Canadian Journal of

School Psychology
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School-Based Intervention: Relaxation and Guided Imagery for Students

With Asthma and Anxiety Disorder
Vineeta Gandotra Kapoor, Melissa A. Bray and Thomas J. Kehle
Canadian Journal of School Psychology 2010 25: 311 originally published online 29 July
2010
DOI: 10.1177/0829573510375551
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School-Based
Intervention: Relaxation
and Guided Imagery for
Students With Asthma
and Anxiety Disorder

Canadian Journal of School Psychology

25(4) 311327
2010 SAGE Publications
Reprints and permission: http://www.
sagepub.com/journalsPermissions.nav
DOI: 10.1177/0829573510375551
http://cjs.sagepub.com

Vineeta Gandotra Kapoor1, Melissa A. Bray1,

and Thomas J. Kehle1
Abstract
This school-based study analyzed the impact of RGI on lung functioning (forced expiratory
volume in 1 s [FEV1] and forced expiratory flow 25-75 [FEF25-75]) and by employing a
multiple baseline design across 3 high school students with asthma and clinically diagnosed
anxiety disorders. The RGI intervention took place for a 20-min period, an average of
three times per week, over a 4-week period. At the onset of the intervention, it was
found that lung functioning, particularly FEV1 increased in all 3 participants, with effect
sizes ranging from .32 to 2.48. FEF25-75 improved in one of the participants. In addition,
a positive impact was also seen in the lowering of anxiety scores across all 3 participants,
with effect sizes ranging from .12 to 1.69.
Resume
Cette tude cole-bas a analys limpact de RGI sur fonctionner de poumon (a forc le
volume expiratoire dans de 1 seconde [FEV1] et flux expiratoire forc 25-75 [FEF25-75]) et
anxit en employant une conception de base multiple travers 3 lycens avec lasthme
et les dsordres danxit dun point de vue clinique diagnostiqus. Lintervention de RGI
a intervenu pour une priode de 20 minute, une moyenne de trois fois par la semaine,
sur une priode de 4 semaines. Au dbut de lintervention, il a t trouv que le poumon
fonctionne, notamment FEV1 a augment dans tous les trois participants avec les tailles
deffet qui tend de -. 32 -2.48. FEF25- 75 a amlior dans un des participants. En plus,
un impact positif a t aussi vu dans la baisse de scores danxit travers tous les trois
participants, avec les tailles deffet qui tend de 0,12 1,69.
Keywords
relaxation, guided imagery, asthma, anxiety
1

University of Connecticut, Storrs

Corresponding Author:
Thomas J. Kehle, University of Connecticut, Department of Educational Psychology, Storrs, CT 06269-2064
Email: thomas.kehle@uconn.edu
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Canadian Journal of School Psychology 25(4)

Asthma is the most common illness of childhood affecting 6.2 million children. The
mortality rate for asthma has increased 25% since 1960 (Hartrett & Peebles, 2000).
Living with a chronic disease such as this has a wide-ranging impact on the social and
educational environment of the child. Increased absenteeism, decreased ability to participate in peer group activities, and curtailment of physical activities are but some of the
ways that a childs school experience may be affected (De Mesquita & Fiorello, 1998).
Although asthma is manifested and treated through the assessment of clear physiologic
symptoms, there is considerable research linking asthma to emotions and stress (Lehrer,
Feldman, Giardino, Song, & Schmaling, 2002). Research findings suggest that up to one
third of children diagnosed with asthma may meet the criteria for a concurrent diagnosis
of an anxiety disorder (Katon, Richardson, Lozano, & McCauley, 2004). The physical
manifestations of asthma and anxiety can be similar such as chest tightness, feelings of
loss of control, difficulty in breathing, and parasympathetic arousal.
Psychological interventions such as asthma education, biofeedback, yoga, written
emotional expression, and relaxation and guided imagery (RGI) have been used to
treat asthma. Asthma education has been shown to be cost effective in the monitoring
of symptoms and the use of medication (Greineder, Loan, & Parks, 1999). However,
as a sole intervention it does not address the anxiety that is often associated with
asthma. Yoga has shown some promise in ameliorating asthma symptoms (Nagarathna
& Nagendra, 1985) but requires a large block of time and space to administer. Written
emotional expression as a psychological intervention for asthma has shown mixed
results. Some research indicates a positive impact on asthma (Bray et al., 2005; Smyth,
Stone, Hurewitz, & Keall, 1999), whereas others have had less success (Harris,
Thoresen, Humphreys, & Faul, 2005).
RGI as an intervention builds on the mindbody connection to promote health. It is
grounded in the science of psychoneuroimmunology that studies the interaction
between the brain, endocrine, and immune systems (Ader, 1996). An RGI exercise
begins with a relaxation procedure that is believed to be effective in minimizing motor
reactions, thoughts, and external stimuli (Achterberg, 1985). This is followed by the
use of visualization to generate imagery specific to the target disease to alter immune
parameters and enhance the healing process. There is ample evidence that imagery can
lead to biochemical and physiologic changes (Achterberg, 1985). It has been successfully used to improve psychological as well as physical outcomes in a number of
medical conditions such as cancer, osteoarthritis, depression, and pain management
(Adams, Poole, & Richardson, 2006; Antoni et al., 2000; Baird & Sands, 2006; Cameron
et al., 2006; Chou & Lin, 2006).
The use of relaxation and guided imagery (Dobson, Bray, & Kehle, 2005; Peck,
Bray, & Kehle, 2003) has also shown an improvement in the quality of life, lung functioning, and anxiety levels in children with asthma.
Anbar and Geisler (2005) and Castes et al. (1999) have suggested that the treatment of
asthma symptoms in patients with comorbid psychiatric conditions, solely through pharmacological interventions, results in overmedication. Therefore, the purpose of this study
was to determine the efficaciousness of school-based RGI on reducing anxiety and
improving lung functioning in high school students clinically diagnosed with both asthma

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Kapoor et al.

and anxiety disorders. This is the first school-based study that examined individuals diagnosed with asthma comorbid with clinical DSM-IV diagnoses of anxiety disorder.

Method
Participants and Setting
Two ninth grade and one 11th-grade student at a suburban high school in Northern
Massachusetts volunteered to participate in this study. Criteria for participation in the
investigation included documented evidence of a history of asthma as diagnosed by a
physician; a recorded diminishment in expiratory lung functioning. Expiratory lung
functioning was evaluated by employing calibrated spirometry in concert with the
American Thoracic Society guidelines (ATS, 1995); the presence of a clinically diagnosed anxiety disorder as specified in DSM-IV-TR (American Psychological Association,
2004). This was verified through the childs physician. In addition, the diagnosis was
validated through the use of the Anxiety Disorder Interview Schedule (ADIS IV)
child interview schedule (Brown, Di Nardo, & Barlow, 1994).
Participant 1 was a 15-year-old White female; she had been diagnosed with asthma
early in elementary school. At baseline, Participant 1 exhibited moderate persistent
asthma and reported that she experienced symptoms of asthma including wheezing,
coughing, shortness of breath, and chest tightness daily. Participant 1s asthma could
be triggered by physical exertion, extremes in temperature, stress, dust, and animal
dandruff. At baseline her spirometry ratings were borderline (approximately 85% predicted for FEV1 and FEF 25-75). For Asthma, Participant 1 took Flovent, Proventil,
Zyrtec, and Singulair daily. Based on Participant 1s responses to the Pediatric Asthma
Quality of Life Questionnaire (PAQLQ; Juniper, 1999), it was evident that consequences of her asthma included feeling isolated, frustrated, and worried.
Participant 1 also had a clinically diagnosed anxiety disorder, which manifested in
the form of panic attacks. As a result of the panic attacks she experienced shortness of
breath, often accompanied by loss of consciousness. Participant 1s responses on the
ADIS IV (Brown et al., 1994) child interview schedule validated her diagnosis of an
anxiety disorder. Her psychotropic medication included Celexa and Remeron. Consequences of the anxiety included a limitation in daily activities. On one occasion, Participant 1 had to leave a class because she started to hyperventilate. She also reported
that she did not actively participate in outdoor sports without the presence and support
of friends who are aware of her problems.
Student 2 was a 15-year-old White female, who was diagnosed with asthma at the age
of 6. Participant 2 exhibited borderline FEV1 and FEF 25-75 values (approximately 75%
predicted). Her asthma medication included Albuterol and Claritin. Participant 3 experienced coughing, wheezing, and chest tightness several times a month. Known triggers
included dust, exercise, stress, and mold. On the PAQLQ (Juniper, 1999), she noted that
consequences of the asthma included frustration from being excluded from activities.
Participant 2 had a clinically diagnosed anxiety disorder that manifested itself as
generalized anxiety especially in novel situations. The transition from the middle

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Canadian Journal of School Psychology 25(4)

school to the high school was especially difficult for her and was accompanied by
frequent absences. Participant 2s responses on the ADIS IV (Brown et al., 1994) child
interview schedule validated her diagnosis of an anxiety disorder. Her anxiolytic medications included Selexa, Inderal, and Nortriptyline.
Student 3 was a 16-year-old White male who was diagnosed with asthma as a
young child. At baseline, he exhibited symptoms of mild intermittent asthma. He
experienced coughing and shortness of breath once a week. At the initial screening, he
exhibited symptoms of mild intermittent asthma, FEV1 and FEF 25-75 were approximately 90% predicted. Known triggers to his asthma included very hot weather. Participant 3 reported minimal disruption of activities because of asthma. He had not had
an asthma attack in the last year. Participant 3 used an Albuterol inhaler as needed.
Participant 3 also had a clinical diagnosis of anxiety disorder that was manifested by
restlessness, difficulty completing work, and loss of attention. His responses on the
ADIS IV (Brown et al., 1994) child interview schedule confirmed his diagnosis of an
anxiety disorder. His medication included Concerta.

Design
This study employed a multiple baseline design (Kazdin, 1982). Data were collected
across three phases including baseline, intervention, and follow-up over a 4-month period.

Dependent Measures
Lung functioning. Spirometry is a technique used to measure lung functioning. A
SpiroCard spirometer with Office Medic software was utilized. The FEV1, is a measure of large airway functioning, and the FEF 25-75, is a measure of the small airway
functioning. The criterion for good effort, as delineated by the American Thoracic
Society (1995) was explained to all 3 participants. For clinical use, the largest values
of FEV1 were reported (Ritz et al., 2004).
Anxiety. The State Trait Anxiety Inventory for Youth (STAI; Spielberger, 1983)
was administered. The state scale measuring transient anxiety was administered at all
baseline sessions, following each intervention session, and during follow-up. This is a
20-item self-report questionnaire. It is suitable for use with children from Grades 4
through 12. The trait scale that measures a long-term tendency for anxiety was administered at the start of baseline and at the close of follow-up. This scale also consists of
20 items.
Medication and symptoms. The students maintained a daily asthma diary. This included
a record of medication and inhaler use, including time of use and dosage. A record of
physical symptoms was also maintained. The student at each baseline, intervention,
and follow-up session completed the diary. The purpose of this was to ensure that
long-term medication usage was recorded during the study and to avoid taking measures of lung functioning when the use of quick-acting medications such as bronchodilators could affect the results.

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Quality of life. The Paediatric Asthma Quality of Life Questionnaire (PAQLQ; Juniper, 1999) is designed to assess social-emotional factors that affect the overall quality of
life. This scale consists of 23 items administered in an interview format. It is designed
for children 7 to 17 years of age. The PAQLQ is divided into three domains: Symptoms,
emotions, and activity limitations. The scores range from 1 (extremely bothered all the
time) to 7 (not bothered at all). Higher values are a reflection of more adaptive functioning. The minimum difference required to infer significant change is .5 per item per
domain (Juniper, 1999). This measure was employed at baseline and at follow-up.
Happiness. The Multidimensional Students Life Satisfaction Scale (Huebner,
2001) was administered at baseline and follow-up. This scale is designed to measure
the students general sense of happiness. It is a 40-item scale administered in an interview format. It is suitable for children in Grades 3 to 12.
Consumer satisfaction. All students completed a consumer satisfaction questionnaire
based on Bray and Kehles (1996) index during follow-up phase. The scale examined
all aspects of the investigation including how much the students liked filling out each
questionnaire, learning about asthma, following the guided imagery directions, and
using the spirometry equipment. A 5-point Likert-type scale was employed.
Treatment integrity. To maintain treatment integrity, the investigator at the completion
of each session completed a checklist protocol. This protocol was used to ensure that the
intervention was consistently administered across all sessions and participants.

Procedures
Baseline data were collected across 3, 4, and 5 weeks for participants 1, 2, and 3 respectively. At the beginning of the baseline phase, each participant completed an interview or
individual asthma survey, the purpose of which was to assess subjective perceptions of
the asthma. At this time, each student also completed the PAQLQ (Juniper, 1999) and
the Multidimensional Students Life Satisfaction Scale (Huebner, 2001). At each session, the student completed the STAI Y-1 (Spielberger, 1973) and the daily asthma diary
(Creer, Marion, & Creer, 1983) in addition to spirometry readings.
Intervention. Prior to the first intervention session, the student was shown, through
the use of charts and pictures, an operational model of asthma and of the lungs during
an asthmatic episode. Following the presentation, the children were able to demonstrate their understanding of the respiratory function with the help of the visual aids.
Intervention data were collected for 4 weeks. The intervention took place in the
school nurses office with only the researcher present. Each session lasted approximately 20 min, three times per week. Prior to the RGI, the participant completed the
daily asthma diary. Spirometry readings were also taken at this time.
A Relaxation and Guided Imagery script (Achterberg, 1985; Achterberg et al.,
1994; Peck et al., 2003) was developed individually for each participant based on
individualized preferences for relaxing and happy images. RGI imagery focused on a
step-by-step progression toward healthy lungs as well as a final visualization of a
healed lung (Achterberg et al.; Brigham, 1994). The imagery focused on (a) general

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Canadian Journal of School Psychology 25(4)

Table 1. STAI-T Anxiety Baseline and Follow-up standard scores for Participants 1, 2, and 3
Phase
Baseline
Follow-up

Participant 1

Participant 2

Participant 3

46
35

57
43

38
32

relaxation exercises aimed at each body part and imagery specific to the student of a
relaxing place; (b) picturing the specific healing process taking place in the lungs and
bronchi; (c) visualizing the child participating in a favoured activity or sport while free
of asthma; and (d) imagery in which the child pictures (inhaling) a specifically coloured air that will clear the lungs and bronchial tubes enabling easy breathing. After
the RGI, the student completed the STAI-S Anxiety scale (Spielberger, 1973). A second
spirometry reading was also conducted at this time. In addition, the Treatment Integrity Checklist was completed at the end of each session.
Follow-up. Follow-up data were collected for all 3. During this phase the participants
completed the daily asthma diary and the STAI Y-1 (State Anxiety) scale. In addition
Spirometry readings were taken at all follow-up sessions. On the last session, each
participant completed the STAI Y-2 (Trait anxiety) and the MSLSS. The participants
also completed a consumer satisfaction index at that time.

Results
Pulmonary Function and State Anxiety
Busk and Serlins (1992) Approach One: No Assumptions Model was used to calculate the effect sizes. This method was used to calculate the effect sizes for the FEV1,
FEF 25-75, and STAI-S Anxiety scores. Positive effects suggest an improvement in
anxiety, whereas negative effects suggest improved lung functioning.
The following effect sizes were calculated for FEV1 for the intervention phase for
Participants 1, 3, and 2, respectively 2.15, 0.32, and 2.48. The follow-up effect
sizes for FEV1 were 2.05, 0.65, and 2.68, respectively, for Participants 1, 3, and 2
(see Table 1).
Participant 1 did not show a significant improvement in large airway functioning as
a result of the intervention. Participant 2 showed a 78% increase in large airway function over baseline. Participant 3 demonstrated a 20% increase over baseline in large
airway functioning (Figure 1).
The effect sizes for Participant 1, 2, and 3 for FEF25-75 for the intervention phase
were 0.6, 1.98, and 0.49 respectively. The effect sizes for the follow-up phase were
1.12, 2.13, and 0.44, for Participants 1, 2, and 3 respectively (see Table 2).
Participant 1 showed a slight decline in small airway functioning over baseline.
Participant 2 showed an increase of more than 50% over baseline in small airway
functioning. Participant 3 showed a slight increase in small airway functioning
(Figure 2).

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Kapoor et al.

Baseline

Intervention

Follow-up

100

90

80

FEV1 percent predicted

Participant 1

90
80
70
60
50
40
30
Participant 2

155

115

75

35
3/9

3/19

3/29

4/8

4/18

4/28

5/8

5/18

Assessment Sessions

5/28

6/7
Participant 3

Figure 1. FEV1 (percentage predicted) across sessions for participants 1, 2, and 3

The calculated effect sizes for the intervention phase of the STAI-S (State) Anxiety
were 1.69, 1.13, and 0.12 respectively for Participant 1, 2, and 3. The effect sizes for
the follow-up phase were calculated to be 1.03, 1.17, and 0.33, respectively for Participants 1, 2, and 3 (Figure 3).

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Canadian Journal of School Psychology 25(4)

Table 2. PAQLQ Baseline and Follow-Up Scores for Participants 1, 2, and 3

Activity limitations
Symptoms
Emotional functioning
Overall quality of life

Baseline
Follow-up
Baseline
Follow-up
Baseline
Follow-up
Baseline
Follow-up

Participant 1

Participant 2

Participant 3

2.2
4.4
2.7
5.1
3.1
5.1
2.7
4.9

4
4.8
5
4.9
5.8
6.3
5
5.3

5.66
7
6.66
7
6.75
7
6.5
7

Trait anxiety. The STAI-T anxiety scale used to assess trait anxiety was administered at the start of baseline and on the last follow-up session. All 3 participants
showed a decline in trait anxiety at follow-up as compared to baseline scores.
Quality of life. Again, the overall quality of life with specific reference to physical,
emotional, and social impairments experienced by the students as a result of their
asthma was measured through the Paediatric Asthma Quality of Life Questionnaire
(PAQL; Juniper, 1999).
Participant 1 reached a positive minimal important difference across all domains.
Participant 2 reached a positive minimal important difference for activity limitations
and emotional functioning. Participant 3 reached a positive minimal important difference for activity limitations. Participant 1 also reached a positive minimal important
difference for overall quality of life (see Table 2).
Happiness. In this context, life satisfaction has been defined by Pavot and Diener
(1993) as a global evaluation by the person of his or her life. The MSLSS provides
a measure of childrens level of life satisfaction across the specific domains of family,
friends, school, living environment, and self as well as an overall life-satisfaction
score. Higher scores indicate higher levels of satisfaction throughout the scale. All
responses are finally averaged to yield mean global and domain life-satisfaction scores
ranging between 1 and 6. Participants 1 and 3 showed a significant improvement over
baseline scores across all domains. Participant 1 reported a decline in her level of
satisfaction across the domain of family; her scores across the other domains were
essentially unchanged. The scores are presented in Table 3.
Medication and symptoms. The daily asthma diary (Creer et al., 1983) was maintained by each participant to track medication usage and perception of asthma symptoms (see Table 4). Participants 1 and 2 both had two asthma attacks during the study.
Participant 1 noted that on three different occasions there was a need to use an immediate relief bronchodilator. Participant 3 did not need to use any asthma medication
during the course of the study. The mean scores for symptoms across each phase for
each participant are noted in Table 4. Participants rated their symptoms across all
phases on a scale of 0 to 4. Zero indicated no symptoms while 4 was used to denote
the presence of severe symptoms.

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Kapoor et al.

100

Baseline

Intervention

Follow-up

90

80

FEF25-75 percent predicted

Participant 1
125

85

45
Participant 2

135

95

55
3/9

3/19

3/29

4/8

4/18

4/28

5/8

5/18

5/28

6/7
Participant 3

Assessment Sessions

Figure 2. FEF25-75 (percentage predicted) across sessions for Participants 1, 2, and 3

Participant 1 showed a decline in symptoms from baseline to intervention with a

slight increase in follow-up scores over intervention scores; however, follow-up scores
remained lower than baseline scores. Participant 2 showed a decline in symptoms

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Canadian Journal of School Psychology 25(4)

Baseline

Intervention

Follow-up

60
55
50
45
40
35
30

STAIC S Anxiety (T Scores)

Participant 1

50

40

30
Participant 2

30
25
20
15
10
3/9

3/19

3/29

4/8

4/18

4/28

5/8

5/18

5/28

Assessment Sessions

6/7
Participant 3

Figure 3. STAI-S anxiety scores across sessions for Participants 1, 2, and 3

across intervention and follow-up scores over the baseline average. Participant 3 did
not experience any symptoms across the different phases.
Treatment integrity. To ensure consistency during the intervention phase of the study,
a treatment integrity checklist was administered during each session of the intervention

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Table 3. Multidimensional Students Life Satisfaction Scale, Average Scores Across Baseline
and Follow-Up for Participants 1, 2, and 3

Family
Self
Friends
School
Living environment
Global life satisfaction

Baseline
Follow-up
Baseline
Follow-up
Baseline
Follow-up
Baseline
Follow-up
Baseline
Follow-up
Baseline
Follow-up

Participant 1

Participant 2

Participant 3

4.7
3.8
5.7
5.7
5.8
6
5.7
5.6
5.5
5.1
5.5
5.3

3.7
4.4
4.1
4.8
5.4
6
1.8
3.3
4.4
4.7
3.9
4.7

3.7
4.5
5.2
5.4
4.5
5.1
2.7
3.7
4.2
4.7
3.9
4.7

Table 4. Mean Symptom Severity Scores on the Daily Asthma Diary for Participants 1, 2,
and 3
Phase
Baseline
Intervention
Follow-up

Participant 1

Participant 2

Participant 3

.86
.38
.47

.75
.68
.46

0
0
0

phase across all participants. All interventions were completed with 100% accuracy as
per an analysis of this checklist.
Consumer satisfaction. Participants completed a consumer satisfaction survey at the
final session of the follow-up phase to determine their overall satisfaction with the
study. The consumer satisfaction survey employed a 5-point Likert-type scale. A mean
of 5 was obtained for all 3 participants.

Discussion
Relaxation and Guided Imagery (RGI) has been successfully used to improve lung
functioning and quality of life in children with asthma. This study assessed the impact
of RGI on high school students with asthma and clinical anxiety disorders. The results
indicated that RGI as a school-based intervention was successful in improving lung
function, reducing anxiety, and improving the quality of life and happiness in the
participants.
Lung function data were collected immediately prior to and after the RGI exercise
during the intervention phase. For the analysis, post-RGI data were used, as post-RGI

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Canadian Journal of School Psychology 25(4)

means were universally higher than pre-RGI means for all 3 participants on both small
and large airway functioning. This finding is in support of the results obtained by Peck
(2001) but contrary to those found by Lehrer et al. (1997).
It is important to examine the clinical significance of the lung function findings.
Based on the benchmark established by The American Thoracic Society (1995), 2 out
of 3 participants met the clinically significant improvement standard for large airway
functioning, with improvement over baseline of 75% and 16%. One of 3 participants
met the clinically significant standard for improvement in FEF25-75 (small airway functioning), with an improvement in spirometry scores of 57%.
The intervention had a greater impact on FEV1 than FEF25-75 in 2 out of the 3 students. This result is in keeping with previous research, which found that RGI had a
greater impact on large airway functioning as compared to small airway functioning
(Peck, Bray, & Kehle, 2003; Lehrer et al., 1997).

Impact of RGI on Anxiety

In addition, a positive impact was also seen in the lowering of anxiety scores across all
participants. The state anxiety score for all 3 participants decreased significantly over
the course of the study with effect sizes in the range of 0.12 to 1.69. The data indicate
that RGI is a viable tool to improve lung functioning and reduce anxiety in young
adults with asthma and a comorbid anxiety disorder.
Trait anxiety assessed at the beginning of the baseline and end of follow up phases
declined in all 3 participants lending further credence to the efficacy of this intervention. This is an important finding as anxiety is a known trigger for asthma episodes
(Bussing, Burkett, & Kelleher, 1996; Goodwin, Wamboldt, & Pine, 2003). All 3 participants in this study had a diagnosis of anxiety disorder in addition to the asthma;
therefore a reduction in anxiety might contribute to an improvement in the quality of
life and feeling of wellness.

Impact of RGI on the Quality of Life

The quality of life scores improved considerably for Participant 1 across all domains
as well as for overall quality of life. At the last follow-up session, Participant 1 reported
greater ease and a reduction in feelings of anxiety. The school nurse requested a copy
of the RGI imagery to use with this individual in the event of a panic attack in school.
This was also the only student who requested and a copy of the RGI imagery to use
in the future at home. Participant 2 showed a significant improvement in activity limitations and emotional functioning. Anecdotally, it is interesting to note that this
participant missed fewer school days during the course of the study as compared to the
prior 3 months. Attendance rates would be an interesting part of a future investigation.
Participant 3 demonstrated an overall improvement in life satisfaction and also had a
concurrent improvement of 16% in large airway functioning.

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Impact of RGI on Happiness

Happiness, as evaluated by the MSLSS, showed an improvement in 2 out of 3 participants. Participants 2 and 3 who showed significant improvement in lung functioning
also showed improvement in global life satisfaction. Participant 2, who had the maximum improvement in lung functioning, showed improvement across the domains of
family, self, friends, and living environment as well. Participant 1, who did not meet
the clinically significant criteria for improvement in asthma, showed a minimal decline
in the MSLSS scores.
An analysis of the consumer satisfaction survey revealed that all 3 participants enjoyed
the actual RGI procedure; a mean of 5 (maximum level of comfort) was reported.

Implications for Practicing School Psychologists

Living with a chronic disease such as asthma has wide-ranging impact on the social
and educational environment of the child. Increased absenteeism, decreased ability to
participate in peer group activities, possible curtailment in physical activities are but
some of the ways that a childs ability to learn may be affected. Studies have shown
that chronic medical conditions such as asthma are linked with cognitive, academic,
behavioural, and social deficits (Brown & DuPaul, 1999). Despite this, the traditional
role of the school psychologist, focused on psycho-educational assessment, does not
easily lend itself to assessing and treating children struggling with chronic illnesses.
RGI is an intervention that is easily administered in a school setting. All that is
required is a quiet space and a couple of comfortable chairs. It is effective in reducing
stress and anxiety related to chronic medical conditions such as asthma, diabetes, and
life threatening food allergies. Any school nurse will affirm that students often use the
nurses office as a safe and quiet area. These students would be better served by practicing RGI.
It is now estimated that 10% to 15% of all school children live with one or more
chronic medical condition. Given the psychological, emotional, and educational
impact of these, it behoves a reassessment of the traditional role of the school psychologist. A school psychologist must be aware of the educational and behavioural ramifications of various chronic illnesses, including impact of the disease on the childs
educational environment. The need for interventions that may be beneficial in supporting not only the child coping with a chronic condition but also the larger social
environment of peers and teachers is critical (Brown & DuPaul, 1999).

Limitations
The potential for threats to internal validity exist within this study. The course of
asthma itself may have been a threat to the validity of the investigation. Individual
triggers for asthma vary and may be dependent on the weather, activity, and stress

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level of the child. Using spirometry assessments as a sole measure of lung function
may be problematic. Although a computer determines if the trial is valid, the child has
to learn to exhale with force to obtain an accurate assessment. If the child does not use
the correct technique, the spirometry reading may be lower than the actual level. In
addition, the use of spirometry alone to assess the presence or absence of asthma is
problematic. The perception of the severity of asthma symptoms often bears little
relationship to the spirometry readings. Persons with severe symptoms such as wheezing, coughing, and chest tightness may not present with a severely impaired spirometry
and vice versa.
The RGI script was personalized for each child. To that extent, the intervention was
not standardized; in that, all though a standard protocol was followed, the actual script
varied between participants. In addition, the effort put forth during the relaxation procedure may have varied between participants. Despite the fact that every effort was
made to standardize the intervention, the actual relaxation and guided imagery process
is an internal process that is fully controlled by the participants. In as much, the degree
to which they focused and were able to enter a state of relaxation may have varied.
Finally, the symptom ratings on the daily asthma diary were subjective and may not
exactly relate to symptoms as experienced by the participant.
As mentioned earlier, the weather and time of year, medication use, and other
unrelated anxiety-producing situations involving the child may pose a threat to the
internal validity of the research. It is also feasible that the measures used to assess lung
functioning, anxiety, life satisfaction, and happiness were not sensitive enough to
detect minor changes.
Asthma has a wide-ranging and long-term impact on academic performance,
absenteeism, peer acceptance, and participation in extra curricular activities. The scope
of this research does not permit the study of the long-term impact of relaxation and
guided imagery on the sustained participation in extracurricular activities, peer acceptance, academic performance, and absenteeism.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the authorship and/or
publication of this article.

Funding
The author(s) received no financial support for the research and/or authorship of this article.

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Bios

Vineeta G. Kapoor is a School Psychologist currently practicing in Massachusetts. She holds

both national and state certification in School Psychology. Dr. Kapoor is also associated with
the University of Phoenix through which she facilitates online graduate courses in psychology.
Dr. Kapoor has practiced in India, France, and in the U.S.
Melissa A. Bray is a Professor in School Psychology at the University of Connecticut. Her
primary research interests include school-based interventions in the areas of communication,
behavior, and health disorders.
Thomas J. Kehle is a Professor and Director of School Psychology at the University of Connecticut. His primary research interests include the design and implementation of interventions
to improve childrens academic and social functioning. His writing also involves his interest in
practical applications of a theoretical model of wellness to improve both the magnitude and
endurance of positive behavior change.

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