Peter's asthma has always been a concern to his parents. Since his diagnosis of asthma at 2 years of age during his first hospitalization for pneumonia, his mother often reminds doctors that "they said he was very sick-that if we hadn't taken him to the hospital that night, he may have died." Now 10 years old, Peter has had 5 subsequent brief hospitalizations for status asthmaticus. His pattern of illness is predictable: an upper respiratory illness followed by wheezing not completely controlled by inhalation home medication; he spends not more than 2 days in the hospital. He has had only one other episode of pneumonia. Emergency room visits seemed clustered around moments of family disruption. His parents' separation and divorce when he was 5 years old, his mother's loss of her job when he was 7, and his older sister's auto accident when he was 8 were each accompanied by 1 to 3 emergency room visits for asthma. At other times, asthma exacerbations were managed at home. Peter's pediatrician, and subsequently an allergist, provided his mother with a written plan for maintenance and acute treatment medications, as well as attention to household allergen elimination, with limited success. Recently, Peter refused to take his inhaler to school. He resisted going to the school nurse for medication as needed. In the 4th grade, his behavior in class was on occasion disruptive, and he demonstrated less interest in school work. His teacher reported that Peter was often short of breath after playing at recess. Peter now lives with his mother and older sister. His mother works full time as a medical assistant. Since the divorce 5 years ago, Peter spends 1 weekend each month with his father, who lives in a nearby town.