Few trials have been conducted to address the psychological difficulties of parents in managing their child’s asthma. Fostering parental psychological flexibility through Acceptance and Commitment Therapy (ACT) may help parents to accept these psychological difficulties and improve their management of childhood asthma.
In this randomized controlled trial, a 4-session, group-based ACT plus asthma education (ACT group) was compared with an asthma education talk plus 3 telephone follow-ups (control group) to train parents of children diagnosed with asthma. The use of health care services due to asthma exacerbations in children and the psychological well-being of their parents were assessed before, immediately after, and at 6 months after the intervention.
A total of 168 parents and their children aged 3 to 12 years with asthma were consecutively recruited in a public hospital in Hong Kong. When compared with the control group, children whose parents were in the ACT group made significantly fewer emergency department visits (adjusted 6-month incidence rate ratio = 0.20; confidence interval [CI] 0.08 to 0.53; P = .001) due to asthma exacerbations at 6 months postintervention. These parents also reported a decrease in psychological inflexibility (mean difference = −5.45; CI −7.71 to −3.30; P = .014), less anxiety (mean difference = −2.20; CI −3.66 to −0.73; P = .003), and stress (mean difference = −2.50; CI −4.54 to −0.47; P = .016).
Integrating ACT into parental asthma education was effective at decreasing parental anxiety and stress and reducing the asthma-related emergency department visits of children at 6 months postintervention.
Many parents experience psychological difficulties in caring for a child with asthma. There is a paucity of research on the link between how parents manage their own psychological difficulties and how this affects the health of their child with asthma.
This is the first study to investigate the efficacy of Acceptance and Commitment Therapy for parental management of childhood asthma. Use of emergency care services due to childhood asthma exacerbations was reduced, and the psychological health of the parents improved.
Asthma remains the most common chronic disease, affecting one-tenth of children worldwide.1 The unpredictability and life-threatening nature of asthma imposes a heavy psychological burden on parents.2,–4 Parents who find it difficult to cope with the burden may engage in avoidance or hypervigilance or may catastrophize mildly threatening cues related to asthma,5,6 which may affect how they manage their child’s asthma.7,–9 Studies have revealed that poor parental psychological health10 affects childhood asthma morbidity, as indicated by increased symptom severity11 and frequent use of health care services.12,13 Hence, helping parents manage their psychological difficulties may improve their management of childhood asthma, leading to better child health outcomes.
Asthma management programs are focused on self-management education14,–16 but do not address parental psychological needs. Authors of a recent Cochrane review17 identified 5 randomized controlled trials (RCTs) of psychological interventions for parents of children with asthma. Family therapy,18,–20 multisystemic therapy,21 and problem-solving therapy22 were investigated, but no beneficial effects were found on the psychological health of the parents and the asthma symptoms of their children17 when compared with either those who received the usual care18,–20 or an active control that included those who received family counseling21 and asthma education delivered through home visits.22 Importantly, the review further found that the quality of the evidence from these studies was low or very low because of an unclear or high risk of attrition bias or reporting bias.17 Acceptance and Commitment Therapy (ACT) is a third wave of cognitive behavioral therapy aimed at fostering psychological flexibility (PF), which refers to accepting psychological experiences nonjudgmentally and taking values-based actions toward goals leading to healthy functioning.23 There is growing evidence that ACT can be used to help individuals with chronic diseases to self-manage their illnesses.24,–26 Two recent RCTs demonstrated that children diagnosed with acquired brain injuries27,–29 and cerebral palsy,30,31 whose parents had undergone 2 group sessions of ACT plus the Stepping Stone Triple P parenting program, showed fewer behavioral and emotional problems than those who had received rehabilitation services as the usual care. Furthermore, the therapeutic effects lasted for at least 3 to 6 months postintervention.27,28,30,31 In a structural equation model of our recent study, a significant association between the parents’ PF and their child’s asthma morbidity was found,32 implying that children with asthma may achieve better health outcomes if their parents become more psychologically flexible in managing their child’s asthma conditions.
In this present study, an RCT was employed to examine the efficacy of a parental training program using ACT integrated with asthma education on the health outcomes of parent-child dyads in comparison with the usual care of an asthma education talk. We hypothesized that children whose parents had received ACT plus asthma education would use fewer health care services because of asthma exacerbations and exhibit fewer asthma symptoms at 6 months postintervention when compared with those whose parents had received asthma education only. We also hypothesized that parents who had received additional ACT training would be more psychologically flexible, exhibit better psychological adjustment to their child’s illness, report fewer psychological symptoms (ie, anxiety, depression, and stress), and perform better in asthma care (ie, knowledge, self-efficacy, quality of life).
Methods
Settings and Participants
The study was conducted in 2 pediatric respiratory outpatient clinics of a public hospital in Hong Kong (see Supplemental Information). Ethical approval for the study was obtained from the New Territories East Cluster Clinical Research Ethics Committee and The Hong Kong Polytechnic University. This trial has been registered at www.clinicaltrials.gov (identifier NCT02405962).
Parent-child dyads who fulfilled the following eligibility criteria were recruited: the parent should be either the father or mother (18–65 years of age) of the child with asthma, the primary caregiver of a child with asthma, living together with the index child, able to communicate in Cantonese, a Hong Kong permanent resident who planned to stay in Hong Kong for at least 6 months, and accessible by phone or mail. The child of such a parent should be 3 to 12 years old and have received a physician’s diagnosis of asthma (International Classification Diseases, 10th Revision codes J45 and J46) as documented in the electronic medical records. Those parents and/or their children who were currently participating in another asthma-related interventional study were excluded. Also excluded were children who had been diagnosed with congenital problems, oxygen-dependent conditions, autism, epilepsy, attention-deficit/hyperactivity disorders, Down syndrome, cerebral palsy, or psychomotor retardation. This was because the coexistence of asthma with complicated morbidities has a significant impact on the health outcomes of children.33,34
Sample Size Estimation
We referred to the findings of other RCTs examining the efficacy of ACT for parents of children with chronic diseases for improving their child’s health outcomes when compared with the usual care.27,30,35 The effect sizes (ESs) of those trials ranged from 0.47 to 1.33. Using G*Power version 3.1.9.2 statistical software,36 considering the smallest ES (0.47), 2-tailed tests of significance, and an attrition rate of 10%, it was determined that a total of 160 participants, with 80 in each group, was required for a power of 80% and a maximum error of 5% according to an independent-samples t test.
Recruitment
Consecutive sampling was employed. The first author (Y-y. C.) screened the list of children who had appointments in the clinics and identified those children who met the eligibility criteria of this study. Next, for every eligible child who attended the clinic with his or her accompanying parent, Y-y. C. or an advanced practice nurse screened the parent for eligibility through face-to-face interviews. The first author explained the study to the parents, obtained their written consent to participate, and enrolled them in the trial.
Randomization and Allocation Concealment
Randomization in permuted blocks of 6 was conducted through a computer-generated list (www.randomizer.org) by using sequentially numbered, opaque, and sealed envelopes, which were prepared and kept by a nursing student with no other involvement in this study. The envelopes were opened only after the parents had completed the baseline assessments and provided written consent. The nurses in the clinics collected the questionnaires, which were self-administered by the parents. A research assistant entered the data. Neither the nurses nor the research assistant was told about the random assignment of the parents to treatment conditions.
Treatment Conditions
Parents in the control group received a 2-hour asthma education talk, which was the usual care, conducted by an advanced practice nurse from the clinics. Following the Global Initiative for Asthma guidelines,1 the talk was focused on teaching parents about monitoring asthma symptoms, using medications, and managing asthma attacks. To ensure the equivalency of the assigned sessions between groups and to approximate the usual care that the parents ordinarily received in the clinics, the parents received in addition 3 weekly telephone calls of 15 minutes each. One registered nurse from the clinics, who was not involved in the data collection process, invited the parents to report their child’s asthma conditions over the past week.
Parents in the ACT group received 4 weekly sessions of group-based ACT integrated with asthma education. There is evidence that ACT in brief interventions (eg, <5 sessions) is more efficacious than the usual care, with medium-to-large within-group ESs on the physical health conditions of individuals with chronic diseases (eg, diabetes, epilepsy).24 A group-based approach helps to normalize a problem37 and leads to peer support in coping with psychological difficulties.38
The ACT intervention was delivered according to an intervention protocol. This protocol was modified on the basis of ACT training manuals used in previous studies,39,–41 which demonstrated positive effects for parents of children with anorexia nervosa,42,43 acquired brain injuries,28,44 and chronic pain.35,45 These are diseases in which the chronicity and the complexity of care are similar to those of childhood asthma. The protocol of the current study was modified on the basis of findings from interviews with Hong Kong Chinese parents of children who had been diagnosed with asthma. These interviews were conducted to explore the caregiving difficulties of these parents,6 with the aim of devising intervention materials that would be more relevant to the parents’ child care experiences. The protocol was reviewed by a team of experts in ACT and in childhood asthma. The reviewed protocol was then pilot tested on a sample of 11 parents of children with asthma who had been recruited from a community setting. In the pilot study, much improvement was found in the parents’ PF after the ACT training when compared with the baseline (mean difference = 5.73; test-retest reliability coefficient r = 0.55).
In this study, for each session (2 hours), a group of 6 to 8 parents received 90 minutes of ACT followed by 30 minutes of asthma education, the content of which was identical to that delivered to the control group. In each ACT session, multiple activities were conducted to foster parental PF. These included mindfulness exercises to guide the parents in observing painful emotions that they were attempting to avoid when managing asthma and experiential exercises, such as the metaphor of tug-of-war with a monster, so that parents would realize that struggling with psychological distress creates more distress. We also facilitated the parents in reflecting on whether their asthma management and parenting strategies were moving toward or away from their values and in establishing values-based action plans. At the end of each session, parents received a handout on ACT and asthma educational materials (Table 1).
Session Outline
| Theme | Components of ACT | Components of Asthma Education | ||
|---|---|---|---|---|
| Objective(s) | Key Activities | Objective(s) | Content | |
| Session 1: welcome and introduction; creative hopelessness | To discover the long-term cost of struggling with psychological difficulties in childhood asthma care (awareness) | Obtain informed consent, build rapport, open the session with a brief exercise on mindful body sensations; use a mindfulness exercise to allow parents to review the challenges involved in managing their child’s asthma conditions and discuss the long-term workability of using various coping strategies; use of an ACT metaphor, “a man in a hole” metaphor, to help parents to review the impact of psychological difficulties (eg, fear, worry, guilt) on their own health and that of their child; give homework on the mindful parenting of a child with asthma | To provide an overview of asthma in young children | Prevalence of childhood asthma in Hong Kong; basic etiology of asthma; types of asthma triggers |
| Session 2: watch you thinking and explore acceptance | To explore acceptance of psychological difficulties as an alternative to avoidance coping (awareness and acceptance) | Open the session with a brief exercise on mindful body sensations; review homework by using defusion exercises to help parents to detach from an unhelpful self-evaluation that could lead to psychological barriers to caring for their child; use of ACT metaphors, including the tug-of-war and the “passengers on the bus” metaphor, to help parents to accept psychological difficulties nonjudgmentally while working toward values that will promote favorable health outcomes for their child; give homework on mindful parenting by practicing acceptance of psychological difficulties related to caring for a child with asthma | To teach parents about the strategies for monitoring and preventing asthma symptoms | Asthma signs and symptoms; monitoring asthma symptoms; trigger avoidance in asthma; demonstration of the correct ways of using peak flow meters |
| Session 3: be here and now, your observing self, and clarify values | To develop a sense of self as an observer and to explore personally held values as a parent of a child with asthma (awareness and commitment to values-based actions) | Open the session with a brief exercise on mindful body sensations; use the “eyes-on” exercise to encourage parents to experience compassion even in the presence of discomfort; use the “storyline exercise” to help parents to develop a sense of self as an observer by taking note of the life experiences of other parents from different perspectives; use a mindfulness exercise to guide parents in recalling experiences of getting along with the most unforgettable person in their life in relation to their values in caring for their child; give homework to parents to set up their values-based action plan in caring for their child | To teach parents about the use of asthma medications | Differences between controllers (ie, ICS) and relievers (ie, short-acting bronchodilators), the potential side effects of asthma medications; demonstration of the correct ways of using inhalers with different types of aerochambers, the after care of using aerochambers |
| Session 4: commit your value-based action | To make short-term and long-term values-based action plans to improve the management of childhood asthma | Open the session with a brief exercise on mindful body sensations; review their homework by using “The Stand and Commit exercise” to help parents declare their values and explore whether actions relating to managing childhood asthma can move them toward or away from those values | To teach parents about the management of childhood asthma attacks | Management of asthma attacks; use of an asthma action plan |
| Theme | Components of ACT | Components of Asthma Education | ||
|---|---|---|---|---|
| Objective(s) | Key Activities | Objective(s) | Content | |
| Session 1: welcome and introduction; creative hopelessness | To discover the long-term cost of struggling with psychological difficulties in childhood asthma care (awareness) | Obtain informed consent, build rapport, open the session with a brief exercise on mindful body sensations; use a mindfulness exercise to allow parents to review the challenges involved in managing their child’s asthma conditions and discuss the long-term workability of using various coping strategies; use of an ACT metaphor, “a man in a hole” metaphor, to help parents to review the impact of psychological difficulties (eg, fear, worry, guilt) on their own health and that of their child; give homework on the mindful parenting of a child with asthma | To provide an overview of asthma in young children | Prevalence of childhood asthma in Hong Kong; basic etiology of asthma; types of asthma triggers |
| Session 2: watch you thinking and explore acceptance | To explore acceptance of psychological difficulties as an alternative to avoidance coping (awareness and acceptance) | Open the session with a brief exercise on mindful body sensations; review homework by using defusion exercises to help parents to detach from an unhelpful self-evaluation that could lead to psychological barriers to caring for their child; use of ACT metaphors, including the tug-of-war and the “passengers on the bus” metaphor, to help parents to accept psychological difficulties nonjudgmentally while working toward values that will promote favorable health outcomes for their child; give homework on mindful parenting by practicing acceptance of psychological difficulties related to caring for a child with asthma | To teach parents about the strategies for monitoring and preventing asthma symptoms | Asthma signs and symptoms; monitoring asthma symptoms; trigger avoidance in asthma; demonstration of the correct ways of using peak flow meters |
| Session 3: be here and now, your observing self, and clarify values | To develop a sense of self as an observer and to explore personally held values as a parent of a child with asthma (awareness and commitment to values-based actions) | Open the session with a brief exercise on mindful body sensations; use the “eyes-on” exercise to encourage parents to experience compassion even in the presence of discomfort; use the “storyline exercise” to help parents to develop a sense of self as an observer by taking note of the life experiences of other parents from different perspectives; use a mindfulness exercise to guide parents in recalling experiences of getting along with the most unforgettable person in their life in relation to their values in caring for their child; give homework to parents to set up their values-based action plan in caring for their child | To teach parents about the use of asthma medications | Differences between controllers (ie, ICS) and relievers (ie, short-acting bronchodilators), the potential side effects of asthma medications; demonstration of the correct ways of using inhalers with different types of aerochambers, the after care of using aerochambers |
| Session 4: commit your value-based action | To make short-term and long-term values-based action plans to improve the management of childhood asthma | Open the session with a brief exercise on mindful body sensations; review their homework by using “The Stand and Commit exercise” to help parents declare their values and explore whether actions relating to managing childhood asthma can move them toward or away from those values | To teach parents about the management of childhood asthma attacks | Management of asthma attacks; use of an asthma action plan |
Treatment Fidelity
Y-y. C. was the interventionist. She is a registered nurse with experience in patient counseling and pediatric care. She had also received a total of 5 days of training in ACT skills. Throughout the study, her ACT skills were supervised by the corresponding author, an ACT researcher (Y-w. M.), and a psychologist. The interventionist completed a behavioral checklist40 to rate her competence in delivering ACT after each session. All sessions in the ACT group were videotaped after obtaining written consent from the parents. The videotaped ACT sessions were first reviewed independently by Y-w. M. to assess Y-y. C.’s competence and adherence to the protocol. During weekly meetings, Y-y. C. briefed Y-w. M. about anything noteworthy. Y-y.C.’s therapeutic stance and competence in delivering the ACT were mostly rated as being “sometimes true” (score 4) to “frequently true” (score 5), indicating that the intervention that was delivered was consistent with the principles of ACT most of the time.
Child Measures
We assessed the frequency of emergency department (ED) visits (primary outcome), unscheduled visits to general outpatient clinics, private practitioners’ clinics, hospital admissions, and the number of days of stay in the hospital due to asthma exacerbations in children over the past 6 months at baseline and at 6 months after the completion of the intervention. The parents conducted assessments by completing a set of self-administered, structured questionnaires when they accompanied their children for regular visits to the clinic. Follow-up sessions at the clinics are often arranged once every 3 months for children who have been diagnosed with asthma. The question items were retrieved from the consensus reports published by the National Institutes of Health in the United States.46,47 During their visits, we also invited the parents to report their child’s asthma symptoms over the past 4 weeks at baseline and at 3 and 6 months postintervention in the questionnaire. As recommended by the Global Initiative for Asthma,1 the average number of days with asthma symptoms, nights awakening due to asthma symptoms, days with activity limitations due to asthma symptoms, and days requiring inhaled bronchodilators to relieve asthma symptoms per week were assessed (see Supplemental Tables 6 and 7).
Parental Measures
We assessed the following parental outcomes at baseline, postintervention, and at 6 months postintervention: PF via the Acceptance and Action Questionnaire-II,48 psychological adjustment to the child’s illness via the Parent Experience of Child Illness (PECI) scale,49,50 psychological symptoms via the Depression Anxiety Stress Scale-21 (DASS-21),51 asthma knowledge via the Asthma Knowledge Questionnaire (AKQ),52 asthma management self-efficacy via the Parent Asthma Management Self-Efficacy Scale (PAMSES),53 and quality of life via the Pediatric Asthma Caregiver’s Quality of Life Questionnaire (PACQL)54 (see Supplemental Information). All of the items in these instruments were demonstrated to have acceptable internal consistency (Cronbach’s α [α] = 0.74 to 0.90) and a moderate level of stability (intraclass correlation coefficient = 0.76 to 1.00) over 2 weeks in our pilot sample of 49 parents of children with asthma recruited in the study hospital. At baseline and at 6 months postintervention, parents in both groups completed the questionnaires during their regular visits to the clinic. At postintervention, parents in the ACT group completed the questionnaires at the end of the fourth session, whereas those in the control group were assessed through telephone interviews by a trained research assistant using the questionnaire.
Baseline Measures
Before random assignment, parents reported their child’s demographic and asthma-related clinical information, their sociodemographic data, and their personal and family members’ history of asthma in the questionnaires.
Statistical Analyses
The collected data were entered and analyzed via SPSS (version 23.0; IBM SPSS Statistics, IBM Corporation) statistical software. P < .05 (2 tailed) was considered significant. We examined any group differences using χ2 tests, Fisher’s exact tests, independent-sample t tests, or McNemar tests (as appropriate) for all randomly assigned participants assessed at baseline, those who had not attended the sessions after randomization, and those who were lost to follow-up (if any).
Following intention-to-treat principles, in attempting to minimize the missing data, we followed-up on the trial participants, even on those who had not adhered to the allocated intervention.55 We examined the effect of the intervention on each outcome between groups over time using generalized estimating equations56 (GEEs) with the first-order autoregressive working correlation structure, taking into account the extra covariance between repeated measurements with increased spacing across time.57,58 Given that no missing data were found in any of the variables measured at baseline, the proportion of missing data per variable during the follow-up period was small (0%–3.6%), and the missing data mechanism was applied completely at random (χ2 = 63.61; degrees of freedom = 234; P = .99). Therefore, we used standard GEE models, which allow missing data to be modeled by making use of all available data55 without the need to use imputations to replace missing data.59
For child health outcomes (asthma-related events and asthma symptoms, count data), GEE models used to specify a log-link function and a Poisson distribution were used to estimate the incidence rate ratios (IRRs) and 95% confidence intervals (CIs). The analyses were adjusted for the parent’s relationship with the child, the parent’s age, monthly household income, marital status, the child’s age, the child’s sex, types of inhaled corticosteroids (ICSs),1 and the season of enrollment.60 For parental outcomes (continuous data), GEE models used to specify a normal distribution with a linear response scale were employed to estimate the effects of the intervention, adjusted for the parents’ age, relationship with the child, marital status, educational level, and monthly household income.7 Post hoc comparisons were then conducted to examine whether there were any significant between-group differences based on the estimated marginal means derived from the GEE models.
Results
Characteristics of the Participants
We screened 1727 appointments made in the pediatric clinics between January 6 and May 26, 2016. Of the 302 parent-child dyads who were identified as eligible and invited to participate in the study, 168 were enrolled and randomly allocated to either the control group (n = 84) or the ACT group (n = 84) (Fig 1). The sociodemographic characteristics of the parent-child dyads and the parent and child measures at baseline were similar between groups (P values range from .073 to .968). The parents were mainly mothers (88%). About one-tenth of them reported moderate levels of depressive symptoms (8%), stress symptoms (11%), or anxiety symptoms (17%). Their children (60% boys; age mean = 6.8) experienced at least 1 day with asthma symptoms per week, and around 40% had visited EDs because of asthma over the past 6 months (Table 2).
The Consolidated Standards of Reporting Trials diagram used to indicate the flow of participants.
The Consolidated Standards of Reporting Trials diagram used to indicate the flow of participants.
Baseline Characteristics of the Parents and Their Children by Group Assignment
| Total (N = 168) | ACT Group (n = 84) | Control Group (n = 84) | |
|---|---|---|---|
| Parents’ characteristics | |||
| Relationship with the child, n (%) | |||
| Father | 20 (12) | 8 (10) | 12 (14) |
| Mother | 148 (88) | 76 (90) | 72 (86) |
| Age, mean (SD), y | 38.40 (5.90) | 37.74 (5.55) | 39.07 (6.19) |
| Educational attainment, n (%) | |||
| Primary education or below | 9 (5) | 4 (5) | 5 (6) |
| Secondary education | 123 (73) | 58 (69) | 65 (77) |
| Tertiary education or above | 36 (21) | 22 (26) | 14 (17) |
| Monthly household income (HKD),a $, n (%) | |||
| <10 000 | 25 (15) | 10 (12) | 15 (18) |
| 10 000–25 000 | 45 (27) | 18 (21) | 27 (32) |
| 25 001–50 000 | 88 (52) | 51 (61) | 37 (44) |
| >50 000 | 10 (6) | 5 (6) | 5 (6) |
| Marital status, n (%) | |||
| Single, separated, divorced, or widowed | 23 (14) | 11 (13.1) | 12 (14.3) |
| Married | 145 (86) | 73 (86.9) | 72 (85.7) |
| PF (AAQ-II; range: 7–49), mean (SD) | 19.88 (8.64) | 20.90 (8.14) | 18.86 (9.04) |
| Psychological adjustment to the child’s asthma (PECI subscales; range: 0–4), mean (SD) | |||
| Guilt and worry | 1.55 (0.67) | 1.62 (0.67) | 1.47 (0.66) |
| Unresolved sorrow and anger | 1.16 (0.60) | 1.23 (0.64) | 1.10 (0.57) |
| Long-term uncertainty | 1.13 (0.77) | 1.21 (0.79) | 1.05 (0.74) |
| Emotional resources | 2.32 (0.85) | 2.21 (0.81) | 2.43 (0.88) |
| Psychological symptoms | |||
| DASS-21 for depressionb: range, n (%) | |||
| Normal: 0–9 | 134 (80) | 67 (80) | 67 (80) |
| Mild: 10–13 | 14 (8) | 8 (10) | 6 (7) |
| Moderate: 14–20 | 14 (8) | 5 (6) | 9 (11) |
| Severe: 21–27 | 5 (3) | 3 (4) | 2 (2) |
| Extremely severe: ≥28 | 1 (1) | 1 (1) | 0 (0) |
| DASS-21 for anxietyb: range, n (%) | |||
| Normal: 0–7 | 116 (69) | 56 (67) | 60 (71) |
| Mild: 8–9 | 13 (8) | 8 (10) | 5 (6) |
| Moderate: 10–14 | 28 (17) | 13 (16) | 15 (18) |
| Severe: 15–19 | 5 (3) | 3 (4) | 2 (2) |
| Extremely severe: ≥20 | 6 (4) | 4 (5) | 2 (2) |
| DASS-21 for stressb: range, n (%) | |||
| Normal: 0–14 | 126 (75) | 61 (73) | 65 (77) |
| Mild: 15–18 | 13 (8) | 6 (7) | 7 (8) |
| Moderate: 19–25 | 19 (11) | 11 (13) | 8 (10) |
| Severe: 26–33 | 10 (6) | 6 (7) | 4 (5) |
| Asthma knowledge (AKQ; range: 0–25), n (%) | 18.31 (2.47) | 18.31 (2.36) | 18.31 (2.59) |
| Asthma management self-efficacy (PAMSES subscales; range: 1–5), mean (SD) | |||
| Total score | 3.51 (0.78) | 3.46 (0.81) | 3.56 (0.74) |
| Attack prevention | 3.82 (0.75) | 3.81 (0.81) | 3.82 (0.69) |
| Attack management | 3.25 (0.94) | 3.16 (0.89) | 3.33 (0.90) |
| Quality of life (PACQL subscales; range: 1–7), mean (SD) | |||
| Total score | 4.72 (1.20) | 4.58 (1.21) | 4.85 (1.17) |
| Emotional function | 4.74 (1.24) | 4.60 (1.28) | 4.88 (1.19) |
| Activity limitation | 4.66 (1.27) | 4.53 (1.27) | 4.79 (1.27) |
| Children’s characteristics | |||
| Sex, n (%) | |||
| Male | 103 (61) | 51 (61) | 52 (62) |
| Female | 65 (39) | 33 (39) | 32 (38) |
| Child’s age, mean (SD), y | 6.81 (2.50) | 6.67 (2.55) | 6.95 (2.46) |
| Child’s age at diagnosis of asthma, mean (SD), y | 3.46 (1.79) | 3.31 (1.70) | 3.61 (1.88) |
| Current use of oral montelukast as a prophylaxis, n (%) | |||
| Yes | 24 (14) | 11 (13) | 13 (15) |
| No | 144 (86) | 73 (87) | 71 (85) |
| Current use of ICS as a prophylaxis, by types, n (%) | |||
| None | 80 (48) | 47 (56) | 33 (39) |
| Beclomethasone dipropionate | 81 (48) | 35 (42) | 46 (55) |
| Fluticasone propionate | 5 (3) | 1 (1) | 4 (5) |
| Fluticasone propionate and salmeterol | 2 (1) | 1 (1) | 1 (1) |
| One or more course(s) of oral prednisolone taken in the past y because of asthma exacerbation(s), n (%) | |||
| Yes | 94(56) | 50 (60) | 44 (52) |
| No | 74(44) | 34 (40) | 40 (48) |
| Asthma symptoms in the past 4 wk, mean (SD) | |||
| Daytime symptoms per wk | 1.27 (1.82) | 1.48 (1.98) | 1.05 (1.64) |
| Nighttime awakening due to asthma symptoms per wk | 0.96 (1.52) | 0.84 (1.44) | 1.07 (1.60) |
| Days required to use inhaled bronchodilators to relieve asthma symptoms per wk | 1.33 (1.93) | 1.31 (1.79) | 1.35 (2.07) |
| Days with activity limitation due to asthma symptoms per wk | 0.61 (1.34) | 0.60 (1.40) | 0.62 (1.29) |
| Total No. emergency care visit(s) due to asthma exacerbation(s) in the past 6 mo, n (%) | |||
| 0 times | 103 (61) | 49 (58) | 54 (64) |
| 1–2 times | 55 (33) | 29 (35) | 26 (31) |
| 3–4 times | 8 (5) | 5 (6) | 3 (4) |
| ≥5 times | 2 (1) | 1 (1) | 1 (1) |
| Total No. hospital admission(s) due to asthma exacerbation(s) in the past 6 mo, n (%) | |||
| 0 times | 127 (76) | 60 (71) | 67 (80) |
| 1–2 times | 38 (22) | 22 (26) | 16 (19) |
| 3–4 times | 3 (2) | 2 (2) | 1 (1) |
| Total (N = 168) | ACT Group (n = 84) | Control Group (n = 84) | |
|---|---|---|---|
| Parents’ characteristics | |||
| Relationship with the child, n (%) | |||
| Father | 20 (12) | 8 (10) | 12 (14) |
| Mother | 148 (88) | 76 (90) | 72 (86) |
| Age, mean (SD), y | 38.40 (5.90) | 37.74 (5.55) | 39.07 (6.19) |
| Educational attainment, n (%) | |||
| Primary education or below | 9 (5) | 4 (5) | 5 (6) |
| Secondary education | 123 (73) | 58 (69) | 65 (77) |
| Tertiary education or above | 36 (21) | 22 (26) | 14 (17) |
| Monthly household income (HKD),a $, n (%) | |||
| <10 000 | 25 (15) | 10 (12) | 15 (18) |
| 10 000–25 000 | 45 (27) | 18 (21) | 27 (32) |
| 25 001–50 000 | 88 (52) | 51 (61) | 37 (44) |
| >50 000 | 10 (6) | 5 (6) | 5 (6) |
| Marital status, n (%) | |||
| Single, separated, divorced, or widowed | 23 (14) | 11 (13.1) | 12 (14.3) |
| Married | 145 (86) | 73 (86.9) | 72 (85.7) |
| PF (AAQ-II; range: 7–49), mean (SD) | 19.88 (8.64) | 20.90 (8.14) | 18.86 (9.04) |
| Psychological adjustment to the child’s asthma (PECI subscales; range: 0–4), mean (SD) | |||
| Guilt and worry | 1.55 (0.67) | 1.62 (0.67) | 1.47 (0.66) |
| Unresolved sorrow and anger | 1.16 (0.60) | 1.23 (0.64) | 1.10 (0.57) |
| Long-term uncertainty | 1.13 (0.77) | 1.21 (0.79) | 1.05 (0.74) |
| Emotional resources | 2.32 (0.85) | 2.21 (0.81) | 2.43 (0.88) |
| Psychological symptoms | |||
| DASS-21 for depressionb: range, n (%) | |||
| Normal: 0–9 | 134 (80) | 67 (80) | 67 (80) |
| Mild: 10–13 | 14 (8) | 8 (10) | 6 (7) |
| Moderate: 14–20 | 14 (8) | 5 (6) | 9 (11) |
| Severe: 21–27 | 5 (3) | 3 (4) | 2 (2) |
| Extremely severe: ≥28 | 1 (1) | 1 (1) | 0 (0) |
| DASS-21 for anxietyb: range, n (%) | |||
| Normal: 0–7 | 116 (69) | 56 (67) | 60 (71) |
| Mild: 8–9 | 13 (8) | 8 (10) | 5 (6) |
| Moderate: 10–14 | 28 (17) | 13 (16) | 15 (18) |
| Severe: 15–19 | 5 (3) | 3 (4) | 2 (2) |
| Extremely severe: ≥20 | 6 (4) | 4 (5) | 2 (2) |
| DASS-21 for stressb: range, n (%) | |||
| Normal: 0–14 | 126 (75) | 61 (73) | 65 (77) |
| Mild: 15–18 | 13 (8) | 6 (7) | 7 (8) |
| Moderate: 19–25 | 19 (11) | 11 (13) | 8 (10) |
| Severe: 26–33 | 10 (6) | 6 (7) | 4 (5) |
| Asthma knowledge (AKQ; range: 0–25), n (%) | 18.31 (2.47) | 18.31 (2.36) | 18.31 (2.59) |
| Asthma management self-efficacy (PAMSES subscales; range: 1–5), mean (SD) | |||
| Total score | 3.51 (0.78) | 3.46 (0.81) | 3.56 (0.74) |
| Attack prevention | 3.82 (0.75) | 3.81 (0.81) | 3.82 (0.69) |
| Attack management | 3.25 (0.94) | 3.16 (0.89) | 3.33 (0.90) |
| Quality of life (PACQL subscales; range: 1–7), mean (SD) | |||
| Total score | 4.72 (1.20) | 4.58 (1.21) | 4.85 (1.17) |
| Emotional function | 4.74 (1.24) | 4.60 (1.28) | 4.88 (1.19) |
| Activity limitation | 4.66 (1.27) | 4.53 (1.27) | 4.79 (1.27) |
| Children’s characteristics | |||
| Sex, n (%) | |||
| Male | 103 (61) | 51 (61) | 52 (62) |
| Female | 65 (39) | 33 (39) | 32 (38) |
| Child’s age, mean (SD), y | 6.81 (2.50) | 6.67 (2.55) | 6.95 (2.46) |
| Child’s age at diagnosis of asthma, mean (SD), y | 3.46 (1.79) | 3.31 (1.70) | 3.61 (1.88) |
| Current use of oral montelukast as a prophylaxis, n (%) | |||
| Yes | 24 (14) | 11 (13) | 13 (15) |
| No | 144 (86) | 73 (87) | 71 (85) |
| Current use of ICS as a prophylaxis, by types, n (%) | |||
| None | 80 (48) | 47 (56) | 33 (39) |
| Beclomethasone dipropionate | 81 (48) | 35 (42) | 46 (55) |
| Fluticasone propionate | 5 (3) | 1 (1) | 4 (5) |
| Fluticasone propionate and salmeterol | 2 (1) | 1 (1) | 1 (1) |
| One or more course(s) of oral prednisolone taken in the past y because of asthma exacerbation(s), n (%) | |||
| Yes | 94(56) | 50 (60) | 44 (52) |
| No | 74(44) | 34 (40) | 40 (48) |
| Asthma symptoms in the past 4 wk, mean (SD) | |||
| Daytime symptoms per wk | 1.27 (1.82) | 1.48 (1.98) | 1.05 (1.64) |
| Nighttime awakening due to asthma symptoms per wk | 0.96 (1.52) | 0.84 (1.44) | 1.07 (1.60) |
| Days required to use inhaled bronchodilators to relieve asthma symptoms per wk | 1.33 (1.93) | 1.31 (1.79) | 1.35 (2.07) |
| Days with activity limitation due to asthma symptoms per wk | 0.61 (1.34) | 0.60 (1.40) | 0.62 (1.29) |
| Total No. emergency care visit(s) due to asthma exacerbation(s) in the past 6 mo, n (%) | |||
| 0 times | 103 (61) | 49 (58) | 54 (64) |
| 1–2 times | 55 (33) | 29 (35) | 26 (31) |
| 3–4 times | 8 (5) | 5 (6) | 3 (4) |
| ≥5 times | 2 (1) | 1 (1) | 1 (1) |
| Total No. hospital admission(s) due to asthma exacerbation(s) in the past 6 mo, n (%) | |||
| 0 times | 127 (76) | 60 (71) | 67 (80) |
| 1–2 times | 38 (22) | 22 (26) | 16 (19) |
| 3–4 times | 3 (2) | 2 (2) | 1 (1) |
AAQ-II, Acceptance and Action Questionnaire-II; HKD, Hong Kong dollar (1 US dollar = 7.8 HKD); N, total number of participants; n, number of participants per group.
According to the Quarterly Report on the General Household Survey conducted in Hong Kong from January to March 2016, the median monthly household income for an average-sized household of 2.9 (a Hong Kong couple with a child) was ∼$25 000 HKD.
To yield equivalent scores to the full Depression Anxiety Stress Scale-42, the subscale scores of the DASS-21 depression, anxiety, and stress subscales were multiplied by 2, with the possible range of score as 0–42.
Of those 168 randomly assigned parents, 19% (15 in ACT; 16 in control) provided baseline information but did not attend any of the intervention sessions. No significant differences between groups were noted in the characteristics of these parents and their children (P values range from .131 to .921). Six participants (1 in ACT; 5 in control; 3.6% attrition) were lost to follow-up, mainly because of work and/or family commitments (Fig 1).
Child Health Outcomes
The effects of interventions on the use of unscheduled health care services due to asthma exacerbations over a 6-month follow-up period, measured at 6 months postintervention, are summarized in Table 3. When compared with the control group, children whose parents were in the ACT group had significantly fewer visits to the ED (adjusted IRR = 0.20; 95% CI [0.08 to 0.53]; P = .001) and fewer visits to private practitioners’ clinics (adjusted IRR = 0.47; 95% CI [0.26 to 0.85]; P = .012). No significant differences were found in visits to general outpatient clinics (P = .063) and hospital admissions due to a child’s asthma exacerbations (P = .327). In addition, these children experienced fewer days and nights with asthma symptoms (P < .001) (Table 4).
Effects of the Intervention on the Child’s Use of Unscheduled Health Care Services Due to Asthma Exacerbations Over the Past 6 Months by Groups Across Time Using GEEs
| Measures | Mean (SE) | Tests of Adjusted GEE Model Effectsa | Adjusted IRR at 6MFUa | ||||
|---|---|---|---|---|---|---|---|
| Baseline | 6MFU | Time Effect P | Group Effect P | Time-by-Group Effect P | Exponential β (95% CI) | P | |
| ED visit(s) | — | — | <.001 | .002 | .004 | .20 (0.08 to 0.53) | .001 |
| ACT group | 0.69 (0.12) | 0.08 (0.04) | — | — | — | — | — |
| Control group | 0.65 (0.12) | 0.38 (0.11) | — | — | — | — | — |
| GOPC visit(s) | — | — | <.001 | .502 | .008 | .31 (0.09 to 1.07) | .063 |
| ACT group | 0.46 (0.15) | 0.05 (0.02) | — | — | — | — | — |
| Control group | 0.31 (0.11) | 0.18 (0.06) | — | — | — | — | — |
| Private practitioners’ clinic visit(s) | — | — | <.001 | .150 | .013 | .47 (0.26 to 0.85) | .012 |
| ACT group | 1.29 (0.25) | 0.40 (0.09) | — | — | — | — | — |
| Control group | 1.21 (0.28) | 0.85 (0.14) | — | — | — | — | — |
| Hospital admission(s) | — | — | <.001 | .424 | .310 | .47 (0.10 to 2.15) | .327 |
| ACT group | 0.38 (0.08) | 0.04 (0.02) | — | — | — | — | — |
| Control group | 0.30 (0.08) | 0.06 (0.03) | — | — | — | — | — |
| Total number of hospital daysb | — | — | .310 | .617 | .747 | .97 (0.57 to 1.67) | .921 |
| ACT group | 3.79 (0.39) | 3.67 (0.72) | — | — | — | — | — |
| Control group | 4.41 (0.49) | 3.75 (0.42) | — | — | — | — | — |
| Measures | Mean (SE) | Tests of Adjusted GEE Model Effectsa | Adjusted IRR at 6MFUa | ||||
|---|---|---|---|---|---|---|---|
| Baseline | 6MFU | Time Effect P | Group Effect P | Time-by-Group Effect P | Exponential β (95% CI) | P | |
| ED visit(s) | — | — | <.001 | .002 | .004 | .20 (0.08 to 0.53) | .001 |
| ACT group | 0.69 (0.12) | 0.08 (0.04) | — | — | — | — | — |
| Control group | 0.65 (0.12) | 0.38 (0.11) | — | — | — | — | — |
| GOPC visit(s) | — | — | <.001 | .502 | .008 | .31 (0.09 to 1.07) | .063 |
| ACT group | 0.46 (0.15) | 0.05 (0.02) | — | — | — | — | — |
| Control group | 0.31 (0.11) | 0.18 (0.06) | — | — | — | — | — |
| Private practitioners’ clinic visit(s) | — | — | <.001 | .150 | .013 | .47 (0.26 to 0.85) | .012 |
| ACT group | 1.29 (0.25) | 0.40 (0.09) | — | — | — | — | — |
| Control group | 1.21 (0.28) | 0.85 (0.14) | — | — | — | — | — |
| Hospital admission(s) | — | — | <.001 | .424 | .310 | .47 (0.10 to 2.15) | .327 |
| ACT group | 0.38 (0.08) | 0.04 (0.02) | — | — | — | — | — |
| Control group | 0.30 (0.08) | 0.06 (0.03) | — | — | — | — | — |
| Total number of hospital daysb | — | — | .310 | .617 | .747 | .97 (0.57 to 1.67) | .921 |
| ACT group | 3.79 (0.39) | 3.67 (0.72) | — | — | — | — | — |
| Control group | 4.41 (0.49) | 3.75 (0.42) | — | — | — | — | — |
6MFU, 6-mo follow-up after the intervention; GOPC, general outpatient clinics; —, not applicable.
Adjusted for parent’s relationship with the child, parent’s age, monthly household income, marital status, child’s age, child’s sex, types of ICSs used, and season of enrollment.
For those children who had been hospitalized because of asthma exacerbations only (n = 7; 3 in ACT group; 4 in Control group).
Effects of the Intervention on the Child’s Asthma Symptoms Over the Past 4 Weeks by Groups Across Time Using GEEs
| Measures | Mean (SE) | Tests of Adjusted GEE Model Effectsa | Adjusted IRR at 6MFUa | |||||
|---|---|---|---|---|---|---|---|---|
| Baseline | 3MFU | 6MFU | Time Effect P | Group Effect P | Time-by-Group Effect P | Exponential β (95% CI) | P | |
| Day symptomsb | — | — | — | .681 | .005 | <.001 | .25 (0.15 to 0.43) | <.001 |
| ACT group | 1.48 (0.21) | 0.86 (0.17) | 0.58 (0.15) | — | — | — | — | — |
| Control group | 1.05 (0.18) | 1.42 (0.21) | 2.30 (0.22) | — | — | — | — | — |
| Night symptomsc | — | — | — | .700 | <.001 | .011 | .30 (0.18 to 0.50) | <.001 |
| ACT group | 0.84 (0.15) | 0.65 (0.15) | 0.55 (0.13) | — | — | — | — | — |
| Control group | 1.07 (0.17) | 1.22 (0.19) | 1.89 (0.23) | — | — | — | — | — |
| Reliever used | — | — | — | .037 | .010 | .005 | .36 (0.21 to 0.65) | .001 |
| ACT group | 1.31 (0.19) | 0.70 (0.18) | 0.59 (0.15) | — | — | — | — | — |
| Control group | 1.35 (0.23) | 1.13 (0.22) | 1.62 (0.22) | — | — | — | — | — |
| Activity limitatione | — | — | — | .004 | <.001 | .001 | .20 (0.09 to 0.47) | <.001 |
| ACT group | 0.60 (0.15) | 0.12 (0.05) | 0.17 (0.07) | — | — | — | — | — |
| Control group | 0.62 (0.14) | 0.44 (0.13) | 0.84 (0.16) | — | — | — | — | — |
| Measures | Mean (SE) | Tests of Adjusted GEE Model Effectsa | Adjusted IRR at 6MFUa | |||||
|---|---|---|---|---|---|---|---|---|
| Baseline | 3MFU | 6MFU | Time Effect P | Group Effect P | Time-by-Group Effect P | Exponential β (95% CI) | P | |
| Day symptomsb | — | — | — | .681 | .005 | <.001 | .25 (0.15 to 0.43) | <.001 |
| ACT group | 1.48 (0.21) | 0.86 (0.17) | 0.58 (0.15) | — | — | — | — | — |
| Control group | 1.05 (0.18) | 1.42 (0.21) | 2.30 (0.22) | — | — | — | — | — |
| Night symptomsc | — | — | — | .700 | <.001 | .011 | .30 (0.18 to 0.50) | <.001 |
| ACT group | 0.84 (0.15) | 0.65 (0.15) | 0.55 (0.13) | — | — | — | — | — |
| Control group | 1.07 (0.17) | 1.22 (0.19) | 1.89 (0.23) | — | — | — | — | — |
| Reliever used | — | — | — | .037 | .010 | .005 | .36 (0.21 to 0.65) | .001 |
| ACT group | 1.31 (0.19) | 0.70 (0.18) | 0.59 (0.15) | — | — | — | — | — |
| Control group | 1.35 (0.23) | 1.13 (0.22) | 1.62 (0.22) | — | — | — | — | — |
| Activity limitatione | — | — | — | .004 | <.001 | .001 | .20 (0.09 to 0.47) | <.001 |
| ACT group | 0.60 (0.15) | 0.12 (0.05) | 0.17 (0.07) | — | — | — | — | — |
| Control group | 0.62 (0.14) | 0.44 (0.13) | 0.84 (0.16) | — | — | — | — | — |
3MFU, 3-mo follow-up after the intervention; 6MFU, 6-mo follow-up after the intervention; —, not applicable.
Adjusted for parent’s relationship with the child, parent’s age, monthly household income, marital status, child’s age, child’s sex, types of ICSs used, and season of enrollment.
Day symptoms refer to the average number of day(s) per week that the child presented with asthma symptoms (either chronic coughing, wheezing, shortness of breath, or chest tightness) during daytime.
Night symptoms refer to the average number of night(s) per week that the child was awakened because asthma symptoms during nighttime.
Reliever use refers to the average number of day(s) per week that the child was required to use an inhaled bronchodilator to relieve asthma symptoms.
Activity limitation refers to the average number of day(s) per week that the child needed to slow down his or her activities because of asthma symptoms.
Parental Outcomes
Significantly better parental outcomes were also found in the ACT group when compared with the control group when taking the time effect into account (Table 5). When compared with parents who had received asthma education only, those who had been trained in ACT became less psychologically inflexible (Cohen’s d = 0.80), reported having fewer negative emotional experiences such as guilt and worry (d = 0.46) and sorrow and anger (d = 0.39), less anxiety (d = 0.47), and fewer symptoms of stress (d = 0.35) at 6 months postintervention. Parents who had been trained in ACT had a better quality of life at 6 months postintervention than those who had received asthma education only (d = 0.36) (Table 5).
Effects of the Intervention on Parental Outcomes by Groups Across Time Using GEEs
| Measures | Mean (SE) | Tests of Adjusted GEE Model Effectsa | Between-Group Comparison | |||||
|---|---|---|---|---|---|---|---|---|
| Baseline | Postintervention | 6MFU | Time Effect P | Group Effect P | Time-by-Group Effect P | Postintervention Mdiff (95% CI) | 6MFU Mdiff (95% CI) | |
| AAQ-II | — | — | — | <.001 | .036 | <.001 | −3.05 (−5.49 to −0.62) | −5.45 (−7.71 to −3.30) |
| ACT group | 20.90 (0.88) | 16.13 (0.72) | 14.67 (0.72) | — | — | — | — | — |
| Control group | 18.86 (0.98) | 19.42 (1.03) | 20.40 (0.89) | — | — | — | — | — |
| Pb | — | — | — | — | — | — | .014 | <.001 |
| ES (95% CI)c | — | — | — | — | — | — | 0.41 (0.10 to 0.73) | 0.80 (0.48 to 1.12) |
| PECI: guilt and worry | — | — | — | <.001 | .199 | <.001 | −0.16 (−0.37 to 0.04) | −0.28 (−0.46 to −0.10) |
| ACT group | 1.62 (0.07) | 1.25 (0.07) | 1.19 (0.06) | — | — | — | — | — |
| Control group | 1.47 (0.07) | 1.42 (0.08) | 1.46 (0.07) | — | — | — | — | — |
| Pb | — | — | — | — | — | — | .125 | .002 |
| ES (95% CI)c | — | — | — | — | — | — | 0.25 (−0.06 to 0.56) | 0.46 (0.15 to 0.78) |
| PECI: unresolved sorrow and anger | — | — | — | .001 | .580 | .002 | −0.03 (−0.22 to 0.16) | −0.22 (−0.40 to −0.04) |
| ACT group | 1.23 (0.07) | 0.98 (0.07) | 0.95 (0.05) | — | — | — | — | — |
| Control group | 1.10 (0.06) | 1.01 (0.07) | 1.16 (0.07) | — | — | — | — | — |
| Pb | — | — | — | — | — | — | .766 | .017 |
| ES (95% CI)c | — | — | — | — | — | — | 0.05 (−0.26 to 0.36) | 0.39 (0.08 to 0.70) |
| PECI: long-term uncertainty | — | — | — | .001 | .601 | .025 | 0.09 (−0.13 to 0.30) | −0.15 (−0.34 to 0.05) |
| ACT group | 1.21 (0.09) | 0.96 (0.07) | 0.98 (0.06) | — | — | — | — | — |
| Control group | 1.05 (0.08) | 0.88 (0.08) | 1.13 (0.08) | — | — | — | — | — |
| Pb | — | — | — | — | — | — | .427 | .146 |
| ES (95% CI)c | — | — | — | — | — | — | 0.12 (−0.18 to 0.43) | 0.24 (−0.07 to 0.55) |
| PECI: emotional resources | — | — | — | .001 | .827 | .001 | 0.11 (−0.11 to 0.32) | 0.22 (−0.04 to 0.48) |
| ACT group | 2.21 (0.09) | 2.65 (0.07) | 2.64 (0.08) | — | — | — | — | — |
| Control group | 2.43 (0.09) | 2.50 (0.08) | 2.38 (0.10) | — | — | — | — | — |
| Pb | — | — | — | — | — | — | .333 | .097 |
| ES (95% CI)c | — | — | — | — | — | — | 0.22 (−0.09 to 0.53) | 0.32 (0.01 to 0.63) |
| DASS-21: depressiond | — | — | — | .002 | .990 | .055 | 0.13 (−1.37 to 1.62) | −1.18 (−2.57 to 0.20) |
| ACT group | 5.11 (0.74) | 3.02 (0.46) | 2.75 (0.40) | — | — | — | — | — |
| Control group | 4.28 (0.63) | 3.14 (0.60) | 4.12 (0.58) | — | — | — | — | — |
| Pb | — | — | — | — | — | — | .868 | .095 |
| ES (95% CI)c | — | — | — | 0.03 (−0.28 to 0.33) | 0.31 (0.00 to 0.62) | |||
| DASS-21: anxietyd | — | — | — | <.001 | .486 | .002 | −0.12 (−1.70 to 1.46) | −2.20 (−3.66 to −0.73) |
| ACT group | 5.93 (0.65) | 3.23 (0.45) | 3.80 (0.42) | — | — | — | — | — |
| Control group | 5.07 (0.70) | 3.54 (0.69) | 6.10 (0.65) | — | — | — | — | — |
| Pb | — | — | — | — | — | — | .881 | .003 |
| ES (95% CI)c | — | — | — | — | — | — | 0.06 (−0.25 to 0.37) | 0.47 (0.16 to 0.79) |
| DASS-21: stressd | — | — | — | .151 | .218 | .002 | −2.33 (−4.92 to 0.27) | −2.50 (−4.54 to −0.47) |
| ACT group | 10.40 (0.95) | 8.11 (0.80) | 7.41 (0.63) | — | — | — | — | — |
| Control group | 9.17 (0.89) | 10.42 (1.07) | 9.85 (0.90) | — | — | — | — | — |
| Pb | — | — | — | — | — | — | .079 | .016 |
| ES (95% CI)c | — | — | — | — | — | — | 0.27 (−0.04 to 0.58) | 0.35 (0.04 to 0.66) |
| DASS-21: totald | — | — | — | .003 | .433 | .003 | −2.76 (−7.80 to 2.28) | −6.05 (−10.56 to −1.55) |
| ACT group | 21.45 (2.11) | 14.35 (1.48) | 13.97 (1.24) | — | — | — | — | — |
| Control group | 18.52 (2.02) | 17.11 (2.10) | 20.02 (1.94) | — | — | — | — | — |
| Pb | — | — | — | — | — | — | .284 | .008 |
| ES (95% CI)c | — | — | — | — | — | — | 0.17 (−0.14 to 0.48) | 0.42 (0.11 to 0.73) |
| AKQ total score | — | — | — | <.001 | .214 | .053 | 0.86 (0.05 to 1.67) | 0.46 (−0.32 to 1.20) |
| ACT group | 18.31 (0.26) | 20.45 (0.29) | 19.50 (0.27) | — | — | — | — | — |
| Control group | 18.31 (0.28) | 19.33 (0.29) | 18.81 (0.29) | — | — | — | — | — |
| Pb | — | — | — | — | — | — | .037 | .243 |
| ES (95% CI)c | — | — | — | — | — | — | 0.43 (0.12 to 0.75) | 0.28 (−0.03 to 0.59) |
| PAMSES: attack prevention | — | — | — | <.001 | .409 | .168 | 0.03 (−0.18 to 0.24) | 0.20 (0.00 to 0.40) |
| ACT group | 3.81 (0.09) | 4.16 (0.08) | 4.10 (0.07) | — | — | — | — | — |
| Control group | 3.82 (0.07) | 4.10 (0.08) | 3.89 (0.07) | — | — | — | — | — |
| Pb | — | — | — | — | — | — | .775 | .055 |
| ES (95% CI)c | — | — | — | — | — | — | 0.08 (−0.23 to 0.39) | 0.34 (0.03 to 0.65) |
| PAMSES: attack management | — | — | — | <.001 | .940 | .015 | 0.02 (−0.22 to 0.26) | 0.18 (−0.05 to 0.41) |
| ACT group | 3.16 (0.11) | 3.84 (0.09) | 3.81 (0.08) | —— | — | — | — | — |
| Control group | 3.33 (0.10) | 3.77 (0.08) | 3.59 (0.08) | — | — | — | — | — |
| Pb | — | — | — | — | — | — | .891 | .121 |
| ES (95% CI)c | — | — | — | — | — | — | 0.09 (−0.22 to 0.40) | 0.31 (−0.01 to 0.62) |
| PAMSES: total | — | — | — | <.001 | .753 | .020 | 0.03 (−0.17 to 0.22) | 0.19 (0.00 to 0.38) |
| ACT group | 3.46 (0.09) | 3.99 (0.07) | 3.94 (0.07) | — | — | — | — | — |
| Control group | 3.56 (0.08) | 3.92 (0.07) | 3.72 (0.07) | — | — | — | — | — |
| Pb | — | — | — | — | — | — | .797 | .055 |
| ES (95% CI)c | — | — | — | — | — | — | 0.11 (−0.20 to 0.42) | 0.35 (0.04 to 0.66) |
| PACQL: emotional function | — | — | — | <.001 | .231 | .001 | 0.43 (0.08 to 0.79) | 0.33 (0.02 to 0.64) |
| ACT group | 4.60 (0.14) | 5.68 (0.11) | 5.69 (0.10) | — | — | — | — | — |
| Control group | 4.88 (0.13) | 5.25 (0.14) | 5.36 (0.12) | — | — | — | — | — |
| Pb | — | — | — | — | — | — | .017 | .039 |
| ES (95% CI)c | — | — | — | — | — | — | 0.38 (0.07 to 0.69) | 0.34 (0.03 to 0.65) |
| PACQL: activity limitation | — | — | — | <.001 | .069 | .001 | 0.60 (0.20 to 0.98) | 0.44 (0.09 to 0.78) |
| ACT group | 4.53 (0.14) | 5.61 (0.12) | 5.65 (0.11) | — | — | — | — | — |
| Control group | 4.79 (0.14) | 5.03 (0.16) | 5.23 (0.13) | — | — | — | — | — |
| Pb | — | — | — | — | — | — | .003 | .014 |
| ES (95% CI)c | — | — | — | — | — | — | 0.46 (0.15 to 0.77) | 0.39 (0.08 to 0.70) |
| PACQL: total score | — | — | — | <.001 | .148 | .001 | 0.48 (0.13 to 0.84) | 0.36 (0.05 to 0.67) |
| ACT group | 4.58 (0.13) | 5.66 (0.11) | 5.67 (0.10) | — | — | — | — | — |
| Control group | 4.85 (0.13) | 5.18 (0.14) | 5.32 (0.12) | — | — | — | — | — |
| Pb | — | — | — | — | — | — | .008 | .023 |
| ES (95% CI)c | — | — | — | — | — | — | 0.43 (0.11 to 0.74) | 0.36 (0.05 to 0.67) |
| Measures | Mean (SE) | Tests of Adjusted GEE Model Effectsa | Between-Group Comparison | |||||
|---|---|---|---|---|---|---|---|---|
| Baseline | Postintervention | 6MFU | Time Effect P | Group Effect P | Time-by-Group Effect P | Postintervention Mdiff (95% CI) | 6MFU Mdiff (95% CI) | |
| AAQ-II | — | — | — | <.001 | .036 | <.001 | −3.05 (−5.49 to −0.62) | −5.45 (−7.71 to −3.30) |
| ACT group | 20.90 (0.88) | 16.13 (0.72) | 14.67 (0.72) | — | — | — | — | — |
| Control group | 18.86 (0.98) | 19.42 (1.03) | 20.40 (0.89) | — | — | — | — | — |
| Pb | — | — | — | — | — | — | .014 | <.001 |
| ES (95% CI)c | — | — | — | — | — | — | 0.41 (0.10 to 0.73) | 0.80 (0.48 to 1.12) |
| PECI: guilt and worry | — | — | — | <.001 | .199 | <.001 | −0.16 (−0.37 to 0.04) | −0.28 (−0.46 to −0.10) |
| ACT group | 1.62 (0.07) | 1.25 (0.07) | 1.19 (0.06) | — | — | — | — | — |
| Control group | 1.47 (0.07) | 1.42 (0.08) | 1.46 (0.07) | — | — | — | — | — |
| Pb | — | — | — | — | — | — | .125 | .002 |
| ES (95% CI)c | — | — | — | — | — | — | 0.25 (−0.06 to 0.56) | 0.46 (0.15 to 0.78) |
| PECI: unresolved sorrow and anger | — | — | — | .001 | .580 | .002 | −0.03 (−0.22 to 0.16) | −0.22 (−0.40 to −0.04) |
| ACT group | 1.23 (0.07) | 0.98 (0.07) | 0.95 (0.05) | — | — | — | — | — |
| Control group | 1.10 (0.06) | 1.01 (0.07) | 1.16 (0.07) | — | — | — | — | — |
| Pb | — | — | — | — | — | — | .766 | .017 |
| ES (95% CI)c | — | — | — | — | — | — | 0.05 (−0.26 to 0.36) | 0.39 (0.08 to 0.70) |
| PECI: long-term uncertainty | — | — | — | .001 | .601 | .025 | 0.09 (−0.13 to 0.30) | −0.15 (−0.34 to 0.05) |
| ACT group | 1.21 (0.09) | 0.96 (0.07) | 0.98 (0.06) | — | — | — | — | — |
| Control group | 1.05 (0.08) | 0.88 (0.08) | 1.13 (0.08) | — | — | — | — | — |
| Pb | — | — | — | — | — | — | .427 | .146 |
| ES (95% CI)c | — | — | — | — | — | — | 0.12 (−0.18 to 0.43) | 0.24 (−0.07 to 0.55) |
| PECI: emotional resources | — | — | — | .001 | .827 | .001 | 0.11 (−0.11 to 0.32) | 0.22 (−0.04 to 0.48) |
| ACT group | 2.21 (0.09) | 2.65 (0.07) | 2.64 (0.08) | — | — | — | — | — |
| Control group | 2.43 (0.09) | 2.50 (0.08) | 2.38 (0.10) | — | — | — | — | — |
| Pb | — | — | — | — | — | — | .333 | .097 |
| ES (95% CI)c | — | — | — | — | — | — | 0.22 (−0.09 to 0.53) | 0.32 (0.01 to 0.63) |
| DASS-21: depressiond | — | — | — | .002 | .990 | .055 | 0.13 (−1.37 to 1.62) | −1.18 (−2.57 to 0.20) |
| ACT group | 5.11 (0.74) | 3.02 (0.46) | 2.75 (0.40) | — | — | — | — | — |
| Control group | 4.28 (0.63) | 3.14 (0.60) | 4.12 (0.58) | — | — | — | — | — |
| Pb | — | — | — | — | — | — | .868 | .095 |
| ES (95% CI)c | — | — | — | 0.03 (−0.28 to 0.33) | 0.31 (0.00 to 0.62) | |||
| DASS-21: anxietyd | — | — | — | <.001 | .486 | .002 | −0.12 (−1.70 to 1.46) | −2.20 (−3.66 to −0.73) |
| ACT group | 5.93 (0.65) | 3.23 (0.45) | 3.80 (0.42) | — | — | — | — | — |
| Control group | 5.07 (0.70) | 3.54 (0.69) | 6.10 (0.65) | — | — | — | — | — |
| Pb | — | — | — | — | — | — | .881 | .003 |
| ES (95% CI)c | — | — | — | — | — | — | 0.06 (−0.25 to 0.37) | 0.47 (0.16 to 0.79) |
| DASS-21: stressd | — | — | — | .151 | .218 | .002 | −2.33 (−4.92 to 0.27) | −2.50 (−4.54 to −0.47) |
| ACT group | 10.40 (0.95) | 8.11 (0.80) | 7.41 (0.63) | — | — | — | — | — |
| Control group | 9.17 (0.89) | 10.42 (1.07) | 9.85 (0.90) | — | — | — | — | — |
| Pb | — | — | — | — | — | — | .079 | .016 |
| ES (95% CI)c | — | — | — | — | — | — | 0.27 (−0.04 to 0.58) | 0.35 (0.04 to 0.66) |
| DASS-21: totald | — | — | — | .003 | .433 | .003 | −2.76 (−7.80 to 2.28) | −6.05 (−10.56 to −1.55) |
| ACT group | 21.45 (2.11) | 14.35 (1.48) | 13.97 (1.24) | — | — | — | — | — |
| Control group | 18.52 (2.02) | 17.11 (2.10) | 20.02 (1.94) | — | — | — | — | — |
| Pb | — | — | — | — | — | — | .284 | .008 |
| ES (95% CI)c | — | — | — | — | — | — | 0.17 (−0.14 to 0.48) | 0.42 (0.11 to 0.73) |
| AKQ total score | — | — | — | <.001 | .214 | .053 | 0.86 (0.05 to 1.67) | 0.46 (−0.32 to 1.20) |
| ACT group | 18.31 (0.26) | 20.45 (0.29) | 19.50 (0.27) | — | — | — | — | — |
| Control group | 18.31 (0.28) | 19.33 (0.29) | 18.81 (0.29) | — | — | — | — | — |
| Pb | — | — | — | — | — | — | .037 | .243 |
| ES (95% CI)c | — | — | — | — | — | — | 0.43 (0.12 to 0.75) | 0.28 (−0.03 to 0.59) |
| PAMSES: attack prevention | — | — | — | <.001 | .409 | .168 | 0.03 (−0.18 to 0.24) | 0.20 (0.00 to 0.40) |
| ACT group | 3.81 (0.09) | 4.16 (0.08) | 4.10 (0.07) | — | — | — | — | — |
| Control group | 3.82 (0.07) | 4.10 (0.08) | 3.89 (0.07) | — | — | — | — | — |
| Pb | — | — | — | — | — | — | .775 | .055 |
| ES (95% CI)c | — | — | — | — | — | — | 0.08 (−0.23 to 0.39) | 0.34 (0.03 to 0.65) |
| PAMSES: attack management | — | — | — | <.001 | .940 | .015 | 0.02 (−0.22 to 0.26) | 0.18 (−0.05 to 0.41) |
| ACT group | 3.16 (0.11) | 3.84 (0.09) | 3.81 (0.08) | —— | — | — | — | — |
| Control group | 3.33 (0.10) | 3.77 (0.08) | 3.59 (0.08) | — | — | — | — | — |
| Pb | — | — | — | — | — | — | .891 | .121 |
| ES (95% CI)c | — | — | — | — | — | — | 0.09 (−0.22 to 0.40) | 0.31 (−0.01 to 0.62) |
| PAMSES: total | — | — | — | <.001 | .753 | .020 | 0.03 (−0.17 to 0.22) | 0.19 (0.00 to 0.38) |
| ACT group | 3.46 (0.09) | 3.99 (0.07) | 3.94 (0.07) | — | — | — | — | — |
| Control group | 3.56 (0.08) | 3.92 (0.07) | 3.72 (0.07) | — | — | — | — | — |
| Pb | — | — | — | — | — | — | .797 | .055 |
| ES (95% CI)c | — | — | — | — | — | — | 0.11 (−0.20 to 0.42) | 0.35 (0.04 to 0.66) |
| PACQL: emotional function | — | — | — | <.001 | .231 | .001 | 0.43 (0.08 to 0.79) | 0.33 (0.02 to 0.64) |
| ACT group | 4.60 (0.14) | 5.68 (0.11) | 5.69 (0.10) | — | — | — | — | — |
| Control group | 4.88 (0.13) | 5.25 (0.14) | 5.36 (0.12) | — | — | — | — | — |
| Pb | — | — | — | — | — | — | .017 | .039 |
| ES (95% CI)c | — | — | — | — | — | — | 0.38 (0.07 to 0.69) | 0.34 (0.03 to 0.65) |
| PACQL: activity limitation | — | — | — | <.001 | .069 | .001 | 0.60 (0.20 to 0.98) | 0.44 (0.09 to 0.78) |
| ACT group | 4.53 (0.14) | 5.61 (0.12) | 5.65 (0.11) | — | — | — | — | — |
| Control group | 4.79 (0.14) | 5.03 (0.16) | 5.23 (0.13) | — | — | — | — | — |
| Pb | — | — | — | — | — | — | .003 | .014 |
| ES (95% CI)c | — | — | — | — | — | — | 0.46 (0.15 to 0.77) | 0.39 (0.08 to 0.70) |
| PACQL: total score | — | — | — | <.001 | .148 | .001 | 0.48 (0.13 to 0.84) | 0.36 (0.05 to 0.67) |
| ACT group | 4.58 (0.13) | 5.66 (0.11) | 5.67 (0.10) | — | — | — | — | — |
| Control group | 4.85 (0.13) | 5.18 (0.14) | 5.32 (0.12) | — | — | — | — | — |
| Pb | — | — | — | — | — | — | .008 | .023 |
| ES (95% CI)c | — | — | — | — | — | — | 0.43 (0.11 to 0.74) | 0.36 (0.05 to 0.67) |
6MFU, 6-mo follow-up after the intervention; AAQ-II, Acceptance and Action Questionnaire-II; Mdiff, difference in the estimated marginal means; —, not applicable.
Adjusted for parents’ age, relationship with the child, marital status, educational level, and monthly household income.
P value for the between-group difference measured at postintervention and at the 6-mo follow-up after the intervention.
Cohen’s d ES was calculated for the between-groups effects on the basis of the estimated marginal means and the SEs measured at postintervention and at the 6-mo follow-up after the intervention.
To yield a score equivalent to that of the full Depression Anxiety Stress Scale-42 scale, the scores for the DASS-21 depression, anxiety, and stress subscales were multiplied by 2, with the possible range of scores being 0–42.
Significant time-by-group interactions were found in all subscales measuring parental quality of life (P = .001) but not in parental asthma knowledge (P = .053) and self-efficacy in preventing asthma exacerbations (P = .168).
Discussion
This is the first report of an RCT for which ACT was used in the parental management of childhood asthma. We demonstrated that a 4-session parental training program using group-based ACT integrated with asthma education was more effective than education alone for improving childhood asthma morbidity and reducing psychological distress. For the children of parents who had received ACT training, the 6-month incidence of their ED visits due to asthma exacerbations was only one-fifth that of children whose parents had attended an asthma education talk. Likewise, children whose parents had been trained in ACT reported fewer asthma symptoms during daytime and nighttime (0.5–0.6 days per week) when compared with their counterparts (1.9–2.3 days per week).
A growing number of RCTs have supported the efficacy of parent-based interventions for improving childhood asthma morbidity through addressing practical issues in managing childhood asthma, such as poor medication adherence,61 family conflicts,62 and parenting difficulties.63 This trial was an extension of previous studies as the first RCT to use ACT combined with evidence-based asthma education1 to address the psychological difficulties experienced by parents who manage their child’s asthma. Furthermore, our training program for parents was brief (4 sessions), implying that this program would use fewer resources than would be required for other asthma management programs, such as those offering frequent home visits to families,18,64,65 and telephone coaching for 12 months.66
Notably, parents who were trained in ACT had better PF when compared with parents in the control group starting from postintervention, and the reductions in a child’s asthma symptoms and ED visits due to asthma exacerbations occurred at 3 and 6 months postintervention, respectively. From such sequential changes, it could be posited that fostering parental PF via ACT could be a way to improve parental management of childhood asthma, eventually leading to better childhood asthma outcomes. A further study exploring the mediating role of parental PF is warranted. Recent research has suggested that parents may influence their child’s interpretation of asthma-related threatening cues.67 Hence, parents who become less anxious after the ACT training might reduce their child’s biases toward their asthma symptoms and encourage adaptive coping for better health outcomes.
Consistent with our earlier study,6 the parents in the current study felt great distress, with their mean combined DASS-21 scores being close to those whose children presented with disruptive behavioral problems68 and attention-deficient/hyperactivity disorders.69 Nevertheless, our ACT intervention yielded significant small-to-moderate between-group ESs in parental psychological adjustment to a child’s illness and in parental anxiety and stress symptoms at 6 months postintervention. Although the efficacy of ACT on the psychological health outcomes of adult populations has been shown,25,70,71 including those of parents of children with acquired brain injuries28 or cerebral palsy,31 our study is the first to indicate such a therapeutic effect in parents of children with asthma.
In our trial, we found no significant differences between groups over time in visits to general outpatient clinics, hospital admissions due to a child’s asthma exacerbations, parental asthma knowledge, and parental self-efficacy in asthma management. The parents in both groups received asthma education with the same content and number of contact hours, but the additional ACT components, as reflected in the improved parental PF, might confer additional benefits on many other parental and child health outcomes. A 12-month follow-up study may capture relatively rare or seasonal asthma-related events.47
This study has its limitations. The extended amount of time devoted to parents who were allocated to the ACT group might have contributed to the significant intervention effects. Nevertheless, we included PF, an ACT-specific measure of therapeutic processes, specifically to assess the effect of the ACT.23 In addition, our findings indicated that ACT significantly enhanced the PF of parents who joined the ACT group. Thus, we believe that ACT, and not merely clinical attention, contributed to the outcomes that were observed in this study. Another limitation is that the expectations of the parents were not measured. Hence, we were unable to determine the role played by treatment expectations in the outcomes between groups.
All of the data on child and parental outcomes were collected by parental reports in the questionnaires and not through blinded assessors; thus, there was a chance of response bias. Nevertheless, some studies have supported the argument that parents can accurately report their child’s asthma-related events if the recall period is ≤6 months.47,72,73 Young children present challenges for spirometric measurements74; however, a self-report by parents on their child’s asthma symptoms and the use of rescue medications may reflect even more closely the actual disease status of a child at the time of data collection.75,76 Furthermore, the instruments for assessing parental outcomes were all validated.48,–54
At baseline, 75% of the children had not been hospitalized because of asthma exacerbations, and half (52.4%) did not require ICS, implying that the children in this study generally had a low level of severity of asthma. Our sample is similar to that of a recent study in which 45.1% of children with asthma recruited in another local hospital in Hong Kong did not require ICS.77 Our sample may therefore be representative of urban Asian families in general who are rearing children with a low severity of asthma.78 Hence, we suggest that ACT integrated with asthma education could be universally adopted to help parents to improve their management of childhood asthma, regardless of the severity of their child’s asthma symptoms. There is a need to replicate our study in other geographical contexts and among different target populations, such as among parents of children with asthma who need daily ICS and/or who frequently need to be hospitalized. It is expected that such parents may shoulder a greater psychological burden in managing childhood asthma and respond differently to ACT. Future studies could also explore whether training parents in the use of ACT promotes adherence to medications; authors of a recent meta-analysis have reported that psychological interventions could be used to promote adherence to treatment of children with chronic illnesses.79
Conclusions
Our results suggest that a parental training program using group-based ACT plus asthma education is more efficacious than an asthma education talk alone in reducing the frequency of ED visits due to asthma exacerbations, as well as in improving asthma symptoms in young children. Group-based ACT also helps parents to deal with the psychological difficulties of managing childhood asthma.
- ACT
Acceptance and Commitment Therapy
- AKQ
Asthma Knowledge Questionnaire
- CI
confidence interval
- DASS-21
Depression Anxiety Stress Scale-21
- ED
emergency department
- ES
effect size
- GEE
generalized estimating equation
- ICS
inhaled corticosteroid
- IRR
incidence rate ratio
- PACQL
Pediatric Asthma Caregiver’s Quality of Life Questionnaire
- PAMSES
Parent Asthma Management Self-Efficacy Scale
- PECI
Parent Experience of Child Illness
- PF
psychological flexibility
- RCT
randomized controlled trial
- α
Cronbach’s α
Dr Chong was responsible for the conception and design of this study and for developing the intervention protocol, managing the randomized controlled trial, performing the analysis, and drafting the manuscript; Dr Mak was responsible for the conception and design of the study, for monitoring the overall quality of the study, assessing the fidelity of the intervention, and supervising the implementation of the Acceptance and Commitment Therapy intervention, and reviewed and revised the manuscript for intellectual content; Ms Leung and Dr Lam contributed to the design of the study and implemented the asthma education talk; Prof Loke reviewed and revised the manuscript for intellectual content; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
This trial has been registered at www.clinicaltrials.gov (identifier NCT02405962).
FUNDING: This work was supported by Central Research Grant, The Hong Kong Polytechnic University for PhD research study (Yuen-yu Chong, student account code: RTSX).
Acknowledgments
We thank Dr Allen Dorcas for his substantial contribution in providing the interventionist with training in acceptance and mindfulness skills, as well as group skills. We also thank Dr Paul Lee for providing us with statistical advice, Miss Pui Man Li and Miss Flora Wong for their assistance in managing the data, and the nursing staff of the Department of Pediatric and Adolescent Medicine, Tuen Mun Hospital, for their assistance in collecting the data. We also thank all of the participants who took part in this study.
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