engaged in more pleasurable in-
person activities (interaction: β =-0.06, p=0.009). For those who reported 1SD below the mean
of pleasurable activities, youth who reported 1 (vs. 0) respiratory symptoms reported greater
mean anxiety symptoms (β=0.22, SE=0.06, p<0.001; see Figure 2B); there was no association of
respiratory problems (1 vs. 0) for those who engaged in 1SD above the mean pleasurable
activities (β=0.004, SE=0.06, p=0.94). Again, youth reporting 2-3 respiratory problems (vs. no
35
problems) reported more anxiety symptoms, regardless of level of engagement in pleasurable
activities (p-interaction=0.75-0.99). Interactions between engagement with in-person pleasurable
activities and specific respiratory symptom variables, as well as any respiratory problem
variable, were not statistically significant (p-interaction=0.13-0.97). Significant interaction terms
did not maintain significance after Benjamini-Hochberg corrections were applied. Complete
regression models can be viewed in Appendix H.
Moderation by Engagement in Digital/Online Pleasurable Activities
Engagement in pleasurable digital/online activities was considered as a moderator of the
associations between respiratory problems and depression. The significant interactions are
depicted in Figure 3. A significant two-way interaction was found between pleasurable
digital/online activity level and bronchitis in models examining associations with both mean
depression (interaction: β=-0.005, p=0.003) and anxiety (interaction: β=-0.006, p=0.005)
symptoms. There was a positive association of bronchitis with depression and anxiety among
those engaging in less pleasurable digital/online activities (1 SD below the mean; depression:
β=0.19, SE=0.05, p<0.001; anxiety: β=0.32, SE=0.07, p<0.001) and no association with
depression and anxiety among those engaging in higher levels of pleasurable activities (1 SD
above the mean; depression: β =0.005, SE=0.04, p=0.90; anxiety: β =0.005, SE=0.07, p=0.95).
Similar interactions with digital/online pleasurable activities were not identified for other
specific respiratory problems and depression (p-interaction=0.38-0.94) or anxiety (p-
interaction=0.21-0.69). There was an association between activity level and any respiratory
problem on depression (p-interaction=0.036), such that there was a weaker association among
those with any respiratory problem and depression for those who engaged in high levels of
digital/online pleasurable activities and a stronger association with depression for those engaging
36
in low levels of digital/online pleasurable activities. There were no significant interactions
between specific number of respiratory problems and digital/online pleasurable activities on
depression (p-interaction=0.10-0.22) or on anxiety (p-interaction=0.08-0.63). Significant
interaction terms did not maintain significance after Benjamini-Hochberg corrections were
applied. Complete regression models can be viewed in Appendix G (depressive symptoms) and
Appendix I (anxiety symptoms).
Discussion
This prospective study of adolescents during the transition to early adulthood identified
that many youth experience symptoms of respiratory distress, and that these respiratory problems
were related to depression and anxiety symptoms 2-3 years later. As a longitudinal study
examining the impact of respiratory problems on subsequent psychological functioning during
the transition to adulthood, this study provides new information and insights on youths’ chronic
health symptoms. These findings provide evidence of longitudinal associations between
respiratory problems and subsequent symptoms of depression and anxiety. Each respiratory
problem – bronchitis, wheeze, and shortness of breath – as well as all composite variables were
positively associated with symptoms of depression and anxiety, even after adjusting for baseline
depression or anxiety, demographic characteristics, asthma diagnosis, history of cigarette, e-
cigarette, and cannabis use, as well as exposure to substance use in the home. Overall,
experiencing respiratory problems in high school was associated with higher levels of depression
and anxiety post-graduation compared to youth not experiencing respiratory problems.
Significant relations between respiratory problems, anxiety, and depression have been
identified in prior cross-sectional research among adults and youth (Delmas et al., 2011;
Goodwin et al., 2003; Katon et al., 2004; Leander et al., 2014; Ortega et al., 2002; Ortega et al.,
37
2004). Longitudinally, in analyses with primarily younger children, researchers identified
support for asthma or asthma attacks on anxiety and internalizing symptoms, though these
associations were not found to be significant after accounting for confounding variables or
baseline psychopathology, or among some older adolescent age groups (Feldman et al., 2006;
Ferro et al., 2016; Goodwin et al., 2004). We are aware of one study that specifically examined
bronchitis among young children (i.e., age 5) and found a significant, positive association with
subsequent internalizing symptoms (Alati et al., 2005). However, the associations of specific
respiratory problems (i.e., bronchitic symptoms, wheeze, and shortness of breath) on
psychological functioning have not been studied, to our knowledge, in a longitudinal study of
late adolescents, while simultaneously controlling for multiple demographic and behavioral
covariates. The current findings thus build on existing respiratory health and psychological
functioning research among late adolescents. Our findings indicate that there are longitudinal
associations between specific respiratory problems and depression and anxiety that persist after
considering baseline psychopathology and a variety of clinically-relevant covariates.
The underlying mechanisms driving associations between respiratory problems and
psychological functioning are unclear. However, there are a variety of factors that likely
contribute to increases in mental health symptoms among youth reporting respiratory problems.
Cognitive, biological, and behavioral factors may contribute to increases in depression and
anxiety among youth who experience respiratory problems. One possibility is that youth with
respiratory problems are more likely to suffer from a disease course that requires continued
vigilance and monitoring of symptoms which could correspond to increases in awareness of
other symptoms, including those associated with depression and anxiety (Bruzzese et al., 2016;
Feldman et al., 2009). If an adolescent has to monitor their respiratory problems to determine
38
what activities they can participate in or to decide if they need to take medication or follow other
treatment protocols, they might also be more likely to notice and report psychological symptoms
compared to a youth who does not need to monitor their health with such frequency. Similarly,
youth who experience respiratory problems associated with a medical diagnosis or poorly
controlled respiratory problems may attribute more catastrophic beliefs or attentional biases to
their respiratory problems, which could contribute to symptoms of depression or anxiety
(Dudeney et al., 2017; Katon et al., 2004).
Biological explanations for the link between respiratory problems, anxiety, and
depression have also been posited. Individuals with respiratory problems that include
experiences of hypoxia or hypercapnia may have different neural circuit responses and
sensitivities particularly in the amygdala and locus coeruleus that could be linked to
psychological disorders (Gorman et al., 2001; Katon et al., 2004). Behavioral considerations of
this association could also explain the link between respiratory problems, anxiety, and
depression. Specifically, youth who experience respiratory problems may be less likely to engage
in positively reinforcing activities which could be linked to subsequent depression (Lewinsohn &
Graf, 1973; Lewinsohn & Libet, 1972). Relatedly, some youth might choose to stop engaging in
activities (e.g., athletics) that could increase their respiratory problems due to concerns about
respiratory functioning (Welsh et al., 2005; Wildhaber et al., 2012), and avoidance of these
situations could precipitate the development of anxiety symptoms (Rosen & Schulkin, 1998).
Reverse causation must also be considered as an explanation of the relations between
respiratory problems with depression and anxiety. In fact, some studies of respiratory problems
and psychological functioning among adults have found that depression and anxiety are more
likely to contribute to subsequent respiratory distress, rather than the reverse hypothesized in the
39
current study (Neuman et al., 2006). Of course, diagnoses of depression and anxiety are often
associated with cognitive and attentional biases that focus on health threats, particularly among
those with co-occurring physical health conditions (Alexeeva & Martin, 2018). Thus, one often-
identified consideration is that individuals with symptoms of depression or anxiety are more
likely to attend to negative states and to view the world as a threatening or dangerous place,
which would lead individuals to also over-report other health symptoms (Watson & Pennebaker,
1989). The prospective longitudinal design and statistical adjustment of psychological
functioning at the time of exposure reduces the influence of reverse causal pathways on the
current findings. Nonetheless, the study methodology was designed to identify statistical
associations and is not well-suited to make rigorous causal inferences.
While there may be a direct link between respiratory problems and subsequent depression
and anxiety, other explanations are possible because of the observational design of the current
study. Risk factors for respiratory problems (i.e., exposure to second-hand smoke, low SES,
environmental exposures, pollution, family history of respiratory problems, family stress, access
to healthcare; e.g. Ellison-Loschmann et al., 2007; Freeman et al., 2003; Gilmour et al., 2006;
Shankardass et al., 2009) might also be associated with elevated levels of depression and anxiety.
The current study has responded to these considerations by adjusting for demographic
characteristics and other variables that may have shared risk factors. However, a number of
unmeasured factors might contribute to these associations. Future studies can evaluate the role of
factors such as insurance status, familial stress, and environmental pollutants in the association
between respiratory problems, anxiety, and depression.
Regardless of the underlying mechanisms that might contribute to the associations
between respiratory problems and psychological functioning, the clinical implications are clear.
40
The frequency with which youth reported symptoms of respiratory distress, anxiety, and
depression was high and interrelated. These data highlight the importance of studying chronic
health conditions among adolescents. In the current study, 32.9% of participants reported
experiencing one or more respiratory problems, with the majority of those reporting respiratory
problems endorsing symptoms of bronchitis. This is generally consistent with previous literature
indicating that many youth experience respiratory problems (Hoek et al., 2012; Pallasaho et al.,
2002). Furthermore, youth reported experience of many symptoms consistent with depression
and anxiety, with slightly less than a quarter of youth meeting the clinical cut-off for anxiety and
slightly less than a half of youth meeting the cut-off for depression. While these measures of
psychological functioning, and in particular our measure of depression, are insufficient to make a
clinical diagnosis (Björgvinsson et al., 2013), they can be used to screen individuals to determine
who might be at risk for these psychological disorders. From a clinical and public health
perspective, it is crucial to consider efforts to minimize the likelihood that youth will develop
respiratory problems and psychological disorders, to implement interventions supporting those
with a diagnosed disorder, and to appropriately screen and assess youth for these disorders.
Special attention is needed to address the co-occurring nature of these physical and mental health
symptoms. Problems associated with psychological functioning (e.g., depressive disorders,
anxiety disorders, self harm, substance use disorders) and diagnoses linked to respiratory
problems contribute to the leading causes of morbidity among adolescents in the United States
(World Health Organization, 2020). Additional research, attention, and intervention is needed to
address these high rates of chronic health problems in this vulnerable population.
To this end, the current study also aimed to identify possible moderators of the
association between respiratory problems and psychological functioning, with the goal of
41
identifying modifiable behaviors that could be harnessed in prevention and intervention efforts.
Our analyses considered engagement in pleasurable in-person and online activities as two
separate moderators of these associations. Overall, we found a weak pattern of evidence to
support moderation by engagement in pleasurable in-person and digital/online activities. In a
majority of models considering interactions, the interaction terms were not significant, and none
maintained significance following corrections for tests of multiple comparisons. Therefore, we
cautiously interpret the models with significant interaction terms.
We hypothesized that engagement in pleasurable in-person activities would moderate
associations such that the association of respiratory problems with depression and anxiety would
be attenuated among youth with greater engagement in pleasurable in-person activities. The
association between having one respiratory symptom (vs. 0 symptoms) and depression was
stronger among youth who reported lower levels of in-person pleasurable activities and weaker
for youth reporting higher levels of in-person pleasurable activities. However, the association of
report of 2 or 3 respiratory symptoms (vs. 0 symptoms) with higher levels of depression was not
modified or attenuated with greater engagement in in-person activities (i.e., no moderation was
observed). Similar findings were observed for the association of number of respiratory problems
with mean anxiety symptoms.
We recognize the need to interpret these two findings with caution, given that most
interactions probed in the current analyses did not moderate the association between respiratory
problems and psychological functioning. Nonetheless, there are a few reasons why engagement
in pleasurable in-person activities might have moderated this association, as well as
considerations for why moderation by engagement in pleasurable in-person activities was not
consistently found. Engagement in various pleasurable in-person activities has been shown to
42
support youth’s self-esteem, self-efficacy, academic engagement, and psychological well-being
(Birkeland et al., 2009; Mahoney & Cairns, 1997; Schmalz et al., 2007; Sharp et al., 2011).
Participation in these activities can also facilitate positive peer social relationships and
meaningful relationships with supportive adults (Eccles et al., 2003; Fredricks & Eccles, 2006).
These benefits may be particularly important for youth who report respiratory problems and who
likely struggle to engage in physical activities and experience peer bullying attributed to their
respiratory problems (Wildhaber et al., 2012). In spite of the expected benefits of pleasurable
activities, particularly for youth with respiratory problems, we did not find consistent evidence to
support moderation by in-person pleasurable activities in our analyses. One consideration is that
engagement in pleasurable in-person activities may provide a protective effect for youth with
only one respiratory problem, which likely represents more mild symptoms, but is not effective
at moderating associations of more than one respiratory problem with psychopathology.
However, the current analyses do not systematically address symptom severity beyond the
threshold required for identification of the specific respiratory problems.
It is also possible that our assessment and operationalization of in-person pleasurable
activities impacted our ability to find significant results, or that other factors not including
engagement in pleasurable activities moderate these associations. In the current analysis, we
considered a wide variety of activities and summed participants’ scores of level of involvement x
pleasure for each activity, a strategy taken in other research projects using the same activity scale
(Leventhal, Bello, et al., 2015). However, it’s possible that heavy investment in a few activities
rather than minimal investment in many activities might confer a protective advantage. The
current analyses do not make a distinction between these two styles of activity involvement.
Another possibility is that other factors such as engagement with peers, a sense of belonging,
43
self-efficacy, or a variety of other variables might moderate the association between respiratory
problems and psychological functioning but were not measured in the current study. Future
research should assess other potential moderators – in particular modifiable behaviors – of the
association between respiratory problems with psychological functioning to inform intervention
efforts.
We also evaluated two competing hypotheses while considering the moderating role of
pleasurable digital/online activities on the association between respiratory problems and
psychological functioning. Engagement in pleasurable digital/online activities was a significant
moderator in the associations between bronchitic symptoms and subsequent depression and
anxiety, but not in any other models of respiratory problems with psychological functioning.
Again, moderation by pleasurable digital/online activities on the associations between bronchitic
symptoms and mental health outcomes must be interpreted with caution, given that a majority of
the moderation models did not include significant interaction terms. Some research has identified
beneficial aspects of digital/online media use including affordances that support users’
intensification of existing in-person relationships, particularly among youth who have adaptive
social skills and existing in-person relationships (Nesi et al., 2018). In fact, online engagement
with peers may provide youth with opportunities to connect to similar peers, build camaraderie,
develop their own identity, and to receive social support (Daniels et al., 2021). Another study
found that youth share health information digitally through social media platforms and identified
that youth with reportedly poorer health were more likely to share health information than their
healthy peers (Hausmann et al., 2017). It is possible that youth experiencing health problems,
such as those with bronchitic symptoms, are able to use digital media platforms to receive
support and information regarding their health problems (De Nardi et al., 2020; Frey et al.,
44
2020), to engage with medical education online, or to interact with their health care team
(Hausmann et al., 2017), all of which could mitigate symptoms of depression and anxiety.
Additional research examining the interacting effects of pleasurable digital and online
engagement on respiratory problems and other health problems is needed to more fully
understand possible links between digital media use, physical health concerns, and psychological
functioning. Understanding how youth with physical health problems engage with digital and
online technology may be particularly important for assessing the impact of digital and online
media on mental health.
Excluding associations with bronchitic symptoms, models of wheeze, shortness of breath,
and composite respiratory variables with symptoms of depression or anxiety did not have
significant moderation by digital/online activities. While we hesitate to interpret null findings,
there are a variety of reasons why engagement in online activity may not have consistently
moderated the current analyses. Engaging in digital/ online media activities is less likely to
support youths’ mastery of new skills or strong relationships with supportive adults, but is more
likely to be linked to a sedentary lifestyle with less in-person engagement (Costigan et al., 2013;
Kremer et al., 2014) which may not support moderation in the link between respiratory, anxiety,
and depressive symptoms. In fact, some data suggests that digital media use may be positively
associated with depression and anxiety (Keles et al., 2020). However, the link between digital
media and psychological functioning is complex and there is little consistency across studies, as
some found no association between digital media use for social purposes and psychological
functioning (Banjanin et al., 2015; Neira & Barber, 2014). Considering the extant literature and
findings from the current study, there is little consensus in how digital media engagement may,
or may not, contribute as a moderator in associations between respiratory and other health
45
symptoms and psychological functioning. Future research exploring how youth with physical
health problems interact with digital media, the role it plays in contributing to subsequent
functioning, and the potential differences in these associations by health condition and
presentation is warranted, as digital/online media might be one avenue through which to provide
health interventions.
This prospective, longitudinal study examined the impact of specific respiratory problems
on subsequent depression and anxiety symptoms during the transition from late adolescence to
early adulthood. While we carefully considered the role of key confounding variables (e.g.,
substance use, second-hand smoking exposure, SES) and potential moderators (i.e., engagement
in pleasurable in-person and digital/online activities) on these associations, this study also has
some limitations. Data were self-reported and are therefore subjected to recall and social
desirability biases. Furthermore, we did not have any objective measures of lung functioning or
respiratory conditions, instead relying on student report of respiratory functioning. Future
research should examine the extent to which self-reported lung functioning corresponds to
objective measures, as this would provide further insight into understanding respiratory problems
and functioning among youth.
Additionally, due to the methods and priorities of the current data collection, youth not
present at school on the day of survey administration received an abbreviated survey that did not
include respiratory health questions. Therefore, the sample size of the current study is
substantially smaller than the full data collection sample. Additionally, youth not in attendance
on the day of the survey might have different respiratory and psychological symptoms compared
to youth in attendance. Thus, the current sample represents youth in attendance at school but is
limited in its assessment of youth absent from school. It is likely that findings from the current
46
study provide more conservative estimates compared to what might be expected across the full
population, given that youth with symptoms (and more severe symptom presentations) of
respiratory distress, anxiety, and depression may be more likely to be absent from school.
Despite these limitations, the current findings expand the research and provide additional support
linking respiratory problems to psychological functioning among adolescents and young adults.
These results can inform screening and prevention strategies to support the health of youth and to
mitigate the risk of respiratory and psychological symptoms among adolescents and young
adults.
Conclusion
This study highlights that a considerable portion of adolescents reported experiencing
respiratory problems including bronchitic symptoms, wheeze, and shortness of breath, and that
an association exists between respiratory problems and subsequent symptoms of depression and
anxiety during the transition to adulthood. The current study was designed to help understand the
impact of a variety of respiratory problems on adolescents’ psychological functioning using a
prospective, community-based sample of adolescents in the United States, thus adding a unique,
community-based, longitudinal study to the extant literature. Given the identified link between
respiratory problems and mental health outcomes, medical professionals should screen for
depression and anxiety when an adolescent patient presents with respiratory problems.
Consideration of co-location of physicians and psychologists in adolescent pulmonary and
allergy clinics and pediatricians’ offices may be useful to ensure that both physical and mental
health can be addressed and treated simultaneously.
Furthermore, these data can inform screening, treatment, and intervention for respiratory
problems and psychiatric diagnoses, with the ultimate goal of reducing the morbidity of the most
47
common health concerns among youth in the United States. Additional study is needed to
identify optimal intervention strategies for youth with respiratory problems to reduce risk of
development of depression and anxiety. Engagement in pleasurable activities may be an easy
target for brief intervention, but other intervention strategies need to be identified. While the
current study only found minimal evidence for moderation by involvement in pleasurable
activities, we are aware of a paucity of research considering modifiable moderators of the
association between respiratory problems and psychological functioning. Therefore, additional
research aimed at examining potential moderators of the association between respiratory
problems and mental health outcomes is warranted to support further intervention efforts aimed
at reducing the morbidity of these conditions among adolescents and young adults.
48
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Table 1. Demographic characteristics of analytic sample
Full Analytic
Sample
a
(n=1923)
Any Respiratory
Symptoms
No
(n=1291)
67.1%
Yes
(n=632)
32.9%
Mean (SD) Mean (SD) Mean (SD)
Age
b
17.4 (0.4) 17.4 (0.4) 17.4 (0.4)
Body Mass Index
b
23.3 (4.7) 23.1 (4.4) 23.9 (5.1)
Baseline Depressive Symptoms 0.7 (0.6) 0.7 (0.6) 0.9 (0.7)
Baseline Anxiety Symptoms 1.2 (0.8) 1.1 (0.7) 1.4 (0.8)
In-person Pleasurable Activities Score 54.3 (24.5) 53.9 (24.8) 55.2 (23.8)
Online Pleasurable Activities Score 34.6 (17.1) 34.5 (17.4) 34.8 (16.4)
N (col %) n (row %) n (row %)
Gender
b
Male 775 (40.3) 565 (72.9) 210 (27.1)
Female 1147 (59.7) 725 (63.2) 422 (36.8)
Race/ethnicity
c
Hispanic 835 (43.4) 558 (66.8) 277 (33.2)
Asian 452 (23.5) 323 (71.5) 129 (28.5)
White 300 (15.6) 186 (62.0) 114 (38.0)
Other 298 (15.5) 195 (65.4) 103 (34.6)
Missing 38 (2.0) 29 (76.3) 9 (23.7)
Free or Subsidized lunch
c
No 971 (50.5) 690 (71.1) 281 (28.9)
Reduced cost 197 (10.2) 126 (64.0) 71 (36.0)
Free lunch 654 (34.0) 414 (63.3) 240 (36.7)
Don't know/Missing 101 (5.3) 61 (60.4) 40 (39.6)
Highest Parental Education
c
Some high school or less 204 (10.6) 133 (65.2) 71 (34.8)
High school graduate 246 (12.8) 156 (63.4) 90 (36.6)
Some college 319 (16.6) 206 (64.6) 113 (35.4)
College graduate 575 (29.9) 396 (68.9) 179 (31.1)
Advanced degree 352 (18.3) 241 (68.5) 111 (31.5)
Don't know/Missing 227 (11.8) 159 (70.0) 68 (30.0)
Exposure to Second-hand Smoke at
Home
d
None reported 1396 (72.6) 958 (68.6) 438 (31.4)
Yes 527 (27.4) 333 (63.2) 194 (36.8)
E-Cigarette Use
d
No lifetime use 1164 (60.5) 800 (68.7) 364 (31.3)
No past 6 month use 531 (27.6) 348 (65.5) 183 (34.5)
Past 6 month use 117 (6.1) 74 (63.3) 43 (36.8)
Past 30 day use 54 (2.8) 35 (64.8) 19 (35.2)
74
Note.
a
Full analytic sample includes all participants with anxiety and/or depression data at follow-up and
data on at least one respiratory symptom at baseline; n=1923.
b
Demographic data assessed at study baseline
(Fall of senior year).
c
Demographic data assessed prior to current study at time of enrollment in data
collection (Fall of freshman year).
Missing 57 (3.0) 34 (59.7) 23 (40.4)
Cigarette Use
b
No lifetime use 1227 (63.8) 857 (69.9) 370 (30.2)
No past 6 month use 493 (25.6) 309 (62.7) 184 (37.3)
Past 6 month use 103 (5.4) 66 (64.1) 37 (35.9)
Past 30 day use 80 (4.2) 45 (56.3) 35 (43.8)
Missing 20 (1.0) 14 (70.0) 6 (30.0)
Cannabis Use
b
No lifetime use 1153 (60.0) 802 (69.6) 351 (30.4)
No past 6 month use 291 (15.1) 196 (67.4) 95 (32.7)
Past 6 month use 164 (8.5) 102 (62.2) 62 (37.8)
Past 30 day use 301 (15.7) 180 (59.8) 121 (40.2)
Missing 14 (0.7) 11 (78.6) 3 (21.4)
Asthma Diagnosis
b
No 1369 (71.2) 1012 (73.9) 357 (26.1)
Yes 442 (23.0) 203 (45.9) 239 (54.1)
Missing 112 (5.8) 76 (67.9) 36 (32.1)
75
76
Table 3. Associations of respiratory health problems with depressive symptoms
Note.
a
Minimally adjusted models include gender, subsidized lunch (a proxy for SES), ethnicity, and baseline depression as covariates. All missing covariate data
were imputed.
b
Fully adjusted models include gender, subsidized lunch and parental education (a proxy for SES), ethnicity, history of cannabis, electronic
cigarettes, and combustible cigarettes (never use, past use not in the last 6 months, past 6 month use, past 30 day use), BMI, diagnosed asthma, exposure to
second-hand substance use in the home, and baseline depression as covariates. All missing covariate data were imputed.
c
Total includes only participants with
respiratory data at baseline and depression data at follow-up (n=1917).
d
Mean scores for depressive symptoms ranged from 0-3.
e
Semi-partial correlation
coefficient which denotes the percent of variance in the outcome uniquely accounted for by the specific exposure variables.
f
Any respiratory problem includes
participants who endorsed one or more of the three symptoms (i.e., bronchitis, shortness of breath, wheeze).
g
Total number of respiratory problems denotes total
count of symptoms reported by each participant with respiratory data for one or more symptoms.
†
Significant following Benjamini-Hochberg corrections.
Depressive Symptoms at Follow-up
Minimally adjusted models
a
Fully adjusted models
b
Baseline
Respiratory
Problems
Total
c
n (col %)
Depressive
Symptoms
Mean (SD)
d
B SE β sr
2e
P-value B SE β sr
2e
P-value
Chronic Bronchitis No 1377 (75.6) 0.9 (0.6) REF REF
Yes 445 (24.4) 1.1 (0.7) 0.09 0.03 0.06 0.004 0.003
†
0.09 0.03 0.06 0.003 0.005
†
Shortness of Breath No 1686 (90.1) 0.9 (0.6) REF REF
Yes 186 (9.9) 1.2 (0.7) 0.13 0.04 0.06 0.003 0.005
†
0.12 0.05 0.06 0.003 0.009
†
Wheeze No 1675 (88.4) 0.9 (0.6) REF REF
Yes 219 (11.6) 1.2 (0.6) 0.11 0.04 0.06 0.003 0.007
†
0.11 0.04 0.05 0.003 0.012
†
Any Respiratory
Problem
f
No 1288 (67.2) 0.9 (0.6) REF REF
Yes 629 (32.8) 1.1 (0.7) 0.10 0.03 0.08 0.005 <0.001
†
0.10 0.03 0.07 0.005 0.001
†
Total Number of
Respiratory
Problems
g
0 1288 (67.2) 0.9 (0.6) REF REF
1 449 (23.4) 1.0 (0.6) 0.06 0.03 0.04 0.002 0.042 0.06 0.03 0.04 0.002 0.055
2 139 (7.3) 1.3 (0.6) 0.22 0.05 0.09 0.008 <0.001
†
0.22 0.05 0.09 0.008 <0.001
†
3 41 (2.1) 1.3 (0.6) 0.13 0.09 0.03 0.001 0.163 0.14 0.09 0.03 0.001 0.139
Trend -- -- 0.08 0.02 0.09 0.007 <0.001 0.08 0.02 0.09 0.007 <0.001
†
77
78
Supplemental Table 1. Demographic and key study variables among youth with and
without follow-up data (n=2488)
Full Analytic
Sample
a
(n=1923)
Baseline Data
Only
b
(n=565)
Mean (SD) Mean (SD)
Age
c
17.4 (0.4) 17.5 (0.4)
**
Body Mass Index
c
23.3 (4.7) 23.7 (5.3)
Baseline Depressive Symptoms 0.7 (0.6) 0.7 (0.6)
*
Baseline Anxiety Symptoms 1.2 (0.8) 1.1 (0.8)
***
In-person Pleasurable Activities Score 54.3 (24.5) 53.3 (26.9)
Online Pleasurable Activities Score 34.6 (17.1) 31.6 (18.5)
***
N (col %) n (col %)
Gender
c
Male 775 (40.3) 342 (60.5)
***
Female 1147 (59.7) 223 (39.5)
Race/ethnicity
d
Hispanic 835 (43.4) 265 (46.9)
Asian 452 (23.5) 100 (17.7)
**
White 300 (15.6) 84 (14.9)
Other 298 (15.5) 98 (17.4)
Missing 38 (2.0) 18 (3.2)
Free or Subsidized lunch
d
No 971 (50.5) 248 (43.9)
Reduced cost 197 (10.2) 62 (11.0)
Free lunch 654 (34.0) 216 (38.2)
*
Don't know/Missing 101 (5.3) 39 (6.9)
Highest Parental Education
d
Some high school or less 204 (10.6) 63 (11.2)
High school graduate 246 (12.8) 92 (16.3)
Some college 319 (16.6) 86 (15.2)
College graduate 575 (29.9) 146 (25.8)
Advanced degree 352 (18.3) 86 (15.2)
Don't know/Missing 227 (11.8) 92 (16.3)
Exposure to Second-hand Smoke at
Home
c
None reported 1396 (72.6) 389 (68.9)
Yes 527 (27.4) 176 (31.2)
E-Cigarette Use
c
No lifetime use 1164 (60.5) 310 (54.9)
No past 6 month use 531 (27.6) 179 (31.7)
*
Past 6 month use 117 (6.1) 36 (6.4)
Past 30 day use 54 (2.8) 17 (3.0)
Missing 57 (3.0) 23 (4.1)
79
Cigarette Use
c
No lifetime use 1227 (63.8) 315 (55.8)
No past 6 month use 493 (25.6) 167 (29.6)
*
Past 6 month use 103 (5.4) 32 (5.7)
Past 30 day use 80 (4.2) 44 (7.8)
Missing 20 (1.0) 7 (1.2)
Cannabis Use
c
No lifetime use 1153 (60.0) 292 (51.7)
No past 6 month use 291 (15.1) 122 (21.6)
***
Past 6 month use 164 (8.5) 48 (8.5)
Past 30 day use 301 (15.7) 95 (16.8)
Missing 14 (0.7) 8 (1.4)
Asthma Diagnosis
c
No 1369 (71.2) 376 (66.6)
Yes 442 (23.0) 136 (24.1)
Missing 112 (5.8) 53 (9.4)
Bronchitic Symptoms
No 1379 (71.7) 398 (70.4)
Yes 448 (23.3) 139 (24.6)
Missing 96 (5.0) 28 (5.0)
Shortness of Breath
No 1691 (87.9) 497 (88.0)
Yes 187 (9.7) 51 (9.0)
Missing 45 (2.3) 17 (3.0)
Wheeze
No 1681 (87.4) 511 (90.4)
Yes 219 (11.4) 47 (8.3)
*
Missing 23 (1.2) 7 (1.2)
Any Respiratory Problem
No 1291 (67.1) 382 (67.6)
Yes 632 (32.9) 183 (32.4)
Total Number of Respiratory Problems
0 1291 (67.1) 382 (67.6)
1 451 (23.5) 138 (24.4)
2 140 (7.3) 36 (6.4)
3 41 (2.1) 9 (1.6)
Note.
a
Full analytic sample includes all participants with anxiety and/or depression data at follow-up
and data on at least one respiratory symptom at baseline; n=1923.
b
Baseline only data includes
participants from the larger Happiness and Health Study who were not included in the current
analytic sample given that follow-up data were not provided; n=565.
c
Demographic data assessed at
study baseline (Fall of senior year).
d
Demographic data assessed prior to current study at time of
enrollment in data collection (Fall of freshman year). Asterisks denote significant associations
between demographic variables with inclusion or exclusion of the analytic sample: *p<0.05,
**p<0.01, ***p<0.001. Regression models to assess associations between covariates and sample
variable used “no” as the referent category when applicable, male for gender, Hispanic for ethnicity,
and some high school or less for parental education.
80
81
82
83
84
Figure 2. Moderation by In-person Pleasurable Activities on the Association between Total Number of
Respiratory Problems and Symptoms of Depression (A) and Anxiety (B).
A.
B.
Note. (A) Interaction p-values for model including depression: one respiratory problem p=0.020, two
problems p=0.431, three problems p=0.960 (B) Interaction p-values for model including anxiety: one
respiratory problem p=0.009, two problems p=0.993, three problems p=0.745.
85
Figure 3. Moderation by Digital/Online Pleasurable Activities on the Association between Bronchitis and
Symptoms of Depression (A) and Anxiety (B).
A.
B.
Note. (A) Interaction p-values for model including depression: p=0.003 (B) Interaction p-values for
model including anxiety: p=0.005.
86
Supplemental Figure 1. Consort Flow
87
Supplemental Figure 2. Moderation by Digital/Online Pleasurable Activities on the Association between
Any Respiratory Problems and Depressive Symptoms.
Note. Interaction p-value: p=0.036
88
Appendix A
Respiratory Measures
Respiratory Questions
Bronchitic Symptoms
During the last 12 months, have you had a couth first thing in the morning that lasted for as much as
3 months in a row?
During the last 12 months, have you had a cough at any other times of the day that lasted for as much
as 3 months in row?
Other than with colds, do you usually feel congested in your chest or cough up mucus or phlegm?
During the past 12 months, have you had bronchitis
*Coded as chronic bronchitis if participant endorses 1 or more of the above items.*
Wheeze
Have you ever had wheezing or whistling at any time in the past?
How many attacks of wheezing have you had in the last 12 months?
In the last 12 months, how often, on average, has your sleep been disturbed due to wheezing?
In the last 12 months, has wheezing ever been severe enough to limit your speech to only one or
two words at a time between breaths?
In the last 12 months, has your chest sounded wheezy during or after exercise?
*Coded as wheeze problems if participant endorses the overarching question and 1 or more of the
specific symptoms.*
Shortness of Breath
Are you troubled by shortness of breath when hurrying on level ground or walking up a slight hill?
Do you have to walk slower than people of your age on level ground because of shortness of
breath?
Do you ever have to stop for breath when walking at your pace on level ground?
Do you ever have to stop for breath when walking about 100 yards (or after a few minutes) on
level ground?
*Coded as shortness of breath if participant endorses the overarching question and 1 or more of the
specific symptoms.*
89
Appendix B
In-Person and Digital/Online Activities
Engagement in Pleasurable Activities
In-person Activities
1. Working on a project
2. Writing to friends or family
3. Reading
4. Doing great in your classes
5. Daydreaming about your life
6. Getting out into nature
7. Gambling
8. Doing any activity for a thrill (parachuting, fighting, white water rafting, driving fast, bungee
jumping, etc.)
9. Dancing
10. Cooking
11. Drinking coffee
12. Eating out at a restaurant
13. Eating alone
14. Shopping
15. Taking a long shower or bath
16. Getting a haircut, nails done, a facial or a massage
17. Watching a play, a movie, or T.V.
18. Going to parties
19. Playing with animals
20. Watching wild animals
21. Visiting/hanging out with friends
22. Visiting/hanging out with family
23. Collecting things
24. Taking a drive
25. Acting
26. Traveling
27. Dating
28. Organizing events
29. Playing individual sports (swimming, skiing, gymnastics, wrestling, etc.)
30. Playing team sports (basketball, football, softball, baseball, etc.)
31. Exercising
32. Watching sports
33. Doing arts and crafts (pottery, sewing, painting, drawing, decorating)
34. Playing games (card, video, other)
35. Offering assistance to others (through charity programs, Goodwill, tutoring, etc.)
36. Getting assistance from others (through charity programs, Goodwill, tutoring, etc.)
37. Participating in clubs or community organizations (student gov't, language club, volunteering, etc.)
38. Praising others
39. Receiving praise
90
40. Playing musical instruments
41. Listening to music
42. Participating in religious events
43. Thinking about your religious foundations
44. Going to class or work
*Youth report how often they did this activity in the past 30 days (never, 1-6 times, 7 or more times).*
Digital Activities
1. Checking social media sites (Facebook, Twitter, Instagram, etc.)
2. Posting your own photos, images, videos, status updates, or blogs
3. Liking or commenting on other people’s statuses, wall posts, pictures, etc.
4. Sharing other people's photos, images, videos, status updates, blogs, articles, news, or websites
5. Browsing or viewing photos, images, or videos (YouTube, Vine, Pinterest, Imgur, or Reddit, etc.)
6. Reading blogs, articles, news, online forums, or books on a phone, tablet, or computer
7. Watching streamed television shows or movies (Netflix, Hulu, iTunes, etc.)
8. Streaming or downloading music (iTunes, Pandora, YouTube, etc.)
9. Chatting online (instant messaging, Facebook messenger, etc.)
10. Texting (Text messaging)
11. Video-chatting (Skype, Facetime, Omegle, etc.)
12. Online shopping or viewing products online (clothes, electronics, games, etc.)
13. Playing games with your friends and family on a console (Xbox, Playstation, Wii), personal
computer, or cell phone
14. Playing games by yourself on a console (Xbox, Playstation, Wii), personal computer, or cell phone
*Youth report how often they did this activity in the past week (never, a little, every day, many times a
day)*
91
Appendix C
Psychological Functioning Measures
Depressive Symptoms
*Participants rate how often they have experienced each item during the past week, from 0 (rarely or non
of the time) to 3 (most or all of the time).
**Denotes items that were included in the CESD-10. At baseline, mean score on the full CESD was
calculated and used in analyses. At follow-up, only CESD-10 was included in the data collection and
mean score was used to assess depressive symptoms at follow-up.
CESD (Depression Assessment)
1. I was bothered by things that usually don't bother me.**
2. I did not feel like eating; my appetite was poor.
3. I felt that I could not shake off the blues even with help from my family or friends.
4. I felt I was just as good as other people.
5. I had trouble keeping my mind on what I was doing.**
6. I felt depressed.**
7. I felt that everything I did was an effort.**
8. I felt hopeful about the future.**
9. I thought my life had been a failure.
10. I felt fearful.**
11. My sleep was restless.**
12. I was happy.**
13. I talked less than usual.
14. I felt lonely.**
15. People were unfriendly.
16. I enjoyed life.
17. I had crying spells.
18. I felt sad.
19. I felt that people disliked me.
20. I could not get going. **
92
Anxiety Symptoms
*Youth report how often each of these things happen to them on a scale from 0 (never) to 3 (always).
*Participants report on how often over the last 2 weeks they have been bothered by each problem from 0
(not at all) to 3 (nearly every day)
RCADS – GAD (baseline anxiety assessment)
1. I worry about things.
2. I worry that something awful will happen to someone in my family.
3. I worry that bad things will happen to me.
4. I worry that something bad will happen to me.
5. I worry about what is going to happen.
6. I think about death.
GAD-7 (follow-up anxiety assessment)
1. Feeling nervous, anxious, or on edge.
2. Not being able to stop or control worrying.
3. Worrying too much about different things.
4. Trouble relaxing.
5. Being so restless that it’s hard to sit still.
6. Becoming easily annoyed or irritable.
7. Feeling afraid as if something awful might happen.
93
Appendix D
Regression Coefficients for All Variables Included in Models Examining the Associations
between Respiratory Problems and Subsequent Symptoms of Depression
Model 1. Linear Regression Association between Bronchitic Symptoms and Subsequent
Symptoms of Depression
Depressive Symptoms at Follow-up
B SE β P-value R
2
Bronchitic Symptoms 0.22
No REF
Yes 0.09 0.03 0.06 0.005
Body Mass Index 0.01 0.003 0.04 0.059
Baseline Mean Depressive Symptoms 0.46 0.02 0.45 <0.001
Gender
Female REF
Male 0.001 0.03 0.001 0.967
Race/ethnicity
Hispanic REF
Asian -0.01 0.04 -0.01 0.741
White -0.11 0.04 -0.07 0.008
Other -0.04 0.04 -0.02 0.310
Free or Subsidized Lunch
No REF
Reduced cost 0.01 0.05 0.004 0.846
Free lunch -0.02 0.03 -0.02 0.501
Highest Parental Education
Some high school or less REF
High school graduate -0.13 0.05 -0.07 0.015
Some college -0.07 0.05 -0.04 0.188
College graduate 0.00 0.06 -0.002 0.954
Advanced degree -0.08 0.06 -0.05 0.151
Exposure to Second-hand Smoke at Home
None reported REF
Yes -0.01 0.03 -0.01 0.790
E-Cigarette Use
No lifetime use REF
No past 6 month use -0.01 0.04 -0.004 0.891
Past 6 month use -0.05 0.06 -0.02 0.395
Past 30 day use -0.07 0.09 -0.02 0.422
Cigarette Use
No lifetime use REF
No past 6 month use 0.03 0.04 0.02 0.405
Past 6 month use -0.01 0.07 -0.003 0.899
Past 30 day use 0.04 0.08 0.01 0.642
Cannabis Use
No lifetime use REF
No past 6 month use -0.08 0.04 -0.04 0.083
Past 6 month use -0.01 0.05 -0.004 0.856
Past 30 day use -0.02 0.05 -0.01 0.634
Asthma Diagnosis
No REF
Yes 0.003 0.03 0.002 0.922
94
Model 2. Linear Regression Association between Shortness of Breath and Subsequent Symptoms
of Depression
Depressive Symptoms at Follow-up
B SE β P-value R
2
Shortness of Breath 0.22
No REF
Yes 0.12 0.05 0.06 0.009
Body Mass Index 0.01 0.003 0.05 0.033
Baseline Mean Depressive Symptoms 0.46 0.02 0.46 <0.001
Gender
Female REF
Male 0.01 0.03 0.01 0.639
Race/ethnicity
Hispanic REF
Asian 0.01 0.04 0.01 0.712
White -0.10 0.04 -0.06 0.015
Other -0.02 0.04 -0.01 0.567
Free or Subsidized Lunch
No REF
Reduced cost -0.01 0.05 -0.004 0.864
Free lunch -0.01 0.03 -0.01 0.662
Highest Parental Education
Some high school or less REF
High school graduate -0.10 0.05 -0.06 0.058
Some college -0.06 0.05 -0.04 0.250
College graduate 0.01 0.05 0.01 0.846
Advanced degree -0.08 0.06 -0.05 0.165
Exposure to Second-hand Smoke at Home
None reported REF
Yes -0.01 0.03 -0.01 0.772
E-Cigarette Use
No lifetime use REF
No past 6 month use -0.03 0.04 -0.02 0.447
Past 6 month use -0.02 0.06 -0.01 0.792
Past 30 day use -0.09 0.09 -0.03 0.321
Cigarette Use
No lifetime use REF
No past 6 month use 0.06 0.04 0.04 0.161
Past 6 month use 0.01 0.07 0.01 0.831
Past 30 day use 0.08 0.08 0.02 0.333
Cannabis Use
No lifetime use REF
No past 6 month use -0.09 0.04 -0.05 0.040
Past 6 month use -0.02 0.05 -0.01 0.679
Past 30 day use -0.03 0.05 -0.02 0.567
Asthma Diagnosis
No REF
Yes 0.01 0.03 0.01 0.698
95
Model 3. Linear Regression Association between Wheeze and Subsequent Symptoms of
Depression
Depressive Symptoms at Follow-up
B SE β P-value R
2
Wheeze 0.21
No REF
Yes 0.11 0.04 0.05 0.012
Body Mass Index 0.01 0.003 0.04 0.047
Baseline Mean Depressive Symptoms 0.46 0.02 0.45 <0.001
Gender
Female REF
Male 0.01 0.03 0.01 0.695
Race/ethnicity
Hispanic REF
Asian 0.01 0.04 0.004 0.874
White -0.11 0.04 -0.06 0.008
Other -0.03 0.04 -0.02 0.507
Free or Subsidized Lunch
No REF
Reduced cost -0.02 0.04 -0.01 0.729
Free lunch -0.02 0.03 -0.01 0.607
Highest Parental Education
Some high school or less REF
High school graduate -0.10 0.05 -0.05 0.071
Some college -0.06 0.05 -0.03 0.287
College graduate 0.02 0.05 0.01 0.779
Advanced degree -0.06 0.06 -0.04 0.275
Exposure to Second-hand Smoke at Home
None reported REF
Yes -0.01 0.03 -0.005 0.814
E-Cigarette Use
No lifetime use REF
No past 6 month use -0.02 0.04 -0.01 0.655
Past 6 month use 0.001 0.06 0.001 0.981
Past 30 day use -0.08 0.09 -0.02 0.330
Cigarette Use
No lifetime use REF
No past 6 month use 0.04 0.04 0.03 0.270
Past 6 month use -0.01 0.07 -0.004 0.874
Past 30 day use 0.09 0.08 0.03 0.260
Cannabis Use
No lifetime use REF
No past 6 month use -0.08 0.04 -0.04 0.084
Past 6 month use -0.02 0.05 -0.01 0.766
Past 30 day use -0.03 0.05 -0.02 0.555
Asthma Diagnosis
No REF
Yes -0.003 0.03 -0.002 0.927
96
Model 4. Linear Regression Association between Any Respiratory Problem and Subsequent
Symptoms of Depression
Depressive Symptoms at Follow-up
B SE β P-value R
2
Any Respiratory Problem 0.22
No REF
Yes 0.10 0.03 0.07 0.001
Body Mass Index 0.01 0.003 0.04 0.080
Baseline Mean Depressive Symptoms 0.45 0.02 0.45 <0.001
Gender
Female REF
Male 0.01 0.03 0.01 0.653
Race/ethnicity
Hispanic REF
Asian 0.0003 0.04 0.0002 0.994
White -0.12 0.04 -0.07 0.005
Other -0.03 0.04 -0.02 0.404
Free or Subsidized Lunch
No REF
Reduced cost -0.02 0.04 -0.01 0.693
Free lunch -0.02 0.03 -0.02 0.538
Highest Parental Education
Some high school or less REF
High school graduate -0.10 0.05 -0.06 0.058
Some college -0.06 0.05 -0.04 0.279
College graduate 0.02 0.05 0.01 0.769
Advanced degree -0.06 0.06 -0.04 0.257
Exposure to Second-hand Smoke at Home
None reported REF
Yes -0.01 0.03 -0.01 0.783
E-Cigarette Use
No lifetime use REF
No past 6 month use -0.02 0.04 -0.01 0.653
Past 6 month use -0.001 0.06 -0.001 0.981
Past 30 day use -0.07 0.08 -0.02 0.393
Cigarette Use
No lifetime use REF
No past 6 month use 0.04 0.04 0.03 0.277
Past 6 month use -0.02 0.07 -0.01 0.801
Past 30 day use 0.07 0.08 0.02 0.358
Cannabis Use
No lifetime use REF
No past 6 month use -0.08 0.04 -0.04 0.082
Past 6 month use -0.02 0.05 -0.01 0.728
Past 30 day use -0.02 0.05 -0.01 0.609
Asthma Diagnosis
No REF
Yes -0.01 0.03 -0.01 0.790
97
Model 5. Linear Regression Association between Total Number of Respiratory Problems
(modelled categorically) and Subsequent Symptoms of Depression
Depressive Symptoms at Follow-up
Fully adjusted models
b
B SE β P-value R
2
Total Respiratory problems 0.23
None REF
1 0.06 0.03 0.04 0.055
2 0.22 0.05 0.09 <0.001
3 0.14 0.09 0.03 0.139
Body Mass Index 0.005 0.003 0.04 0.077
Baseline Mean Depressive Symptoms 0.45 0.02 0.44 <0.001
Gender
Female REF
Male 0.01 0.03 0.01 0.598
Race/ethnicity
Hispanic REF
Asian -0.002 0.04 -0.001 0.967
White -0.12 0.04 -0.07 0.004
Other -0.03 0.04 -0.02 0.423
Free or Subsidized Lunch
No REF
Reduced cost -0.02 0.04 -0.01 0.680
Free lunch -0.02 0.03 -0.02 0.461
Highest Parental Education
Some high school or less REF
High school graduate -0.10 0.05 -0.05 0.063
Some college -0.06 0.05 -0.04 0.267
College graduate 0.02 0.05 0.01 0.733
Advanced degree -0.06 0.06 -0.04 0.275
Exposure to Second-hand Smoke at Home
None reported REF
Yes -0.01 0.03 -0.005 0.820
E-Cigarette Use
No lifetime use REF
No past 6 month use -0.02 0.04 -0.01 0.624
Past 6 month use 0.004 0.06 0.002 0.942
Past 30 day use -0.08 0.08 -0.02 0.370
Cigarette Use
No lifetime use REF
No past 6 month use 0.04 0.04 0.03 0.313
Past 6 month use -0.01 0.07 -0.003 0.885
Past 30 day use 0.07 0.08 0.02 0.364
Cannabis Use
No lifetime use REF
No past 6 month use -0.08 0.04 -0.04 0.083
Past 6 month use -0.02 0.05 -0.01 0.731
Past 30 day use -0.03 0.05 -0.02 0.559
Asthma Diagnosis
No REF
Yes -0.01 0.03 -0.01 0.648
98
Model 6. Linear Regression Association between Total Number of Respiratory Problems
(modelled continuously) and Subsequent Symptoms of Depression
Depressive Symptoms at Follow-up
B SE β P-value R
2
Total Number of Respiratory Problems 0.22
None REF
+1 Problem 0.08 0.02 0.09 <0.001
Body Mass Index 0.01 0.003 0.04 0.088
Baseline Mean Depressive Symptoms 0.45 0.02 0.44 <0.001
Gender
Female REF
Male 0.01 0.03 0.01 0.586
Race/ethnicity
Hispanic REF
Asian 0.0002 0.04 0.0001 0.996
White -0.12 0.04 -0.07 0.004
Other -0.03 0.04 -0.02 0.423
Free or Subsidized Lunch
No REF
Reduced cost -0.02 0.04 -0.01 0.691
Free lunch -0.02 0.03 -0.02 0.485
Highest Parental Education
Some high school or less REF
High school graduate -0.10 0.05 -0.06 0.054
Some college -0.06 0.05 -0.04 0.269
College graduate 0.02 0.05 0.01 0.767
Advanced degree -0.06 0.06 -0.04 0.254
Exposure to Second-hand Smoke at Home
None reported REF
Yes -0.01 0.03 -0.01 0.796
E-Cigarette Use
No lifetime use REF
No past 6 month use -0.02 0.04 -0.01 0.637
Past 6 month use 0.002 0.06 0.001 0.968
Past 30 day use -0.07 0.08 -0.02 0.394
Cigarette Use
No lifetime use REF
No past 6 month use 0.04 0.04 0.03 0.302
Past 6 month use -0.01 0.07 -0.005 0.843
Past 30 day use 0.07 0.08 0.02 0.384
Cannabis Use
No lifetime use REF
No past 6 month use -0.08 0.04 -0.04 0.073
Past 6 month use -0.02 0.05 -0.01 0.686
Past 30 day use -0.03 0.05 -0.01 0.590
Asthma Diagnosis
No REF
Yes -0.02 0.03 -0.01 0.607
99
Appendix E
Regression Coefficients for All Variables Included in Models Examining the Associations
between Respiratory Problems and Subsequent Symptoms of Anxiety
Model 1. Linear Regression Association between Bronchitic Symptoms and Subsequent
Symptoms of Anxiety
Anxiety Symptoms at Follow-up
B SE β P-value R
2
Bronchitic Symptoms 0.19
No REF
Yes 0.15 0.04 0.08 <0.001
Body Mass Index 0.001 0.004 0.01 0.734
Baseline Mean Anxiety Symptoms 0.41 0.02 0.40 <0.001
Gender
Female REF
Male -0.07 0.04 -0.04 0.048
Race/ethnicity
Hispanic REF
Asian -0.03 0.05 -0.02 0.551
White -0.06 0.06 -0.03 0.254
Other 0.01 0.05 0.005 0.853
Free or Subsidized Lunch
No REF
Reduced cost 0.04 0.06 0.01 0.533
Free lunch 0.01 0.04 0.004 0.893
Highest Parental Education
Some high school or less REF
High school graduate -0.09 0.07 -0.04 0.151
Some college -0.04 0.07 -0.02 0.547
College graduate 0.03 0.07 0.02 0.628
Advanced degree -0.04 0.07 -0.02 0.550
Exposure to Second-hand Smoke at Home
None reported REF
Yes -0.03 0.04 -0.02 0.370
E-Cigarette Use
No lifetime use REF
No past 6 month use -0.07 0.05 -0.04 0.162
Past 6 month use -0.14 0.08 -0.05 0.078
Past 30 day use -0.21 0.12 -0.05 0.075
Cigarette Use
No lifetime use REF
No past 6 month use 0.08 0.05 0.04 0.136
Past 6 month use 0.04 0.09 0.01 0.647
Past 30 day use 0.24 0.10 0.06 0.016
Cannabis Use
No lifetime use REF
No past 6 month use -0.05 0.06 -0.02 0.388
Past 6 month use -0.02 0.07 -0.01 0.733
Past 30 day use 0.06 0.06 0.03 0.329
Asthma Diagnosis
No REF
Yes 0.05 0.04 0.03 0.199
100
Model 2. Linear Regression Association between Shortness of Breath and Subsequent Symptoms
of Anxiety
Anxiety Symptoms at Follow-up
B SE β P-value R
2
Shortness of Breath 0.19
No REF
Yes 0.26 0.06 0.10 <0.001
Body Mass Index 0.002 0.004 0.01 0.609
Baseline Mean Anxiety Symptoms 0.41 0.02 0.40 <0.001
Gender
Female REF
Male -0.05 0.04 -0.03 0.186
Race/ethnicity
Hispanic REF
Asian -0.001 0.05 -0.0003 0.991
White -0.05 0.05 -0.02 0.389
Other 0.04 0.05 0.02 0.465
Free or Subsidized Lunch
No REF
Reduced cost 0.01 0.06 0.004 0.856
Free lunch 0.01 0.04 0.004 0.871
Highest Parental Education
Some high school or less REF
High school graduate -0.07 0.06 -0.03 0.269
Some college -0.02 0.07 -0.01 0.707
College graduate 0.03 0.07 0.02 0.688
Advanced degree -0.05 0.07 -0.02 0.535
Exposure to Second-hand Smoke at Home
None reported REF
Yes -0.04 0.04 -0.02 0.253
E-Cigarette Use
No lifetime use REF
No past 6 month use -0.07 0.05 -0.04 0.129
Past 6 month use -0.11 0.08 -0.03 0.189
Past 30 day use -0.22 0.12 -0.05 0.061
Cigarette Use
No lifetime use REF
No past 6 month use 0.08 0.05 0.05 0.112
Past 6 month use 0.07 0.08 0.02 0.427
Past 30 day use 0.25 0.10 0.06 0.012
Cannabis Use
No lifetime use REF
No past 6 month use -0.06 0.06 -0.03 0.302
Past 6 month use -0.02 0.06 -0.01 0.760
Past 30 day use 0.05 0.06 0.02 0.391
Asthma Diagnosis
No REF
Yes 0.06 0.04 0.03 0.178
101
Model 3. Linear Regression Association between Wheeze and Subsequent Symptoms of Anxiety
Anxiety Symptoms at Follow-up
B SE β P-value R
2
Wheeze 0.19
No REF
Yes 0.14 0.05 0.06 0.009
Body Mass Index 0.002 0.004 0.01 0.535
Baseline Mean Anxiety Symptoms 0.41 0.02 0.41 <0.001
Gender
Female REF
Male -0.06 0.04 -0.04 0.096
Race/ethnicity
Hispanic REF
Asian -0.01 0.05 -0.01 0.834
White -0.05 0.05 -0.03 0.320
Other 0.02 0.05 0.01 0.653
Free or Subsidized Lunch
No REF
Reduced cost 0.01 0.06 0.003 0.879
Free lunch 0.004 0.04 0.003 0.918
Highest Parental Education
Some high school or less REF
High school graduate -0.06 0.06 -0.03 0.329
Some college -0.02 0.07 -0.01 0.787
College graduate 0.04 0.07 0.02 0.550
Advanced degree -0.03 0.07 -0.02 0.689
Exposure to Second-hand Smoke at Home
None reported REF
Yes -0.04 0.04 -0.02 0.329
E-Cigarette Use
No lifetime use REF
No past 6 month use -0.06 0.05 -0.04 0.190
Past 6 month use -0.10 0.08 -0.03 0.211
Past 30 day use -0.22 0.11 -0.05 0.051
Cigarette Use
No lifetime use REF
No past 6 month use 0.07 0.05 0.04 0.134
Past 6 month use 0.04 0.08 0.01 0.615
Past 30 day use 0.26 0.10 0.07 0.008
Cannabis Use
No lifetime use REF
No past 6 month use -0.05 0.05 -0.02 0.379
Past 6 month use -0.01 0.07 -0.004 0.874
Past 30 day use 0.06 0.06 0.03 0.285
Asthma Diagnosis
No REF
Yes 0.05 0.04 0.03 0.220
102
Model 4. Linear Regression Association between Any Respiratory Problem and Subsequent
Symptoms of Anxiety
Anxiety Symptoms at Follow-up
B SE β P-value R
2
Any Respiratory Problem 0.19
None REF
Yes 0.16 0.04 0.10 <0.001
Body Mass Index 0.001 0.004 0.01 0.739
Baseline Mean Anxiety Symptoms 0.40 0.02 0.39 <0.001
Gender
Female REF
Male -0.06 0.03 -0.04 0.096
Race/ethnicity
Hispanic REF
Asian -0.01 0.05 -0.01 0.784
White -0.07 0.05 -0.03 0.203
Other 0.02 0.05 0.01 0.763
Free or Subsidized Lunch
No REF
Reduced cost 0.003 0.06 0.001 0.959
Free lunch 0.004 0.04 0.002 0.927
Highest Parental Education
Some high school or less REF
High school graduate -0.07 0.06 -0.03 0.266
Some college -0.03 0.07 -0.01 0.690
College graduate 0.04 0.07 0.03 0.512
Advanced degree -0.04 0.07 -0.02 0.584
Exposure to Second-hand Smoke at Home
None reported REF
Yes -0.04 0.04 -0.02 0.345
E-Cigarette Use
No lifetime use REF
No past 6 month use -0.07 0.05 -0.04 0.131
Past 6 month use -0.12 0.08 -0.04 0.143
Past 30 day use -0.21 0.11 -0.05 0.065
Cigarette Use
No lifetime use REF
No past 6 month use 0.08 0.05 0.04 0.114
Past 6 month use 0.04 0.08 0.01 0.633
Past 30 day use 0.24 0.10 0.06 0.015
Cannabis Use
No lifetime use REF
No past 6 month use -0.05 0.05 -0.02 0.390
Past 6 month use -0.02 0.06 -0.01 0.805
Past 30 day use 0.06 0.06 0.03 0.303
Asthma Diagnosis
No REF
Yes 0.03 0.04 0.02 0.449
103
Model 5. Linear Regression Association between Total Number of Respiratory Problems
(modelled categorically) and Subsequent Symptoms of Anxiety
Anxiety Symptoms at Follow-up
Fully adjusted models
b
B SE β P-value R
2
Total Number of Respiratory Problems 0.19
None REF
1 0.11 0.04 0.06 0.007
2 0.33 0.07 0.11 <0.001
3 0.34 0.12 0.06 0.003
Body Mass Index 0.001 0.004 0.01 0.762
Baseline Mean Anxiety Symptoms 0.39 0.02 0.39 <0.001
Gender
Female REF
Male -0.05 0.03 -0.03 0.119
Race/ethnicity
Hispanic REF
Asian -0.02 0.05 -0.01 0.757
White -0.07 0.05 -0.03 0.171
Other 0.02 0.05 0.01 0.721
Free or Subsidized Lunch
No REF
Reduced cost 0.001 0.06 0.001 0.981
Free lunch -0.002 0.04 -0.001 0.958
Highest Parental Education
Some high school or less REF
High school graduate -0.07 0.06 -0.03 0.254
Some college -0.03 0.07 -0.01 0.669
College graduate 0.04 0.06 0.03 0.490
Advanced degree -0.04 0.07 -0.02 0.590
Exposure to Secondhand Smoke at Home
None reported REF -0.02
Yes -0.03 0.04 0.363
E-Cigarette Use
No lifetime use REF
No past 6 month use -0.08 0.05 -0.04 0.116
Past 6 month use -0.11 0.08 -0.03 0.175
Past 30 day use -0.21 0.11 -0.05 0.065
Cigarette Use
No lifetime use
No past 6 month use 0.07 0.05 0.04 0.137
Past 6 month use 0.05 0.08 0.01 0.559
Past 30 day use 0.23 0.10 0.06 0.017
Cannabis Use
No lifetime use REF
No past 6 month use -0.05 0.05 -0.02 0.368
Past 6 month use -0.02 0.06 -0.01 0.768
Past 30 day use 0.06 0.06 0.03 0.334
Asthma Diagnosis
No REF
Yes 0.02 0.04 0.01 0.643
104
Model 6. Linear Regression Association between Total Number of Respiratory Problems
(modelled continuously) and Subsequent Symptoms of Anxiety
Anxiety Symptoms at Follow-up
B SE β P-value R
2
Total Number of Respiratory Problems 0.19
None REF
+1 Problems 0.13 0.02 0.12 <0.001
Body Mass Index 0.001 0.004 0.01 0.794
Baseline Mean Anxiety Symptoms 0.39 0.02 0.39 <0.001
Gender
Female REF
Male -0.05 0.03 -0.03 0.123
Race/ethnicity
Hispanic REF
Asian -0.01 0.05 -0.01 0.778
White -0.07 0.05 -0.03 0.180
Other 0.02 0.05 0.01 0.728
Free or Subsidized Lunch
No REF
Reduced cost 0.001 0.06 0.001 0.980
Free lunch -0.001 0.04 -0.001 0.977
Highest Parental Education
Some high school or less REF
High school graduate -0.08 0.06 -0.03 0.236
Some college -0.03 0.07 -0.01 0.673
College graduate 0.04 0.07 0.03 0.509
Advanced degree -0.04 0.07 -0.02 0.569
Exposure to Second-hand Smoke at Home
None reported REF
Yes -0.03 0.04 -0.02 0.352
E-Cigarette Use
No lifetime use REF
No past 6 month use -0.07 0.05 -0.04 0.121
Past 6 month use -0.11 0.08 -0.04 0.164
Past 30 day use -0.21 0.11 -0.05 0.069
Cigarette Use
No lifetime use REF
No past 6 month use 0.07 0.05 0.04 0.132
Past 6 month use 0.04 0.08 0.01 0.587
Past 30 day use 0.23 0.10 0.06 0.019
Cannabis Use
No lifetime use REF
No past 6 month use -0.05 0.05 -0.02 0.352
Past 6 month use -0.02 0.06 -0.01 0.743
Past 30 day use 0.06 0.06 0.03 0.320
Asthma Diagnosis
No REF
Yes 0.02 0.04 0.01 0.680
105
Appendix F
Regression Coefficients for All Variables Included in Models Examining the Associations
between Respiratory Problems and Symptoms of Depression, Moderated by In-Person Activity
Model 1. Linear Regression Association between Bronchitic Symptoms and Subsequent
Symptoms of Depression, Moderated by Engagement in Pleasurable In-Person Activity
Depressive Symptoms at Follow-up
B SE β P-value R
2
STEP 1 Bronchitic Symptoms 0.22
None REF
Yes 0.10 0.03 0.07 0.003
Body Mass Index 0.006 0.003 0.04 0.059
Baseline Mean Depressive Symptoms 0.45 0.02 0.45 <0.001
Gender
Female REF
Male -0.003 0.03 -0.003 0.907
Race/ethnicity
Hispanic REF
Asian -0.02 0.04 -0.01 0.689
White -0.11 0.04 -0.07 0.008
Other -0.04 0.04 -0.02 0.334
Free or Subsidized Lunch
No REF
Reduced cost 0.007 0.05 0.003 0.886
Free lunch -0.03 0.03 -0.02 0.447
Highest Parental Education
Some high school or less REF
High school graduate -0.13 0.05 -0.07 0.015
Some college -0.07 0.05 -0.04 0.192
College graduate -0.003 0.06 -0.002 0.954
Advanced degree -0.08 0.06 -0.05 0.172
Exposure to Second-hand Smoke at Home
None reported REF
Yes -0.004 0.03 -0.003 0.902
E-Cigarette Use
No lifetime use REF
No past 6 month use -0.006 0.04 -0.004 0.880
Past 6 month use -0.05 0.06 -0.02 0.411
Past 30 day use -0.07 0.09 -0.02 0.437
Cigarette Use
No lifetime use REF
No past 6 month use 0.04 0.04 0.03 0.368
Past 6 month use -0.006 0.07 -0.002 0.927
Past 30 day use 0.03 0.08 0.01 0.657
Cannabis Use
No lifetime use REF
No past 6 month use -0.08 0.04 -0.04 0.086
Past 6 month use -0.01 0.05 -0.01 0.781
Past 30 day use -0.03 0.05 -0.02 0.546
Asthma Diagnosis
No REF
Yes 0.002 0.03 0.001 0.947
In-Person Pleasurable Activities -0.0005 0.0006 -0.02 0.482
STEP 2 Bronchitic Symptoms* In-Person Activities -0.002 0.001 -0.04 0.148
106
Model 2. Linear Regression Association between Shortness of Breath and Subsequent Symptoms
of Depression, Moderated by Engagement in Pleasurable In-Person Activity
Depressive Symptoms at Follow-up
B SE β P-value R
2
STEP 1 Shortness of Breath 0.22
None REF
Yes 0.12 0.04 0.06 0.008
Body Mass Index 0.01 0.003 0.05 0.034
Baseline Mean Depressive Symptoms 0.46 0.02 0.45 <0.001
Gender
Female REF
Male 0.01 0.03 0.01 0.720
Race/ethnicity
Hispanic REF
Asian 0.01 0.04 0.01 0.751
White -0.10 0.04 -0.06 0.016
Other -0.02 0.04 -0.01 0.608
Free or Subsidized Lunch
No REF
Reduced cost -0.01 0.05 -0.004 0.868
Free lunch -0.02 0.03 -0.01 0.630
Highest Parental Education
Some high school or less REF
High school graduate -0.10 0.05 -0.06 0.051
Some college -0.06 0.05 -0.04 0.251
College graduate 0.01 0.05 0.01 0.854
Advanced degree -0.07 0.06 -0.05 0.184
Exposure to Second-hand Smoke at Home
None reported REF
Yes -0.01 0.03 -0.004 0.844
E-Cigarette Use
No lifetime use REF
No past 6 month use -0.03 0.04 -0.02 0.423
Past 6 month use -0.02 0.06 -0.01 0.802
Past 30 day use -0.09 0.09 -0.03 0.319
Cigarette Use
No lifetime use REF
No past 6 month use 0.06 0.04 0.04 0.153
Past 6 month use 0.02 0.07 0.01 0.809
Past 30 day use 0.08 0.08 0.02 0.332
Cannabis Use
No lifetime use REF
No past 6 month use -0.09 0.04 -0.05 0.041
Past 6 month use 0.02 0.05 -0.01 0.641
Past 30 day use -0.03 0.05 -0.02 0.533
Asthma Diagnosis
No REF
Yes 0.01 0.03 0.01 0.706
Engagement in In-Person Pleasurable
Activities
-0.001 0.001 -0.03 0.228
STEP 2 Shortness of Breath * In-Person Activities -0.001 0.002 -0.01 0.591
107
Model 3. Linear Regression Association between Wheeze and Subsequent Symptoms of
Depression, Moderated by Engagement in Pleasurable In-Person Activity
Depressive Symptoms at Follow-up
B SE β P-value R
2
STEP 1 Wheeze 0.21
None REF
Yes 0.12 0.04 0.06 0.008
Body Mass Index 0.006 0.003 0.04 0.050
Baseline Mean Depressive Symptoms 0.45 0.02 0.45 <0.001
Gender
Female REF
Male 0.008 0.03 0.01 0.761
Race/ethnicity
Hispanic REF
Asian 0.005 0.04 0.003 0.903
White -0.11 0.04 -0.06 0.009
Other -0.03 0.04 -0.01 0.542
Free or Subsidized Lunch
No REF
Reduced cost -0.02 0.04 -0.01 0.727
Free lunch -0.02 0.03 -0.01 0.578
Highest Parental Education
Some high school or less REF
High school graduate -0.10 0.05 -0.06 0.062
Some college -0.06 0.05 -0.03 0.285
College graduate 0.01 0.05 0.01 0.787
Advanced degree -0.06 0.06 -0.04 0.295
Exposure to Second-hand Smoke at Home
None reported REF
Yes -0.004 0.03 -0.003 0.902
E-Cigarette Use
No lifetime use REF
No past 6 month use -0.02 0.04 -0.01 0.628
Past 6 month use 0.002 0.06 0.001 0.979
Past 30 day use -0.08 0.09 -0.02 0.325
Cigarette Use
No lifetime use REF
No past 6 month use 0.04 0.04 0.03 0.254
Past 6 month use -0.009 0.07 -0.003 0.890
Past 30 day use 0.09 0.08 0.03 0.260
Cannabis Use
No lifetime use REF
No past 6 month use -0.08 0.04 -0.04 0.085
Past 6 month use -0.02 0.05 -0.01 0.738
Past 30 day use -0.03 0.05 -0.02 0.519
Asthma Diagnosis
No REF
Yes -0.004 0.03 -0.003 0.903
Engagement in In-Person Pleasurable
Activities
-0.0007 0.0006 -0.03 0.218
STEP 2 Wheeze * In-Person Activities -0.0007 0.002 -0.01 0.671
108
Model 4. Linear Regression Association between Any Respiratory Problem and Subsequent
Symptoms of Depression, Moderated by Engagement in Pleasurable In-Person Activity
Depressive Symptoms at Follow-up
B SE β P-value R
2
STEP 1 Any Respiratory Problem 0.22
None REF
Yes 0.11 0.03 0.08 <0.001
Body Mass Index 0.01 0.003 0.04 0.079
Baseline Mean Depressive Symptoms 0.45 0.02 0.44 <0.001
Gender
Female REF
Male 0.01 0.03 0.01 0.772
Race/ethnicity
Hispanic REF
Asian -0.002 0.04 -0.001 0.957
White -0.12 0.04 -0.07 0.006
Other -0.03 0.04 -0.02 0.445
Free or Subsidized Lunch
No REF
Reduced cost -0.02 0.04 -0.01 0.649
Free lunch -0.02 0.03 -0.02 0.499
Highest Parental Education
Some high school or less REF
High school graduate -0.10 0.05 -0.05 0.061
Some college -0.06 0.05 -0.03 0.291
College graduate 0.02 0.05 0.01 0.765
Advanced degree -0.06 0.06 -0.04 0.295
Exposure to Second-hand Smoke at Home
None reported REF
Yes -0.01 0.03 -0.004 0.852
E-Cigarette Use
No lifetime use REF
No past 6 month use -0.02 0.04 -0.01 0.648
Past 6 month use 0.002 0.06 0.0001 0.998
Past 30 day use -0.07 0.08 -0.02 0.398
Cigarette Use
No lifetime use REF
No past 6 month use 0.05 0.04 0.03 0.240
Past 6 month use -0.01 0.07 -0.005 0.843
Past 30 day use 0.07 0.08 0.02 0.356
Cannabis Use
No lifetime use REF
No past 6 month use -0.08 0.04 -0.04 0.076
Past 6 month use -0.02 0.05 -0.01 0.647
Past 30 day use -0.03 0.05 -0.02 0.500
Asthma Diagnosis
No REF
Yes -0.01 0.03 -0.01 0.776
Engagement in In-Person Pleasurable
Activities
-0.0002 0.001 -0.01 0.760
STEP 2 Any Respiratory Problem* In-Person
Activities
-0.002 0.001 -0.05 0.051
109
Model 5. Linear Regression Association between Total Number of Respiratory Problems
(modelled categorically) and Subsequent Symptoms of Depression, Moderated by Engagement
in Pleasurable In-Person Activity
Depressive Symptoms at Follow-up
B SE β P-value R
2
STEP 1 Total Number of Respiratory Problems 0.22
None REF
1 0.07 0.03 0.05 0.034
2 0.24 0.05 0.10 <0.001
3 0.14 0.09 0.03 0.131
Body Mass Index 0.01 0.003 0.04 0.080
Baseline Mean Depressive Symptoms 0.44 0.02 0.43 <0.001
Gender
Female REF
Male 0.01 0.03 0.01 0.769
Race/ethnicity
Hispanic REF
Asian -0.002 0.04 -0.002 0.950
White -0.12 0.04 -0.07 0.005
Other -0.03 0.04 -0.02 0.502
Free or Subsidized Lunch
No REF
Reduced cost -0.02 0.04 -0.01 0.612
Free lunch -0.03 0.03 -0.02 0.420
Highest Parental Education
Some high school or less REF
High school graduate -0.09 0.05 -0.05 0.076
Some college -0.06 0.05 -0.03 0.288
College graduate 0.02 0.05 0.01 0.725
Advanced degree -0.06 0.05 -0.04 0.316
Exposure to Second-hand Smoke at Home
None reported REF
Yes -0.004 0.03 -0.003 0.895
E-Cigarette Use
No lifetime use REF
No past 6 month use -0.02 0.04 -0.01 0.627
Past 6 month use 0.01 0.06 0.003 0.893
Past 30 day use -0.08 0.08 -0.02 0.370
Cigarette Use
No lifetime use REF
No past 6 month use 0.04 0.04 0.03 0.273
Past 6 month use -0.01 0.07 -0.002 0.935
Past 30 day use 0.07 0.08 0.02 0.343
Cannabis Use
No lifetime use REF
No past 6 month use -0.08 0.04 -0.04 0.079
Past 6 month use -0.02 0.05 -0.01 0.650
Past 30 day use -0.04 0.05 -0.02 0.435
Asthma Diagnosis
No REF
Yes -0.01 0.03 -0.01 0.655
Engagement in In-Person Pleasurable Activities -0.0002 0.001 -0.01 0.717
STEP 2 ON NEXT PAGE
110
STEP 2 Total Problems* In-Person Activities
None REF
1 -0.003 0.001 -0.05 0.020
2 -0.002 0.002 -0.02 0.431
3 -0.0002 0.003 -0.001 0.960
111
Model 6. Linear Regression Association between Total Number of Respiratory Problems
(modelled continuously) and Subsequent Symptoms of Depression, Moderated by Engagement
in Pleasurable In-Person Activity
Depressive Symptoms at Follow-up
B SE β P-value R
2
STEP 1 Total Number of Respiratory Problems 0.22
None REF
+1 Problem 0.08 0.02 0.10 <0.001
Body Mass Index 0.01 0.003 0.04 0.089
Baseline Mean Depressive Symptoms 0.44 0.02 0.44 <0.001
Gender
Female REF
Male 0.01 0.03 0.01 0.665
Race/ethnicity
Hispanic REF
Asian -0.003 0.04 -0.002 0.940
White -0.12 0.04 -0.07 0.005
Other -0.03 0.04 -0.02 0.450
Free or Subsidized Lunch
No REF
Reduced cost -0.02 0.04 -0.01 0.674
Free lunch -0.03 0.03 -0.02 0.438
Highest Parental Education
Some high school or less REF
High school graduate -0.10 0.05 -0.06 0.047
Some college -0.06 0.05 -0.04 0.269
College graduate 0.02 0.05 0.01 0.768
Advanced degree -0.06 0.06 -0.04 0.288
Exposure to Second-hand Smoke at Home
None reported REF
Yes -0.004 0.03 -0.003 0.887
E-Cigarette Use
No lifetime use REF
No past 6 month use -0.02 0.04 -0.01 0.614
Past 6 month use 0.002 0.06 0.001 0.962
Past 30 day use -0.07 0.08 -0.02 0.399
Cigarette Use
No lifetime use REF
No past 6 month use 0.04 0.04 0.03 0.274
Past 6 month use -0.01 0.07 -0.004 0.875
Past 30 day use 0.06 0.08 0.02 0.396
Cannabis Use
No lifetime use REF
No past 6 month use -0.08 0.04 -0.05 0.070
Past 6 month use -0.03 0.05 -0.01 0.618
Past 30 day use -0.03 0.05 -0.02 0.513
Asthma Diagnosis
No REF
Yes -0.02 0.03 -0.01 0.569
Engagement in In-Person Pleasurable
Activities
-0.001 0.001 -0.02 0.376
STEP 2 Total Problems* In-Person Activities -0.001 0.001 -0.03 0.205
112
Appendix G
Regression Coefficients for All Variables Included in Models Examining the Associations
between Respiratory Problems and Subsequent Symptoms of Depression, Moderated by
Digital/Online Activity
Model 1. Linear Regression Association between Bronchitic Symptoms and Subsequent
Symptoms of Depression, Moderated by Engagement in Pleasurable Digital/Online Activity
Depressive Symptoms at Follow-up
B SE β P-value R
2
STEP 1 Bronchitic Symptoms 0.22
None REF
Yes 0.10 0.03 0.07 0.002
Body Mass Index 0.01 0.003 0.04 0.057
Baseline Mean Depressive Symptoms 0.46 0.02 0.45 <0.001
Gender
Female REF
Male -0.002 0.03 -0.001 0.947
Race/ethnicity
Hispanic REF
Asian -0.01 0.04 -0.01 0.731
White -0.12 0.04 -0.07 0.006
Other -0.04 0.04 -0.03 0.298
Free or Subsidized Lunch
No REF
Reduced cost 0.01 0.05 0.003 0.904
Free lunch -0.02 0.03 -0.02 0.510
Highest Parental Education
Some high school or less REF
High school graduate -0.13 0.05 -0.08 0.013
Some college -0.08 0.05 -0.05 0.167
College graduate -0.003 0.06 -0.002 0.955
Advanced degree -0.08 0.06 -0.05 0.143
Exposure to Second-hand Smoke at Home
None reported REF
Yes -0.01 0.03 -0.01 0.748
E-Cigarette Use
No lifetime use REF
No past 6 month use -0.01 0.04 -0.004 0.886
Past 6 month use -0.06 0.06 -0.02 0.375
Past 30 day use -0.07 0.09 -0.02 0.404
Cigarette Use
No lifetime use REF
No past 6 month use 0.04 0.04 0.03 0.340
Past 6 month use -0.004 0.07 -0.002 0.948
Past 30 day use 0.03 0.08 0.01 0.670
Cannabis Use
No lifetime use REF
No past 6 month use -0.08 0.05 -0.05 0.063
Past 6 month use -0.01 0.05 -0.01 0.805
Past 30 day use -0.03 0.05 -0.02 0.575
ADDITIONAL VARIABLES ON NEXT PAGE
Asthma Diagnosis
113
No REF
Yes 0.003 0.03 0.002 0.919
Engagement in Digital/Online Pleasurable
Activities
0.002 0.001 0.04 0.079
STEP 2 Bronchitic Symptoms* Digital/Online Activities -0.01 0.002 -0.07 0.003
114
Model 2. Linear Regression Association between Shortness of Breath and Subsequent Symptoms
of Depression, Moderated by Engagement in Pleasurable Digital/Online Activity
Depressive Symptoms at Follow-up
B SE β P-value R
2
STEP 1 Shortness of Breath 0.22
None REF
Yes 0.12 0.05 0.06 0.009
Body Mass Index 0.01 0.003 0.05 0.036
Baseline Mean Depressive Symptoms 0.46 0.02 0.46 <0.001
Gender
Female REF
Male 0.01 0.03 0.01 0.628
Race/ethnicity
Hispanic REF
Asian 0.01 0.04 0.01 0.732
White -0.10 0.04 -0.06 0.015
Other -0.02 0.04 -0.01 0.548
Free or Subsidized Lunch
No REF
Reduced cost -0.01 0.05 -0.003 0.874
Free lunch -0.01 0.03 -0.01 0.669
Highest Parental Education
Some high school or less REF
High school graduate -0.10 0.05 -0.06 0.058
Some college -0.06 0.05 -0.04 0.244
College graduate 0.01 0.05 0.01 0.841
Advanced degree -0.08 0.06 -0.05 0.162
Exposure to Second-hand Smoke at Home
None reported REF
Yes -0.01 0.03 -0.01 0.759
E-Cigarette Use
No lifetime use REF
No past 6 month use -0.03 0.04 -0.02 0.441
Past 6 month use -0.02 0.06 -0.01 0.785
Past 30 day use -0.09 0.09 -0.03 0.321
Cigarette Use
No lifetime use REF
No past 6 month use 0.06 0.04 0.04 0.160
Past 6 month use 0.01 0.07 0.01 0.828
Past 30 day use 0.08 0.08 0.02 0.329
Cannabis Use
No lifetime use REF
No past 6 month use -0.09 0.04 -0.05 0.038
Past 6 month use -0.02 0.05 -0.01 0.669
Past 30 day use -0.03 0.05 -0.02 0.560
Asthma Diagnosis
No REF
Yes 0.01 0.03 0.01 0.699
Engagement in Digital/Online Pleasurable
Activities
0.0003 0.001 0.01 0.668
STEP 2 Shortness of Breath * Digital/Online Activities -0.0002 0.003 -0.002 0.940
Model 3. Linear Regression Association between Wheeze and Subsequent Symptoms of
Depression, Moderated by Engagement in Pleasurable Digital/Online Activity
115
Depressive Symptoms at Follow-up
B SE β P-value R
2
STEP 1 Wheeze 0.21
None REF
Yes 0.11 0.04 0.06 0.011
Body Mass Index 0.01 0.003 0.04 0.053
Baseline Mean Depressive Symptoms 0.46 0.02 0.45 <0.001
Gender
Female REF
Male 0.01 0.03 0.01 0.665
Race/ethnicity
Hispanic REF
Asian 0.01 0.04 0.004 0.894
White -0.11 0.04 -0.07 0.008
Other -0.03 0.04 -0.02 0.476
Free or Subsidized Lunch
No REF
Reduced cost -0.01 0.04 -0.01 0.741
Free lunch -0.02 0.03 -0.01 0.633
Highest Parental Education
Some high school or less REF
High school graduate -0.10 0.05 -0.05 0.070
Some college -0.06 0.05 -0.04 0.275
College graduate 0.02 0.05 0.01 0.782
Advanced degree -0.06 0.06 -0.04 0.268
Exposure to Second-hand Smoke at Home
None reported REF
Yes -0.01 0.03 -0.01 0.778
E-Cigarette Use
No lifetime use REF
No past 6 month use -0.02 0.04 -0.01 0.642
Past 6 month use <0.0001 0.06 <0.0001 >0.999
Past 30 day use -0.08 0.09 -0.02 0.328
Cigarette Use
No lifetime use REF
No past 6 month use 0.04 0.04 0.03 0.260
Past 6 month use -0.01 0.07 -0.003 0.885
Past 30 day use 0.09 0.08 0.03 0.263
Cannabis Use
No lifetime use REF
No past 6 month use -0.08 0.04 -0.04 0.081
Past 6 month use -0.02 0.05 -0.01 0.758
Past 30 day use -0.03 0.05 -0.02 0.547
Asthma Diagnosis
No REF
Yes -0.002 0.03 -0.001 0.955
Engagement in Digital/Online Pleasurable
Activities
0.001 0.001 0.02 0.464
STEP 2 Wheeze * Digital/Online Activities -0.002 0.003 -0.02 0.376
116
Model 4. Linear Regression Association between Any Respiratory Problem and Subsequent
Symptoms of Depression, Moderated by Engagement in Pleasurable Digital/Online Activity
Depressive Symptoms at Follow-up
B SE β P-value R
2
STEP 1 Any Respiratory Problem 0.22
None REF
Yes 0.10 0.03 0.08 0.001
Body Mass Index 0.01 0.003 0.04 0.088
Baseline Mean Depressive Symptoms 0.45 0.02 0.45 <0.001
Gender
Female REF
Male 0.01 0.03 0.01 0.687
Race/ethnicity
Hispanic REF
Asian 0.001 0.04 0.0004 0.988
White -0.12 0.04 -0.07 0.004
Other -0.04 0.04 -0.02 0.384
Free or Subsidized Lunch
No REF
Reduced cost -0.02 0.04 -0.01 0.650
Free lunch -0.02 0.03 -0.01 0.554
Highest Parental Education
Some high school or less REF
High school graduate -0.10 0.05 -0.06 0.059
Some college -0.06 0.05 -0.03 0.284
College graduate 0.02 0.05 0.01 0.757
Advanced degree -0.06 0.06 -0.04 0.247
Exposure to Second-hand Smoke at Home
None reported REF
Yes -0.01 0.03 -0.01 0.742
E-Cigarette Use
No lifetime use REF
No past 6 month use -0.02 0.04 -0.01 0.636
Past 6 month use -0.003 0.06 -0.001 0.959
Past 30 day use -0.08 0.08 -0.02 0.365
Cigarette Use
No lifetime use REF
No past 6 month use 0.05 0.04 0.03 0.237
Past 6 month use -0.01 0.07 0.00 0.844
Past 30 day use 0.07 0.08 0.02 0.354
Cannabis Use
No lifetime use REF
No past 6 month use -0.08 0.04 -0.05 0.068
Past 6 month use -0.02 0.05 -0.01 0.692
Past 30 day use -0.03 0.05 -0.01 0.589
Asthma Diagnosis
No REF
Yes -0.01 0.03 -0.01 0.778
Engagement in Digital/Online Pleasurable
Activities
0.001 0.001 0.03 0.162
STEP 2
Any Respiratory Problem* Digital/Online
Activities
-0.003 0.002 -0.05 0.036
117
Model 5. Linear Regression Association between Total Number of Respiratory Problems
(modelled categorically) and Subsequent Symptoms of Depression, Moderated by Engagement
in Pleasurable Digital/Online Activity
Depressive Symptoms at Follow-up
B SE β P-value R
2
STEP 1 Total Number of Respiratory Problems 0.22
None REF
1 0.06 0.03 0.04 0.045
2 0.23 0.05 0.09 <0.001
3 0.15 0.09 0.03 0.113
Body Mass Index 0.01 0.003 0.04 0.082
Baseline Mean Depressive Symptoms 0.45 0.02 0.44 <0.001
Gender
Female REF
Male 0.01 0.03 0.01 0.618
Race/ethnicity
Hispanic REF
Asian -0.002 0.04 -0.001 0.961
White -0.12 0.04 -0.07 0.003
Other -0.03 0.04 -0.02 0.400
Free or Subsidized Lunch
No REF
Reduced cost -0.02 0.04 -0.01 0.639
Free lunch -0.02 0.03 -0.02 0.464
Highest Parental Education
Some high school or less REF
High school graduate -0.10 0.05 -0.05 0.063
Some college -0.06 0.05 -0.04 0.270
College graduate 0.02 0.05 0.01 0.722
Advanced degree -0.06 0.06 -0.04 0.268
Exposure to Second-hand Smoke at Home
None reported REF
Yes -0.01 0.03 -0.01 0.772
E-Cigarette Use
No lifetime use REF
No past 6 month use -0.02 0.04 -0.01 0.612
Past 6 month use 0.002 0.06 0.001 0.963
Past 30 day use -0.08 0.08 -0.02 0.348
Cigarette Use
No lifetime use REF
No past 6 month use 0.04 0.04 0.03 0.273
Past 6 month use -0.01 0.07 -0.002 0.927
Past 30 day use 0.07 0.08 0.02 0.373
Cannabis Use
No lifetime use REF
No past 6 month use -0.08 0.04 -0.05 0.071
Past 6 month use -0.02 0.05 -0.01 0.679
Past 30 day use -0.03 0.05 -0.02 0.543
Asthma Diagnosis
No REF
Yes -0.02 0.03 -0.01 0.629
Engagement in Digital/Online Pleasurable
Activities 0.001 0.001 0.03
0.170
STEP 2 ON NEXT PAGE
118
STEP 2 Total Problems* Digital/Online Activities
None REF
1 -0.003 0.002 -0.04 0.099
2 -0.004 0.003 -0.03 0.203
3 -0.01 0.005 -0.03 0.216
119
Model 6. Linear Regression Association between Total Number of Respiratory Problems
(modelled continuously) and Subsequent Symptoms of Depression, Moderated by Engagement
in Pleasurable Digital/Online Activity
Depressive Symptoms at Follow-up
B SE β P-value R
2
STEP 1 Total Number of Problem 0.22
None REF
+1 Problem 0.08 0.02 0.09 <0.001
Body Mass Index 0.01 0.003 0.04 0.091
Baseline Mean Depressive Symptoms 0.45 0.02 0.44 <0.001
Gender
Female REF
Male 0.01 0.03 0.01 0.587
Race/ethnicity
Hispanic REF
Asian -0.0003 0.04 -0.0002 0.993
White -0.12 0.04 -0.07 0.003
Other -0.03 0.04 -0.02 0.398
Free or Subsidized Lunch
No REF
Reduced cost -0.02 0.04 -0.01 0.658
Free lunch -0.02 0.03 -0.02 0.489
Highest Parental Education
Some high school or less REF
High school graduate -0.10 0.05 -0.06 0.051
Some college -0.06 0.05 -0.04 0.265
College graduate 0.02 0.05 0.01 0.763
Advanced degree -0.06 0.06 -0.04 0.247
Exposure to Second-hand Smoke at Home
None reported REF
Yes -0.01 0.03 -0.01 0.743
E-Cigarette Use
No lifetime use REF
No past 6 month use -0.02 0.04 -0.01 0.629
Past 6 month use 0.001 0.06 0.0002 0.993
Past 30 day use -0.07 0.09 -0.02 0.385
Cigarette Use
No lifetime use REF
No past 6 month use 0.04 0.04 0.03 0.271
Past 6 month use -0.01 0.07 -0.003 0.881
Past 30 day use 0.06 0.08 0.02 0.401
Cannabis Use
No lifetime use REF
No past 6 month use -0.08 0.04 -0.05 0.063
Past 6 month use -0.02 0.05 -0.01 0.628
Past 30 day use -0.03 0.05 -0.02 0.569
Asthma Diagnosis
No REF
Yes -0.02 0.03 -0.01 0.590
Engagement in Digital/Online Pleasurable
Activities
0.001 0.001 0.03 0.201
STEP 2 Total Problems* Digital/Online Activities -0.002 0.001 -0.05 0.033
120
Appendix H
Regression Coefficients for All Variables Included in Models Examining the Associations of
Respiratory Problems with Subsequent Symptoms of Anxiety, Moderated by In-Person Activity
Model 1. Linear Regression Association between Bronchitic Symptoms and Subsequent
Symptoms of Anxiety, Moderated by Engagement in Pleasurable In-Person Activity
Anxiety Symptoms at Follow-up
B SE β P-value R
2
STEP 1 Bronchitic Symptoms 0.19
None REF
Yes 0.16 0.04 0.09 <0.001
Body Mass Index 0.001 0.004 0.01 0.731
Baseline Mean Anxiety Symptoms 0.41 0.02 0.41 <0.001
Gender
Female REF
Male -0.08 0.04 -0.05 0.035
Race/ethnicity
Hispanic REF
Asian -0.03 0.05 -0.02 0.492
White -0.06 0.06 -0.03 0.268
Other 0.01 0.05 0.01 0.795
Free or Subsidized Lunch
No REF
Reduced cost 0.03 0.06 0.01 0.567
Free lunch 0.001 0.04 0.001 0.974
Highest Parental Education
Some high school or less REF
High school graduate -0.09 0.07 -0.04 0.148
Some college -0.04 0.07 -0.02 0.566
College graduate 0.03 0.07 0.02 0.620
Advanced degree -0.04 0.07 -0.02 0.615
Exposure to Second-hand Smoke at Home
None reported REF
Yes -0.03 0.04 -0.02 0.442
E-Cigarette Use
No lifetime use REF
No past 6 month use -0.07 0.05 -0.04 0.163
Past 6 month use -0.14 0.08 -0.04 0.085
Past 30 day use -0.21 0.12 -0.05 0.080
Cigarette Use
No lifetime use REF
No past 6 month use 0.08 0.05 0.04 0.122
Past 6 month use 0.04 0.09 0.01 0.627
Past 30 day use 0.24 0.10 0.06 0.017
Cannabis Use
No lifetime use REF
No past 6 month use -0.05 0.06 -0.02 0.395
Past 6 month use -0.03 0.07 -0.01 0.653
Past 30 day use 0.05 0.06 0.02 0.398
Asthma Diagnosis
No REF
Yes 0.05 0.04 0.03 0.213
Engagement in In-Person Pleasurable Activities -0.001 0.001 -0.02 0.381
STEP 2 Bronchitic Symptoms* In-Person Activities -0.002 0.002 -0.04 0.131
121
Model 2. Linear Regression Association between Shortness of Breath and Subsequent Symptoms
of Anxiety, Moderated by Engagement in Pleasurable In-Person Activity
Anxiety Symptoms at Follow-up
B SE β P-value R
2
STEP 1 Shortness of Breath 0.20
None REF
Yes 0.25 0.06 0.10 <0.001
Body Mass Index 0.002 0.004 0.01 0.633
Baseline Mean Anxiety Symptoms 0.41 0.41 0.40 <0.001
Gender
Female REF
Male -0.05 0.04 -0.03 0.150
Race/ethnicity
Hispanic REF
Asian -0.004 0.05 -0.002 0.937
White -0.04 0.05 -0.02 0.423
Other 0.04 0.05 0.02 0.404
Free or Subsidized Lunch
No REF
Reduced cost 0.01 0.06 0.004 0.857
Free lunch 0.004 0.04 0.002 0.927
Highest Parental Education
Some high school or less REF
High school graduate -0.08 0.06 -0.03 0.235
Some college -0.02 0.06 -0.01 0.711
College graduate 0.03 0.07 0.02 0.695
Advanced degree -0.04 0.07 -0.02 0.587
Exposure to Second-hand Smoke at Home
None reported REF
Yes -0.04 0.04 -0.02 0.310
E-Cigarette Use
No lifetime use REF
No past 6 month use -0.08 0.05 -0.04 0.116
Past 6 month use -0.11 0.08 -0.03 0.196
Past 30 day use -0.22 0.12 -0.05 0.060
Cigarette Use
No lifetime use REF
No past 6 month use 0.08 0.05 0.05 0.104
Past 6 month use 0.07 0.08 0.02 0.406
Past 30 day use 0.26 0.10 0.07 0.011
Cannabis Use
No lifetime use REF
No past 6 month use -0.05 0.06 -0.03 0.324
Past 6 month use -0.02 0.06 -0.01 0.719
Past 30 day use 0.05 0.06 0.02 0.428
Asthma Diagnosis
No REF
Yes 0.06 0.04 0.03 0.172
Engagement in In-Person Pleasurable
Activities
-0.002 0.001 -0.05 0.031
STEP 2 Shortness of Breath * In-Person Activities <0.0001 0.002 0.001 0.969
Model 3. Linear Regression Association between Wheeze and Subsequent Symptoms of
Anxiety, Moderated by Engagement in Pleasurable In-Person Activity
122
Anxiety Symptoms at Follow-up
B SE β P-value R
2
STEP 1 Wheeze 0.19
None REF
Yes 0.14 0.06 0.06 0.010
Body Mass Index 0.002 0.004 0.01 0.554
Baseline Mean Anxiety Symptoms 0.42 0.02 0.41 <0.001
Gender
Female REF
Male -0.06 0.04 -0.04 0.077
Race/ethnicity
Hispanic REF
Asian -0.01 0.05 -0.01 0.790
White -0.05 0.05 -0.02 0.351
Other 0.03 0.05 0.01 0.584
Free or Subsidized Lunch
No REF
Reduced cost 0.01 0.06 0.003 0.892
Free lunch 0.0002 0.04 0.0001 0.996
Highest Parental Education
Some high school or less REF
High school graduate -0.07 0.07 -0.03 0.294
Some college -0.02 0.07 -0.01 0.792
College graduate 0.04 0.07 0.02 0.565
Advanced degree -0.02 0.07 -0.01 0.738
Exposure to Second-hand Smoke at Home
None reported REF
Yes -0.03 0.04 -0.02 0.413
E-Cigarette Use
No lifetime use REF
No past 6 month use -0.07 0.05 -0.04 0.173
Past 6 month use -0.10 0.08 -0.03 0.221
Past 30 day use -0.22 0.11 -0.05 0.051
Cigarette Use
No lifetime use REF
No past 6 month use 0.08 0.05 0.04 0.130
Past 6 month use 0.04 0.08 0.01 0.607
Past 30 day use 0.26 0.10 0.07 0.008
Cannabis Use
No lifetime use REF
No past 6 month use -0.04 0.05 -0.02 0.415
Past 6 month use -0.01 0.07 -0.01 0.829
Past 30 day use 0.06 0.06 0.03 0.308
Asthma Diagnosis
No REF
Yes 0.05 0.04 0.03 0.229
Engagement in In-Person Pleasurable
Activities
-0.002 0.001 -0.05 0.027
STEP 2 Wheeze * In-Person Activities 0.001 0.002 0.01 0.583
Model 4. Linear Regression Association between Any Respiratory Problem and Subsequent
Symptoms of Anxiety, Moderated by Engagement in Pleasurable In-Person Activity
123
Anxiety Symptoms at Follow-up
B SE β P-value R
2
STEP 1 Any Respiratory Problem 0.19
None REF
Yes 0.17 0.04 0.10 <0.001
Body Mass Index 0.001 0.004 0.01 0.733
Baseline Mean Anxiety Symptoms 0.40 0.02 0.40 <0.001
Gender
Female REF
Male -0.06 0.03 -0.04 0.072
Race/ethnicity
Hispanic REF
Asian -0.02 0.05 -0.01 0.716
White -0.07 0.05 -0.03 0.220
Other 0.02 0.05 0.01 0.687
Free or Subsidized Lunch
No REF
Reduced cost <0.0001 0.06 <0.0001 >0.999
Free lunch 0.0003 0.04 0.0002 0.994
Highest Parental Education
Some high school or less REF
High school graduate -0.07 0.06 -0.03 0.261
Some college -0.02 0.07 -0.01 0.717
College graduate 0.04 0.07 0.03 0.504
Advanced degree -0.03 0.07 -0.02 0.665
Exposure to Second-hand Smoke at Home
None reported REF
Yes -0.03 0.04 -0.02 0.393
E-Cigarette Use
No lifetime use REF
No past 6 month use -0.07 -0.07 -0.04 0.131
Past 6 month use -0.11 -0.11 -0.04 0.154
Past 30 day use -0.21 -0.21 -0.05 0.068
Cigarette Use
No lifetime use REF
No past 6 month use 0.08 0.05 0.05 0.099
Past 6 month use 0.04 0.08 0.01 0.600
Past 30 day use 0.24 0.10 0.06 0.015
Cannabis Use
No lifetime use REF
No past 6 month use -0.05 0.05 -0.02 0.375
Past 6 month use -0.02 0.06 -0.01 0.715
Past 30 day use 0.05 0.06 0.02 0.385
Asthma Diagnosis
No REF
Yes 0.03 0.04 0.02 0.460
Engagement in In-Person Pleasurable Activities -0.001 0.001 -0.02 0.419
STEP 2 Any Respiratory Problem* In-Person Activities -0.003 0.001 -0.04 0.085
124
Model 5. Linear Regression Association between Total Number of Respiratory Problems
(modelled categorically) and Subsequent Symptoms of Anxiety, Moderated by Engagement in
Pleasurable In-Person Activity
Anxiety Symptoms at Follow-up
B SE β P-value R
2
STEP 1 Total Number of Respiratory Problems 0.20
None REF
1 0.11 0.04 0.06 0.005
2 0.33 0.07 0.11 <0.001
3 0.34 0.12 0.06 0.004
Body Mass Index 0.001 0.004 0.01 0.788
Baseline Mean Anxiety Symptoms 0.39 0.02 0.39 <0.001
Gender
Female REF
Male -0.06 0.03 -0.04 0.072
Race/ethnicity
Hispanic REF
Asian -0.02 0.05 -0.01 0.739
White -0.07 0.05 -0.03 0.201
Other 0.03 0.05 0.01 0.589
Free or Subsidized Lunch
No REF
Reduced cost -0.005 0.06 -0.002 0.931
Free lunch -0.01 0.04 -0.004 0.879
Highest Parental Education
Some high school or less REF
High school graduate -0.07 0.06 -0.03 0.305
Some college -0.02 0.06 -0.01 0.740
College graduate 0.05 0.06 0.03 0.467
Advanced degree -0.03 0.07 -0.02 0.675
Exposure to Second-hand Smoke at Home
None reported REF
Yes -0.03 0.04 -0.02 0.400
E-Cigarette Use
No lifetime use REF
No past 6 month use -0.07 0.05 -0.04 0.124
Past 6 month use -0.10 0.08 -0.03 0.206
Past 30 day use -0.21 0.11 -0.05 0.066
Cigarette Use
No lifetime use REF
No past 6 month use 0.08 0.05 0.04 0.120
Past 6 month use 0.05 0.08 0.01 0.534
Past 30 day use 0.24 0.10 0.06 0.016
Cannabis Use
No lifetime use REF
No past 6 month use -0.05 0.05 -0.02 0.363
Past 6 month use -0.03 0.06 -0.01 0.676
Past 30 day use 0.05 0.06 0.02 0.435
Asthma Diagnosis
No REF
Yes 0.02 0.04 0.01 0.607
Engagement in In-Person Pleasurable Activities -0.001 0.001 -0.02 0.416
STEP 2 ON NEXT PAGE
125
TEP 2 Total Problems* In-Person Activities
None REF
1 -0.004 0.002 -0.06 0.009
2 <0.0001 0.003 0.0002 0.993
3 0.001 0.004 0.01 0.745
126
Model 6. Linear Regression Association between Total Number of Respiratory Problems
(modelled continuously) and Subsequent Symptoms of Anxiety, Moderated by Engagement in
Pleasurable In-Person Activity
Anxiety Symptoms at Follow-up
B SE β P-value R
2
STEP 1 Total Number of Respiratory Problems 0.20
None REF
+1 Symptoms 0.14 0.02 0.13 <0.001
Body Mass Index 0.001 0.004 0.01 0.802
Baseline Mean Anxiety Symptoms 0.39 0.02 0.39 <0.001
Gender
Female REF
Male -0.06 0.03 -0.04 0.102
Race/ethnicity
Hispanic REF
Asian -0.02 0.05 -0.01 0.708
White -0.07 0.05 -0.03 0.192
Other 0.02 0.05 0.01 0.671
Free or Subsidized Lunch
No REF
Reduced cost 0.0005 0.06 0.0002 0.993
Free lunch -0.01 0.04 -0.003 0.899
Highest Parental Education
Some high school or less REF
High school graduate -0.08 0.06 -0.04 0.205
Some college -0.03 0.06 -0.01 0.678
College graduate 0.04 0.07 0.03 0.512
Advanced degree -0.03 0.07 -0.02 0.633
Exposure to Second-hand Smoke at Home
None reported REF
Yes -0.03 0.04 -0.02 0.419
E-Cigarette Use
No lifetime use REF
No past 6 month use -0.08 0.05 -0.04 0.112
Past 6 month use -0.11 0.08 -0.03 0.170
Past 30 day use -0.21 0.11 -0.05 0.070
Cigarette Use
No lifetime use REF
No past 6 month use 0.08 0.05 0.04 0.122
Past 6 month use 0.05 0.08 0.01 0.565
Past 30 day use 0.23 0.10 0.06 0.020
Cannabis Use
No lifetime use REF
No past 6 month use -0.05 0.05 -0.02 0.357
Past 6 month use -0.03 0.06 -0.01 0.676
Past 30 day use 0.05 0.06 0.02 0.373
Asthma Diagnosis
No REF
Yes 0.02 0.04 0.01 0.707
Engagement in In-Person Pleasurable
Activities
-0.001 0.001 -0.04 0.119
STEP 2 Total Problems* In-Person Activities -0.001 0.001 -0.02 0.474
Appendix I
127
Regression Coefficients for All Variables Included in Models Examining the Associations
between Respiratory Problems and Subsequent Symptoms of Anxiety, Moderated by
Digital/Online Activity
Model 1. Linear Regression Association between Bronchitic Symptoms and Subsequent
Symptoms of Anxiety, Moderated by Engagement in Pleasurable Digital/Online Activity
Anxiety Symptoms at Follow-up
B SE β P-value R
2
STEP 1 Bronchitic Symptoms 0.19
None REF
Yes 0.16 0.04 0.09 <0.001
Body Mass Index 0.002 0.004 0.01 0.702
Baseline Mean Anxiety Symptoms 0.41 0.02 0.41 <0.001
Gender
Female REF
Male -0.08 0.04 -0.05 0.035
Race/ethnicity
Hispanic REF
Asian -0.03 0.05 -0.02 0.560
White -0.07 0.06 -0.03 0.232
Other 0.01 0.05 0.01 0.836
Free or Subsidized Lunch
No REF
Reduced cost 0.03 0.06 0.01 0.589
Free lunch 0.01 0.04 0.003 0.897
Highest Parental Education
Some high school or less REF
High school graduate -0.10 0.07 -0.04 0.136
Some college -0.04 0.07 -0.02 0.531
College graduate 0.03 0.07 0.02 0.620
Advanced degree -0.04 0.07 -0.02 0.551
Exposure to Second-hand Smoke at Home
None reported REF
Yes -0.04 0.04 -0.02 0.344
E-Cigarette Use
No lifetime use REF
No past 6 month use -0.07 0.05 -0.04 0.172
Past 6 month use -0.15 0.08 -0.05 0.075
Past 30 day use -0.21 0.12 -0.05 0.073
Cigarette Use
No lifetime use REF
No past 6 month use 0.08 0.05 0.05 0.113
Past 6 month use 0.04 0.09 0.01 0.613
Past 30 day use 0.24 0.10 0.06 0.019
Cannabis Use
No lifetime use REF
No past 6 month use -0.06 0.06 -0.03 0.326
Past 6 month use -0.03 0.07 -0.01 0.699
Past 30 day use 0.06 0.06 0.03 0.358
ADDITIONAL VARIABLES ON NEXT PAGE
Asthma Diagnosis
No REF
128
Yes 0.05 0.04 0.03 0.202
Engagement in Digital/Online Pleasurable
Activities
0.001 0.001 0.03 0.231
STEP 2 Bronchitic Symptoms* Digital/Online Activities -0.01 0.002 -0.07 0.005
129
Model 2. Linear Regression Association between Shortness of Breath and Subsequent Symptoms
of Anxiety, Moderated by Engagement in Pleasurable Digital/Online Activity
Anxiety Symptoms at Follow-up
B SE β P-value R
2
STEP 1 Shortness of Breath 0.19
None REF
Yes 0.26 0.06 0.10 <0.001
Body Mass Index 0.002 0.004 0.01 0.598
Baseline Mean Anxiety Symptoms 0.41 0.02 0.40 <0.001
Gender
Female REF
Male -0.05 0.04 -0.03 0.186
Race/ethnicity
Hispanic REF
Asian -0.0003 0.05 -0.0001 0.996
White -0.05 0.05 -0.02 0.396
Other 0.04 0.05 0.02 0.452
Free or Subsidized Lunch
No REF
Reduced cost 0.01 0.06 0.004 0.841
Free lunch 0.01 0.04 0.005 0.853
Highest Parental Education
Some high school or less REF
High school graduate -0.07 0.06 -0.03 0.264
Some college -0.03 0.07 -0.01 0.685
College graduate 0.02 0.07 0.02 0.704
Advanced degree -0.05 0.07 -0.02 0.535
Exposure to Second-hand Smoke at Home
None reported REF
Yes -0.04 0.04 -0.02 0.263
E-Cigarette Use
No lifetime use REF
No past 6 month use -0.07 0.05 -0.04 0.132
Past 6 month use -0.11 0.08 -0.03 0.194
Past 30 day use -0.22 0.11 -0.05 0.063
Cigarette Use
No lifetime use REF
No past 6 month use 0.08 0.05 0.05 0.115
Past 6 month use 0.06 0.08 0.02 0.450
Past 30 day use 0.25 0.10 0.06 0.012
Cannabis Use
No lifetime use REF
No past 6 month use -0.06 0.06 -0.03 0.310
Past 6 month use -0.02 0.06 -0.01 0.808
Past 30 day use 0.05 0.06 0.02 0.386
Asthma Diagnosis
No REF
Yes 0.06 0.04 0.03 0.161
Engagement in Digital/Online Pleasurable
Activities
-0.001 0.001 -0.01 0.586
STEP 2 Shortness of Breath * Digital/Online
Activities
0.004 0.003 0.03 0.206
130
Model 3. Linear Regression Association between Wheeze and Subsequent Symptoms of
Anxiety, Moderated by Engagement in Pleasurable Digital/Online Activity
Anxiety Symptoms at Follow-up
B SE β P-value R
2
STEP 1 Wheeze 0.19
None REF
Yes 0.14 0.05 0.06 0.008
Body Mass Index 0.002 0.004 0.01 0.539
Baseline Mean Anxiety Symptoms 0.41 0.02 0.41 <0.001
Gender
Female REF
Male -0.06 0.04 -0.04 0.099
Race/ethnicity
Hispanic REF
Asian -0.01 0.05 -0.01 0.834
White -0.05 0.05 -0.03 0.314
Other 0.02 0.05 0.01 0.660
Free or Subsidized Lunch
No REF
Reduced cost 0.01 0.06 0.003 0.880
Free lunch 0.005 0.04 0.003 0.911
Highest Parental Education
Some high school or less REF
High school graduate -0.06 0.06 -0.03 0.328
Some college -0.02 0.07 -0.01 0.786
College graduate 0.04 0.07 0.02 0.553
Advanced degree -0.03 0.07 -0.02 0.688
Exposure to Second-hand Smoke at Home
None reported REF
Yes -0.04 0.04 -0.02 0.324
E-Cigarette Use
No lifetime use REF
No past 6 month use -0.06 0.05 -0.04 0.190
Past 6 month use -0.10 0.08 -0.03 0.210
Past 30 day use -0.22 0.11 -0.05 0.051
Cigarette Use
No lifetime use REF
No past 6 month use 0.08 0.05 0.04 0.132
Past 6 month use 0.04 0.08 0.01 0.612
Past 30 day use 0.26 0.10 0.07 0.008
Cannabis Use
No lifetime use REF
No past 6 month use -0.05 0.05 -0.02 0.380
Past 6 month use -0.01 0.07 -0.004 0.873
Past 30 day use 0.06 0.06 0.03 0.286
Asthma Diagnosis
No REF
Yes 0.05 0.04 0.03 0.216
Engagement in Digital/Online Pleasurable
Activities
0.0001 0.001 0.003 0.907
STEP 2 Wheeze * Digital/Online Activities -0.001 0.003 -0.01 0.692
131
Model 4. Linear Regression Association between Any Respiratory Problem and Subsequent
Symptoms of Anxiety, Moderated by Engagement in Pleasurable Digital/Online Activity
Anxiety Symptoms at Follow-up
B SE β P-value R
2
STEP 1 Any Respiratory Problem 0.19
None REF
Yes 0.17 0.04 0.10 <0.001
Body Mass Index 0.001 0.004 0.01 0.748
Baseline Mean Anxiety Symptoms 0.40 0.02 0.40 <0.001
Gender
Female REF
Male -0.06 0.03 -0.04 0.086
Race/ethnicity
Hispanic REF
Asian -0.01 0.05 -0.01 0.805
White -0.07 0.05 -0.03 0.195
Other 0.02 0.05 0.01 0.762
Free or Subsidized Lunch
No REF
Reduced cost -0.004 0.06 -0.0001 0.995
Free lunch 0.004 0.04 0.003 0.923
Highest Parental Education
Some high school or less REF
High school graduate -0.07 0.06 -0.03 0.266
Some college -0.02 0.07 -0.01 0.715
College graduate 0.04 0.07 0.03 0.502
Advanced degree -0.04 0.07 -0.02 0.582
Exposure to Second-hand Smoke at Home
None reported REF
Yes -0.04 0.04 -0.02 0.326
E-Cigarette Use
No lifetime use REF
No past 6 month use -0.07 0.05 -0.04 0.132
Past 6 month use -0.12 0.08 -0.04 0.139
Past 30 day use -0.21 0.11 -0.05 0.061
Cigarette Use
No lifetime use REF
No past 6 month use 0.08 0.05 0.05 0.100
Past 6 month use 0.04 0.08 0.01 0.604
Past 30 day use 0.24 0.10 0.06 0.015
Cannabis Use
No lifetime use REF
No past 6 month use -0.05 0.05 -0.02 0.357
Past 6 month use -0.02 0.06 -0.01 0.785
Past 30 day use 0.06 0.06 0.03 0.310
Asthma Diagnosis
No REF
Yes 0.03 0.04 0.02 0.460
Engagement in Digital/Online Pleasurable
Activities
0.001 0.001 0.02 0.414
STEP 2 Any Respiratory Problem* Digital/Online
Activities
-0.003 0.002 -0.04 0.091
132
Model 5. Linear Regression Association between Total Number of Respiratory Problems
(modelled categorically) and Subsequent Symptoms of Anxiety, Moderated by Engagement in
Pleasurable Digital/Online Activity
Anxiety Symptoms at Follow-up
B SE β P-value R
2
STEP 1 Total Number of Respiratory Problems 0.19
None REF
1 0.11 0.04 0.06 0.006
2 0.33 0.07 0.11 <0.001
3 0.35 0.12 0.06 0.003
Body Mass Index 0.001 0.004 0.01 0.776
Baseline Mean Anxiety Symptoms 0.39 0.02 0.39 <0.001
Gender
Female REF
Male -0.06 0.03 -0.04 0.105
Race/ethnicity
Hispanic REF
Asian -0.01 0.05 -0.01 0.779
White -0.08 0.05 -0.04 0.165
Other 0.02 0.05 0.01 0.717
Free or Subsidized Lunch
No REF
Reduced cost -0.002 0.06 -0.001 0.967
Free lunch -0.002 0.04 -0.001 0.957
Highest Parental Education
Some high school or less REF
High school graduate -0.07 0.06 -0.03 0.261
Some college -0.02 0.07 -0.01 0.704
College graduate 0.05 0.06 0.03 0.473
Advanced degree -0.04 0.07 -0.02 0.590
Exposure to Second-hand Smoke at Home
None reported REF
Yes -0.04 0.04 -0.02 0.345
E-Cigarette Use
No lifetime use REF
No past 6 month use -0.08 0.05 -0.04 0.117
Past 6 month use -0.11 0.08 -0.03 0.173
Past 30 day use -0.22 0.11 -0.05 0.059
Cigarette Use
No lifetime use REF
No past 6 month use 0.08 0.05 0.04 0.118
Past 6 month use 0.05 0.08 0.01 0.533
Past 30 day use 0.23 0.10 0.06 0.017
Cannabis Use
No lifetime use REF
No past 6 month use -0.05 0.05 -0.02 0.334
Past 6 month use -0.02 0.06 -0.01 0.754
Past 30 day use 0.06 0.06 0.03 0.338
Asthma Diagnosis
No REF
Yes 0.02 0.04 0.01 0.662
ADDITIONAL VARIABLES ON NEXT PAGE
133
Engagement in Digital/Online Pleasurable
Activities 0.001 0.001 0.02 0.403
STEP 2 Total Problems* Digital/Online Activities
None REF
1 -0.004 0.002 -0.04 0.081
2 -0.003 0.004 -0.02 0.477
3 -0.003 0.006 -0.01 0.630
134
Model 6. Linear Regression Association between Total Number of Respiratory Problems
(modelled continuously) and Subsequent Symptoms of Anxiety, Moderated by Engagement in
Pleasurable Digital/Online Activity
Anxiety Symptoms at Follow-up
B SE β P-value R
2
STEP 1 Total Number of Problem 0.19
None REF
+1 Symptom 0.14 0.02 0.13 <0.001
Body Mass Index 0.001 0.004 0.01 0.786
Baseline Mean Anxiety Symptoms 0.39 0.02 0.39 <0.001
Gender
Female REF
Male -0.05 0.03 -0.03 0.120
Race/ethnicity
Hispanic REF
Asian -0.01 0.05 -0.01 0.785
White -0.07 0.05 -0.04 0.167
Other 0.02 0.05 0.01 0.732
Free or Subsidized Lunch
No REF
Reduced cost -0.001 0.06 -0.0003 0.988
Free lunch -0.001 0.04 -0.001 0.973
Highest Parental Education
Some high school or less REF
High school graduate -0.08 0.06 -0.03 0.231
Some college -0.03 0.07 -0.01 0.682
College graduate 0.04 0.07 0.03 0.507
Advanced degree -0.04 0.07 -0.02 0.570
Exposure to Second-hand Smoke at Home
None reported REF
Yes -0.04 0.04 -0.02 0.334
E-Cigarette Use
No lifetime use REF
No past 6 month use -0.07 0.05 -0.04 0.124
Past 6 month use -0.11 0.08 -0.04 0.161
Past 30 day use -0.21 0.11 -0.05 0.069
Cigarette Use
No lifetime use REF
No past 6 month use 0.08 0.05 0.04 0.123
Past 6 month use 0.05 0.08 0.01 0.566
Past 30 day use 0.23 0.10 0.06 0.020
Cannabis Use
No lifetime use REF
No past 6 month use -0.05 0.05 -0.02 0.335
Past 6 month use -0.02 0.06 -0.01 0.713
Past 30 day use 0.06 0.06 0.03 0.327
Asthma Diagnosis
No REF
Yes 0.02 0.04 0.01 0.696
Engagement in Digital/Online Pleasurable
Activities
0.001 0.001 0.01 0.577
STEP 2 Total Problems* Digital/Online Activities -0.002 0.001 -0.03 0.169
Abstract (if available)
Abstract
Background: Respiratory problems often manifest in childhood and are one of the most common health problems among youth. Respiratory problems have been shown to contribute to poor psychosocial functioning, including detriments to academic achievement, sleep, social and peer relationships, and mental health. While common, respiratory problems are often unpredictable and can thus substantively, adversely impact youths’ daily lives. Respiratory problems can contribute to adolescents’ stress, fear of symptoms flares, and impairments in routine activities, all of which can exacerbate problems with adolescent functioning and mental health. Yet, little is known about whether respiratory problems and symptoms of depression and anxiety co-occur, or if there is a prospective association of respiratory health with adverse psychological functioning over time that may indicate a causal relation. The current study aims to investigate this prospective association and to identify whether the association may weaken (leading to better mental health outcomes) for youth who are able to engage in pleasurable activities. ? Methods: A total of 1,923 adolescents (59.7% female) with a mean age of 17.4 years (SD=0.4) at baseline, completed surveys on respiratory problems, psychological functioning, engagement in pleasurable activities, and demographic data during the fall of 2016 (12th grade) and again in 2018–2019, following graduation from high school. Linear regression models were used to examine the association between past 12 month respiratory problems (i.e., shortness of breath, wheeze, bronchitis, any respiratory problem, total number of symptoms) at baseline with anxiety and depressive symptoms at follow-up (continuous), adjusting for baseline characteristics and variables hypothesized to confound the association. We assessed moderation by pleasurable in-person and digital/online activities on the association between respiratory problems and psychological functioning by inclusion of multiplicative interaction terms in linear regression models. In sensitivity analyses, we used logistic regression models to evaluate the association of each respiratory symptom with the odds of any clinically significant depression or anxiety (yes/no, in separate models). ? Results: Having any (vs. no) respiratory problem at baseline was associated with mean levels of depression and anxiety symptoms more than two years later, even after accounting for initial levels of depression or anxiety. These effects held when analyses examined specific respiratory problems (i.e., bronchitic symptoms, shortness of breath, wheeze). In sensitivity analyses, logistic regression analyses also showed that each specific respiratory symptom was associated with about 1.43?1.98 times greater odds of report of clinically significant depression or anxiety (ps<0.05), with the exception of wheeze, which was not significantly associated with depression (OR=1.36; p=0.064). Each additional respiratory symptom increased the odds of report of any clinically significant depression or anxiety. ? In-person pleasurable activities moderated the association of one total respiratory problem with symptoms of depression (p=0.02) and anxiety (p=0.009). Report of 1 (vs. 0) respiratory problem was associated with both depression and anxiety symptoms, an association which lessened with increasing engagement in pleasurable in-person activities; the association of the report of 2 or 3 respiratory problems (vs. 0 problems) with mean depression and anxiety symptoms did not differ by level of engagement with pleasurable in-person activities. A significant two-way interaction was found between pleasurable digital/online activity and bronchitis with both mean depression (p=0.003) and anxiety (p=0.005) symptoms. The association of bronchitis with subsequent symptoms of depression and anxiety lessened with increasing engagement in pleasurable digital/online activities. ? Conclusions: A considerable proportion of adolescents reported experiencing respiratory problems including bronchitic symptoms, wheeze, and shortness of breath, and these problems were prospectively associated with both depression and anxiety in early adulthood. These findings warrant consideration of screening for depression and anxiety when an adolescent patient presents with respiratory problems and in follow-up assessments. Consideration of co-location of physicians and psychologists in adolescent pulmonary and allergy clinics and pediatricians’ offices may be useful to ensure that both physical and mental health can be addressed and treated simultaneously. Earlier identification and treatment of mental health problems among youth with respiratory problems may reduce the severity of mental health outcomes and related sequelae. Moreover, additional study is needed to identify optimal intervention strategies for youth with respiratory problems to reduce risk of development of depression and anxiety. Engagement in pleasurable activities may be an easy target for brief intervention, but additional intervention strategies need to be identified.
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Asset Metadata
Creator
Kelleghan, Annemarie R.
(author)
Core Title
Examining the associations of respiratory problems with psychological functioning and the moderating role of engagement in pleasurable activities during late adolescence
School
College of Letters, Arts and Sciences
Degree
Doctor of Philosophy
Degree Program
Psychology
Degree Conferral Date
2021-08
Publication Date
07/18/2021
Defense Date
06/08/2021
Publisher
University of Southern California
(original),
University of Southern California. Libraries
(digital)
Tag
anxiety,Depression,late adolescence,OAI-PMH Harvest,pleasurable activities,respiratory problems
Format
application/pdf
(imt)
Language
English
Contributor
Electronically uploaded by the author
(provenance)
Advisor
Barrington-Trimis, Jessica (
committee chair
), Schwartz, David (
committee chair
), Manis, Frank (
committee member
), Margolin, Gayla (
committee member
)
Creator Email
akelleghan@gmail.com,kellegha@usc.edu
Permanent Link (DOI)
https://doi.org/10.25549/usctheses-oUC15607941
Unique identifier
UC15607941
Legacy Identifier
etd-KelleghanA-9778
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Dissertation
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application/pdf (imt)
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Kelleghan, Annemarie R.
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University of Southern California
(contributing entity),
University of Southern California Dissertations and Theses
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The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the author, as the original true and official version of the work, but does not grant the reader permission to use the work if the desired use is covered by copyright. It is the author, as rights holder, who must provide use permission if such use is covered by copyright. The original signature page accompanying the original submission of the work to the USC Libraries is retained by the USC Libraries and a copy of it may be obtained by authorized requesters contacting the repository e-mail address given.
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Tags
anxiety
late adolescence
pleasurable activities
respiratory problems