Relationships between parenting and illness factors and child behaviour difficulties in children with asthma and/or eczema

Abstract

Chronic health conditions such as asthma and eczema are common and are associated with significant psychosocial sequelae for children and their families. A number of parenting variables have been implicated in child health outcomes; however, there are gaps in understanding of the relationships between parenting and child adjustment in the context of chronic illness. This study examined the role that modifiable parenting factors including parenting style, self-efficacy, and adjustment play in explaining general and illness-related child behaviour and emotional problems. Parents (N = 107) of children diagnosed with asthma only (n = 22), eczema only (n = 59), or both conditions (n = 26) completed a range of parenting and child adjustment measures. The majority of the modifiable parenting factors (parents’ self-efficacy with managing their child’s internalising, asthma-related, and eczema-related behaviours; parent adjustment; and use of ineffective parenting strategies) made significant contributions to explaining variance child behaviour. Parenting variables consistently explained greater proportions of variance in general and illness-related child behaviour difficulties compared to demographic and illness factors and represent important intervention targets.

Keywords

Child health child behaviour parenting chronic disease

Introduction

Chronic health conditions are common (Van Cleave et al., 2010), have no cure, and the burden of disease is often greatest in childhood (e.g. AIHW, 2015). Treatment of these conditions can be time-consuming, complex, costly, and distressing for parent and child (Teasdale et al., 2021; Urban et al., 2021; Foronda et al., 2020), and treatment adherence is low (50–75%; Rapoff, 2010).

Childhood chronic health conditions have considerable psychosocial effects on children and their families (Moore et al., 2006; Pinquart, 2013a, 2018). Children show elevated levels of emotional and behavioural problems (Blackman and Gurka, 2007; Catal et al., 2016; Goodwin et al., 2013; Hammer-Helmich et al., 2016) with higher rates of internalising and externalising problems (Brady et al., 2017; Pinquart and Shen, 2011b; Tegethoff et al., 2015) including anxiety (Pinquart and Shen, 2011a), lower self-esteem (Pinquart, 2013b), increased incidence of being bullied (Pinquart, 2017), and more loneliness (Maes et al., 2017). These difficulties contribute to impairments in physical, social, and academic functioning (Pinquart and Teubert, 2012), affect the course of the illness (Tibosch et al., 2011), and tend to persist into adulthood (Secinti et al., 2017).

While the precise aetiology of these psychosocial difficulties is yet to be established, factors that have been proposed to play a role in the development and maintenance of emotional and behavioural problems include genetic vulnerabilities (Wamboldt et al., 1998), illness-related factors such as disease and symptom severity (McQuaid et al., 2001; Meldrum et al., 2012), and medication side effects (Cooper et al., 2015; De Vries et al., 2008; Quak et al., 2012). These factors are largely non-modifiable. In contrast, modifiable factors such as anxiety and stress associated with having a chronic health condition (Goodwin et al., 2013; Stevenson, 2003), aspects of the family environment (Klinnert et al., 2008), and parenting factors including parenting style and self-efficacy (Klinnert et al., 1994; McQuaid et al., 2001; Pinquart, 2013a) have also been implicated, and they may provide useful targets for psychosocial intervention to improve condition management and child health outcomes (Mitchell et al., 2020).

Parenting and the family environment impact on children’s health directly and indirectly (Al Ghriwati et al., 2017; Pinquart, 2018; Tibosch et al., 2011; Verkleij et al., 2015; Wood et al., 2007), and parents play a crucial role in paediatric illness management and child health outcomes (Morawska et al., 2015). Difficult child behaviour (e.g. poor cooperation) and ineffective parenting practices have been identified as important contributors to management difficulties and worse health outcomes (Mitchell et al., 2015, 2016). Conversely, positive parenting that is characterised by confident, consistent use of effective parenting strategies is associated with more competent and confident illness management, reduced symptom severity, and improved child health (Davis et al., 2001).

Children’s resistance to treatment is a significant obstacle to treatment adherence (Burgess et al., 2008; Santer et al., 2013; LeBovidge et al., 2007); one recognised even by children themselves (Penza-Clyve et al., 2004). To compound this problem, many parents lack the confidence and effective parenting skills to prevent and manage child behaviour problems (Mitchell et al., 2015; Faught et al., 2007), which may directly contribute to the development of ongoing child behaviour difficulties, non-adherence to the child’s management plan, and treatment failure. It is also noteworthy that parent–child interactions are dynamic and reciprocal, and over time parents and children can enter cyclical patterns of interaction which serve to reinforce either positive or negative behaviour patterns, with substantial implications for children’s short- and long-term physical and mental health (Morawska et al., 2015).

In summary, behavioural and emotional problems among children with chronic health conditions are common and contribute to difficulties with illness management. While various parenting variables have been identified as important to child health outcomes, the relationships between parenting factors and child adjustment in the context of chronic illness are still unclear. In particular, there is a paucity of studies examining parenting in the context of childhood asthma and eczema, two of the most common childhood chronic health conditions. Greater understanding of the modifiable variables associated with child behaviour has the potential to assist in the development and targeting of interventions designed to support children and families.

Aim

To increase knowledge of the factors associated with child adjustment in the context of childhood asthma and eczema.

Methods

This study employed a cross-sectional design, using baseline (pre-intervention) data from a randomised controlled trial of a brief parenting intervention for parents of children with asthma and/or eczema (Morawska et al., 2016, 2017). Parents were recruited from the metropolitan region of Brisbane, Australia, from June 2011 to June 2013. Parents responded to advertisements for the parenting intervention study placed in school and childcare centre newsletters and displayed in paediatric hospital emergency and outpatient departments and medical practice waiting areas. Ethical clearance was obtained from The University of Queensland Behavioural and Social Sciences Ethical Review Committee (2010001427) and the Royal Children’s Hospital (HREC/11/QRCH/86) and Mater Health Services Human Research Ethics Committees. Parents were eligible to participate if they were (a) the primary caregiver for a 2- to 10-year-old child with medically diagnosed asthma and/or eczema and (b) concerned about the child’s behaviour or emotions and/or illness management (yes/no). Ineligible families, where (a) the child was diagnosed with a developmental disorder or disability, (b) parents were currently receiving professional assistance for the child’s behaviour problems, or (c) parents were currently receiving psychological help or counselling for themselves, were referred to other services as needed.

We examined the role that modifiable parenting factors including parenting style, self-efficacy, and adjustment play in explaining general and illness-related child behaviour and emotional problems. These modifiable factors were chosen as they have previously been identified in the literature as playing a role in child outcomes both broadly and in the context of child chronic health conditions. We expected that these factors would explain more of the variance in child adjustment compared to non-modifiable demographic variables (child age and parent education) and illness factors (comorbid asthma and eczema, age at diagnosis, and symptom severity).

Measures

Asthma and eczema management information (diagnosis and prescribed medication) was obtained from the child’s treating team (family doctor, paediatrician, or dermatologist/respiratory physician).

Parent-report measures

The Family Background Questionnaire (Sanders and Morawska, 2010) collected sociodemographic information including child age and sex, ethnicity, family composition, and parent age and education.

The 25-item Eczema Behaviour Checklist (EBC; Mitchell et al., 2017) and the 22-item Asthma Behaviour Checklist (ABC; Morawska et al., 2008) assess behavioural difficulties that children with eczema or asthma often experience. For both questionnaires, parents use a 7-point scale ranging from 1 (not at all) to 7 (very much) to rate the extent to which each behaviour has been a problem for them with their child over the past 4 weeks (extent score) and a 10-point scale from 1 (certain I can’t do it) to 10 (certain I can do it) to rate their self-efficacy for successfully dealing with each behaviour (confidence score). Extent and confidence scores in this study had high internal consistency for the EBC (α = 0.92 and 0.95) and the ABC (α = 0.93 and 0.98).

The 36-item Eyberg Child Behavior Inventory (ECBI; Eyberg and Pincus, 1999) assesses parental perceptions of disruptive child behaviours. Items are rated on an intensity scale assessing the frequency of disruptive behaviours using a 7-point scale ranging from 1 (never) to 7 (always) and a problem scale assessing the number of behaviours that are a problem for parents, using a yes/no response format. We used only the intensity scale in this study, which showed high internal consistency (α = 0.92) and has good test–retest reliability (r = 0.86; Eyberg and Pincus, 1999).

The Child Adjustment and Parent Efficacy Scale (CAPES; Morawska et al., 2014) measures child behavioural and emotional adjustment and parental efficacy. Only the 4-item Emotional Maladjustment subscale was used in this study. Parents rate the extent of emotional maladjustment difficulties on a 4-point scale ranging from 0 (not true of my child at all) to 3 (true of my child very much, or most of the time). Parents also rate their self-efficacy for dealing with each child behaviour on a scale from 1 (certain I can’t do it) to 10 (certain I can do it). CAPES has shown good evidence of validity (Morawska et al., 2014) and had satisfactory internal consistency for the Emotional Maladjustment Extent (α = 0.66) and Self-Efficacy (α = 0.90) subscales in this sample.

The 25-item Child Eczema Management Questionnaire (CEMQ; Mitchell and Fraser, 2011) Self-Efficacy scale and the 17-item Asthma Parent Tasks Checklist (APTC; Morawska et al., 2008) Confidence scale assess parents’ self-efficacy for performing tasks necessary to manage their child’s eczema or asthma and have excellent internal consistency (α = 0.96 and 0.93, respectively). Parents rate their confidence with undertaking common management tasks (e.g. administering medication or treatment and avoiding triggers), from 0 (cannot do at all) to 10 (highly certain can do) for the CEMQ, and from 1 (certain I can’t do it) to 10 (certain I can do it) for the APTC.

The 30-item Parenting Scale (PS; Arnold et al., 1993) measures use of dysfunctional parenting strategies across the subscales of Laxness (permissive discipline), Overreactivity (authoritarian discipline and displays of anger), and Verbosity (overly long reprimands or reliance on talking). Parents rate their usual style of parenting in each of 30 situations using 7-point response scales with more effective and less effective anchors. Higher scores indicate higher levels of dysfunctional parenting strategies. Internal consistency was satisfactory for the total score (α = 0.83), which was used in analyses.

The Depression Anxiety Stress Scales–21 (DASS; Lovibond and Lovibond, 1995) is a widely used 21-item measure of depression, anxiety, and stress symptoms in adults. Each item is rated on a 4-point scale ranging from 0 (did not apply to me at all) to 3 (applied to me very much or most of the time). The total scale had good internal consistency (α = 0.94) in this study.

Following questionnaire completion, all families undertook 14 days of eczema and/or asthma symptom monitoring. The Patient-Oriented Eczema Measure (POEM; Charman et al., 2004) assesses signs and symptoms of eczema (itch, sleep disruption, bleeding, weeping/oozing, cracking, flaking, and dryness) over the past 7 days. Eczema monitoring data collected by parents were recoded and summed to generate two 7-day POEM symptom severity scores, which were averaged. Parents of children with asthma used diaries to record the number of asthma episodes per day, and data were summed and averaged to generate a score for mean number of asthma episodes per week.

Procedure

Parents were provided with detailed written study information and completed a telephone screening interview with the study coordinator (AEM) to assess for eligibility. Eligible parents choosing to participate consented online via the study website and were automatically directed to the online questionnaire (hosted via Qualtrics). Hardcopy questionnaires were sent to parents on request. All parents completed a 2-week diary of asthma and/or eczema signs and symptoms. Parents provided written consent for the researchers to contact their child’s medical team to confirm their diagnosis and collect information about currently prescribed asthma and eczema treatment.

Statistical analyses

Descriptive statistics were used to summarise the characteristics of the sample. Individual variable data were approximately normally distributed and therefore considered appropriate for parametric analysis. Pearson’s correlations examined relationships among demographic and illness variables, parenting indicators, and general and illness-related child behaviour difficulties, and t-tests and ANOVAs were used to assess differences across groups. Hierarchical multiple regression analyses were used to test whether demographic and child health variables and parenting indicators explained significant proportions of variation in general and illness-related child behaviour difficulties. Selection of variables for inclusion in the models was guided by an initial evaluation of the zero-order correlations between the variables, and the maximum number of predictor variables allowed in each model changed depending on the sample size of the subgroup being examined to ensure analyses were adequately powered.

For analysis purposes, the child’s age at diagnosis was recoded into two categories (early diagnosis versus later diagnosis) using a median split. Diagnosis by 6 months of age for eczema (n = 51, 63.7%) and/or 2 years of age for asthma (n = 25, 59.5%) was considered to represent early diagnosis (Hill et al., 2016). Early diagnosis with either condition was used to assess the contribution of relatively early development of a chronic health condition to later emotional and behavioural difficulties and to enable inclusion of all children in the same regression analysis regardless of whether they were diagnosed with either or both conditions.

In each model, child age and parent education were entered at step 1: parent education was entered as a binary variable (trade/college/high school degree or less = 0, university degree = 1). Illness factors were entered at step 2: early diagnosis (coded as 1, later diagnosis = 0) and treatment intensity (no prescribed corticosteroid or preventer medication = 0, one or more prescribed corticosteroid or preventer medications = 1) were also entered as binary variables.

All analyses were performed using IBM SPSS v.25. Overall, 1.54% of data were missing, and the pattern of missing data was completely random. Analyses of standardised residuals and casewise diagnostics were carried out and indicated that the data contained no outliers and the models were not unduly influenced by any cases.

Results

Overall, 169 parents expressed interest in participating, 148 parents met eligibility criteria, and 107 completed the baseline (pre-intervention) questionnaires (recruitment rate = 72.3%). Most (n = 101, 94.4%) of the participants were mothers, and the remainder (n = 6, 5.6%) were fathers. Participants had a mean age of 37.28 years (SD = 5.08). Twenty-two (20.6%) children were diagnosed with asthma only, 59 (55.1%) were diagnosed with eczema only, and 26 (24.3%) were diagnosed with both asthma and eczema (see Table 1).

Table 1.

Demographic clinical characteristics of participants by condition.

Variables	Asthma only (n = 22)	Eczema only (n = 59)	Asthma and eczema (n = 26)	Full sample (N = 107)
Variables	M (SD)	M (SD)	M (SD)	M (SD)
Parent age (years)	37.36 (6.99)	36.93 (4.48)	38.00 (4.57)	37.28 (5.08)
Child age (years)	5.86 (2.42)	4.49 (2.06)	5.58 (2.00)	5.04 (2.19)
Child age at diagnosis (years)^a
Asthma	2.81 (2.09)	—	2.56 (1.28)	2.67 (1.66)
Eczema	—	0.87 (1.15)	1.08 (1.86)	0.93 (1.39)
	% (n)	% (n)	% (n)	% (n)
Treatment intensity^b
No prescribed preventer	28.6 (6)	20.7 (12)	19.2 (5)	21.9 (23)
Prescribed only preventer for asthma	71.4 (15)	—	30.8 (8)	21.9 (23)
Prescribed only topical steroids for eczema	—	79.3 (46)	15.4 (4)	47.6 (50)
Prescribed both	—	—	34.6 (9)	8.6 (9)
Previous hospital separations (yes)^a
For asthma	40.9 (9)	—	30.8 (8)	15.9 (17)
For eczema	—	16.9 (10)	7.7 (2)	11.2 (12)
Child sex
Male	54.5 (12)	44.1 (26)	69.2 (18)	52.3 (56)
Female	45.5 (10)	55.9 (33)	30.8 (8)	47.7 (51)
Ethnicity
Caucasian	86.4 (19)	86.4 (51)	80.8 (21)	85.0 (91)
Asian	9.1 (2)	8.5 (5)	15.4 (4)	10.3 (11)
Pacific Islander	—	1.7 (1)	—	1.0 (1)
Not specified	4.5 (1)	3.4 (2)	3.8 (1)	3.7 (4)
Household
Original family	59.1 (13)	88.1 (52)	88.5 (23)	82.2 (88)
Sole parent/step-family/other	40.9 (9)	11.9 (7)	11.5 (3)	17.8 (19)
Parent relationship to child
Mother	95.5 (21)	93.2 (55)	96.2 (25)	94.4 (101)
Father	4.5 (1)	6.8 (4)	3.8 (1)	5.6 (6)
Parent education
High school or less	9.1 (2)	20.3 (12)	19.2 (5)	17.8 (19)
Trade/college	27.3 (6)	11.9 (7)	15.4 (4)	15.9 (17)
University degree	50 (11)	54.2 (32)	26.9 (7)	46.7 (50)
Postgraduate degree	13.6 (3)	13.6 (8)	38.5 (10)	19.6 (21)
Relationship status
Married/de facto	59.1 (13)	89.8 (53)	92.3 (24)	84.1 (90)
Separated/divorced/single	40.9 (9)	10.2 (6)	7.7 (2)	15.9 (17)
Parent employment
Full-time/part-time	54.5 (12)	57.6 (34)	88.5 (23)	64.5 (69)
Not working/job seeking	45.5 (10)	42.4 (25)	11.5 (3)	35.5 (38)
Able to meet essential expenses^c
Yes	77.3 (17)	81.4 (48)	92.3 (24)	83.2 (89)
No	18.2 (4)	16.9 (10)	7.7 (2)	15.0 (16)
Don’t know	4.5 (1)	1.7 (1)		1.9 (2)
After expenses can afford
Not much	18.2 (4)	16.9 (10)	11.5 (3)	15.9 (17)
Some things	63.6 (14)	49.2 (29)	42.3 (11)	50.5 (54)
Most things	18.2 (4)	33.9 (20)	46.2 (12)	33.6 (36)

^aData missing for four asthma only cases, three eczema only cases, and 2 cases with both asthma and eczema.

^bData missing for one asthma only and one eczema only cases.

^cAble to meet essential household expenses during the past 12 months.

Descriptive statistics for child and parent variables are presented in Table 2. Mean number of asthma episodes per week was not significantly different for children with asthma alone (M = 2.03, SD = 2.87, n = 18) compared to those with both asthma and eczema (M = 2.58, SD = 2.91, n = 25), mean difference = −0.55, and 95% confidence interval (CI) of [−2.36, 1.26]. Likewise, average eczema severity scores (POEM) were in the moderate range and were not significantly different for children with eczema alone (M = 14.40, SD = 5.52, n = 57) compared to those with both eczema and asthma (M = 12.37, SD = 6.56, n = 26), mean difference = 2.03, and 95% CI of [−.73, 4.79]. In terms of scores for extent of illness-related child behaviour difficulties, there were no differences between parents of children with both asthma and eczema compared to parents of children with only one of the conditions for asthma-related behaviour difficulties (mean difference = −6.61 and 95% CI of [−19.12, 5.90]), or eczema-related behaviour difficulties (mean difference = 3.51 and 95% CI of [−9.76, 16.77]). Overall, parents tended to report a greater average intensity of eczema-related behaviours (mean item score = 3.57, SD = 1.11) than asthma-related behaviours (mean item score = 2.13, SD = 0.97). Parents of children with both asthma and eczema, in particular, reported significantly higher average intensity of eczema-related behaviours (mean item score = 3.47, SD = 1.11) than asthma-related behaviours (mean item score = 2.27, SD = 1.01), mean difference = −1.20, and 95% CI of [−2.02, −0.88]. Parents of children with asthma alone reported higher levels of self-efficacy with asthma management (M = 150.00, SD = 18.06, n = 22) than parents of children with both asthma and eczema (M = 125.96, SD = 25.69, n = 25), mean difference = 24.04, and 95% CI of [10.82, 37.26]. Similarly, parents of children with asthma alone (M = 202.59, SD = 20.78, n = 22) reported higher levels of self-efficacy with asthma-related behaviour management than parents of children with both asthma and eczema (M = 167.28, SD = 43.75, n = 25), mean difference = 35.31, and 95% CI of [14.73, 55.90]. In contrast, parents of children with eczema alone and parents of children with both asthma and eczema did not differ in self-efficacy with eczema management (mean difference = 0.49 and 95% CI of [−0.28, 1.25]) or self-efficacy with eczema-related behaviour management (mean difference = 0.27 and 95% CI of [−18.72, 19.27]).

Table 2.

Descriptive statistics of child and parent variables.

Variables	Asthma only (n = 22)		Eczema only (n = 59)		Asthma and eczema (n = 26)		Full sample (N = 107)
Variables	M	SD	M	SD	M	SD	M	SD	Min-Max
Asthma severity^a	2.03	2.87	—	—	2.58	2.91	2.35	2.88	0 – 11.5
Eczema severity^a	—	—	14.40	5.52	12.37	6.56	13.76	5.90	0 – 28
DASS Total	19.18	18.19	22.68	17.57	25.12	24.30	22.53	19.38	0 – 114
CAPES Confidence	33.82	6.57	29.05	7.52	27.36	9.04	29.64	7.98	8 – 40
ABC Confidence	202.59	20.78	—	—	167.28	43.75	183.81	38.90	40 – 220
EBC Confidence	—	—	177.59	38.23	177.32	44.01	177.51	39.77	55 – 250
APTC Confidence	150.00	18.06	—	—	125.96	25.69	137.21	25.30	70 – 170
CEMQ Self-Efficacy	—	—	7.55	1.46	7.07	1.95	7.41	1.62	2.40 – 10
PS Total	3.20	0.60	3.07	0.53	3.13	0.71	3.11	0.59	1.90 – 4.73
ECBI Intensity	129.82	34.32	126.14	29.60	126.00	32.11	126.87	30.95	62 – 186
CAPES Emotional Maladjustment	3.68	2.48	3.92	2.25	4.52	2.26	4.01	2.29	0 – 11
ABC Extent	43.27	20.11	—	—	49.88	22.19	46.79	21.28	22 – 102
EBC Extent	—	—	90.31	28.06	86.8	27.68	89.26	27.83	38 – 143

Note. Asthma severity indicates the mean asthma episodes per week. Eczema severity indicates the scores of Patient-Oriented Eczema Measure (POEM). DASS = Depression Anxiety Stress Scales. CAPES = Child Adjustment and Parent Efficacy Scale. ABC = Asthma Behaviour Checklist. EBC = Eczema Behaviour Checklist. APTC = Asthma Parent Tasks Checklist. CEMQ = Child Eczema Management Questionnaire. PS = Parenting Scale. ECBI = Eyberg Child Behavior Inventory. Questionnaire data missing for one case with both asthma and eczema.

^a Data missing for four asthma-only cases and two eczema-only cases; asthma episodes/week missing for one case with both asthma and eczema.

Parent adjustment (F(2,103) = 0.55, p = 0.579) and dysfunctional parenting (F(2,103) = 0.45, p = 0.642) did not differ by condition, nor did general child behaviour difficulties (F(2,103) = 0.12, p = 0.883) or emotional maladjustment (F(2,103) = 0.89, p = 0.414). On the other hand, parents’ self-efficacy for managing their child’s emotional difficulties showed significant differences by condition, F(2,103) = 4.48, p = 0.014; post hoc analyses for multiple pairwise comparisons showed that parents of children with asthma alone scored significantly higher on this variable, indicating greater self-efficacy for managing their child’s emotional difficulties, than parents of children with both asthma and eczema (mean difference = 6.46 and 95% CI of [0.98, 11.93]) or eczema alone (mean difference = 4.77 and 95% CI of [0.22, 9.32]).

Predicting general child behaviour difficulties

Hierarchical multiple regression analysis assessed the extent to which child, parent, and illness-related variables explained variation in children’s (1) general behaviour difficulties (ECBI Intensity) and (2) emotional maladjustment (CAPES Emotional Maladjustment) (Table 3). To enable inclusion of all cases in the analyses, only general variables (rather than illness-specific variables relevant only to children with one condition or the other) were considered for inclusion.

Table 3.

Hierarchical regression analysis predicting children’s (1) general behaviour difficulties (n = 106) and (2) emotional maladjustment (n = 106).

	Step 1		Step 2		Step 3		Step 4
	β	95% CI for β	β	95% CI for β	β	95% CI for β	β	95% CI for β
(1) DV: General behaviour difficulties (ECBI Intensity)
Child age	−0.12	−0.24, 0.16	−0.05	−0.24, 0.15	−0.04	−0.23, 0.16	−0.05	−0.24, 0.14
Parent’s education	0.16	−0.04, 0.36	0.21*	0.01, 0.40	0.21*	0.02, 0.40	0.16	−0.03, 0.35
One disease versus both			−0.06	−0.26, 0.15	−0.08	−0.28, 0.12	−0.06	−0.25, 0.13
Diagnosis age			0.23*	0.02, 0.43	0.25*	0.05, 0.45	0.19	−0.01, 0.39
Treatment intensity			−0.22*	−0.44, −0.02	−0.23*	−0.45, −0.04	−0.21*	−0.42, −0.02
DASS Total					0.24*	0.05, 0.42	0.15	−0.05, 0.33
PS Total							0.27**	0.07, 0.46
R² (adjusted R²)	0.04 (0.02)		0.13 (0.08)		0.19 (0.13)		0.25 (0.19)
F for change in R²	2.19		2.91*		6.42*		7.16**
(2) DV: Emotional maladjustment (CAPES Emotional Maladjustment)
Child age	0.14	−0.06, 0.34	0.09	−0.12, 0.29	0.10	−0.11, 0.30	0.11	−0.05, 0.27
Parent’s education	0.00	−0.20, 0.20	−0.04	−0.24, 0.17	−0.04	−0.24, 0.17	−0.06	−0.21, 0.10
One disease versus both			0.12	−0.09, 0.33	0.10	−0.11, 0.31	−0.02	−0.18, 0.15
Diagnosis age			−0.20	−0.41, 0.01	−0.18	−0.39, 0.03	−0.06	−0.22, 0.11
Treatment intensity			0.07	−0.15, 0.29	0.06	−0.15, 0.28	−0.06	−0.24, 0.10
DASS Total					0.18	−0.02, 0.37	0.06	−0.09, 0.21
CAPES Confidence							−0.65***	−0.83, −0.49
R² (adjusted R²)	0.02 (0.00)		0.06 (0.01)		0.10 (0.04)		0.46 (0.42)
F for change in R²	.98		1.39		3.27		59.31***

Note. β= standardised coefficient. CI = confidence intervals. Treatment intensity indicates the prescription and use of preventer for asthma, and topical steroids for eczema. ECBI = Eyberg Child Behavior Inventory. CAPES = Child Adjustment and Parent Efficacy Scale. DASS = Depression Anxiety Stress Scales. PS = Parenting Scale. * p < 0.05. ** p < 0.01. *** p < 0.001.

Zero-order correlation coefficients for relationships among child, parent, and illness-related variables and general child behaviour difficulties are presented in Table 4. Greater child behaviour difficulties (ECBI Intensity) were associated with dysfunctional parenting (PS Total) and poorer parent adjustment (DASS Total). In contrast, scores for emotional maladjustment (CAPES Emotional Maladjustment Extent) were most strongly correlated with parents’ self-efficacy for managing their child’s emotional difficulties (CAPES Confidence), followed by older age at diagnosis with asthma or eczema, and parent adjustment.

Table 4.

Correlations among child and parent variables (n = 107).

Variables	1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16	17	18	19
1. Child age	1.00
2. Parent education	−0.07	1.00
3. Comorbidity	0.14	−0.01	1.00
4. Age at asthma diagnosis^a	0.43**	0.06	−0.07	1.00
5. Age at eczema diagnosis^b	0.22*	0.11	0.07	0.16	1.00
6. Treatment intensity	0.20*	0.01	0.04	0.25	−0.12	1.00
7. Asthma severity^a	0.11	0.00	0.10	0.10	−0.26	0.17	1.00
8. Eczema severity^b	0.16	−0.12	−0.16	−0.16	−0.08	0.12	−0.26	1.00
9. DASS Total	−0.01	0.05	0.07	0.19	0.00	0.04	0.25	0.09	1.00
10. CAPES Confidence	−0.08	−0.10	−0.16	−0.27	−0.19	−0.17	0.10	−0.03	−0.20*	1.00
11. ABC Confidence^a	−0.21	0.10	−0.46***	−0.10	−0.52*	−0.02	0.01	−0.33	−0.23	0.63***	1.00
12. EBC Confidence^b	−0.18	−0.15	0.00	−0.25	−0.10	−0.27**	−0.10	−0.25*	−0.29**	0.64***	0.74***	1.00
13. APTC Confidence^a	0.06	−0.13	−0.48***	−0.03	0.01	0.19	−0.17	−0.15	−0.40**	0.42**	0.57***	0.45*	1.00
14. CEMQ Self-Efficacy^b	0.01	−0.15	−0.14	0.12	−0.16	0.01	0.15	−0.18	−0.15	0.49***	0.66***	0.63***	0.48*	1.00
15. PS Total	−0.01	0.16	0.02	0.09	−0.03	−0.06	0.02	0.26*	0.35***	−0.09	−0.21	−0.28*	−0.45***	−0.18	1.00
16. ECBI Intensity	−0.15	0.15	−0.02	−0.05	−0.08	−0.27**	0.22	−0.03	0.22*	−0.11	−0.23	−0.13	−0.23	−0.14	0.41***	1.00
17. CAPES Emotional	0.17	0.02	0.12	0.35*	0.25*	0.08	−0.23	0.17	0.20*	−0.67***	−0.60***	−0.39***	−0.20	−0.36***	0.04	0.20*	1.00
18. ABC Extent^a	0.12	−0.24	0.16	−0.18	0.04	0.06	0.13	0.15	0.33*	−0.26	−0.53***	−0.54**	−0.26	−0.27	0.02	0.21	0.32*	1.00
19. EBC Extent^b	0.24*	0.11	−0.06	0.05	−0.04	0.20	0.35	0.39***	0.37***	−0.31**	−0.38	−0.52***	−0.09	−0.32**	0.26*	0.28**	0.38***	0.70***	1.00

Note. Pearson’s correlations, two-tailed. Parent education, comorbidity, and treatment intensity are binary variables. Asthma severity indicates the mean asthma episodes per week. Eczema severity indicates the scores of Patient-Oriented Eczema Measure (POEM). DASS = Depression Anxiety Stress Scales. CAPES = Child Adjustment and Parent Efficacy Scale. ABC = Asthma Behaviour Checklist. EBC = Eczema Behaviour Checklist. APTC = Asthma Parent Tasks Checklist. CEMQ = Child Eczema Management Questionnaire. PS = Parenting Scale. ECBI = Eyberg Child Behavior Inventory.

* p < 0.05. ** p < 0.01. *** p < 0.001.

^a 41 ≤ n ≤ 47 (subsample of children with asthma and their parents).

^b 79 ≤ n ≤ 84 (subsample of children with eczema and their parents).

For the model predicting the intensity of child behaviour problems, after controlling for child age and parent education at step 1, F(2,94) = 2.19, p = 0.118, addition of illness factors (comorbidity, early diagnosis, and treatment intensity) at step 2 made a significant contribution to the model, F(5,91) = 2.67, p = 0.027, and both early diagnosis and treatment intensity explained a significant proportion of variation. Addition of parent adjustment (DASS Total) at step 3 contributed significantly to the model, F(6,90) = 3.43, p = 0.004. Dysfunctional parenting (PS Total) added at step 4 made the greatest unique contribution to the final model, whereas parent adjustment was no longer significant. Total variance explained by the model (adjusted R²) was 18.2%, F(7,89) = 4.16, p = 0.001. Dysfunctional parenting and treatment intensity were the only variables to make significant contributions to the final model, explaining 6.1% and 4.0% of unique variation in child behaviour difficulties, respectively.

For the model predicting child emotional maladjustment, after controlling for child age and parent education at step 1, F(2,94) = .98, p = 0.381, addition of illness factors at step 2 did not make a significant contribution to the model, F(5,91) = 1.23, p = 0.303. Addition of parent adjustment (DASS Total) at step 3 likewise failed to contribute significantly to the model, F(6,90) = 1.59, p = 0.158. Parents’ self-efficacy for managing their child’s emotional difficulties (CAPES Confidence), added at step 4, made the greatest unique contribution to the final model, whereas parent adjustment was no longer significant. Total variance explained by the model (adjusted R²) was 41.5%, F(7,89) = 10.73, p < 0.001. Only parents’ self-efficacy with managing their child’s emotional difficulties made a significant contribution to the final model, explaining 36.1% of unique variation in children’s emotional maladjustment.

Predicting illness-related child behaviour difficulties

Hierarchical multiple regression analysis was conducted to assess the extent to which child, parent, and illness-related variables explained variation in children’s (1) asthma-specific behavioural difficulties (ABC Extent) and (2) eczema-specific behavioural difficulties (EBC Extent) (Table 5). In each analysis, all parents who completed the measure were included, irrespective of whether their child had one or both conditions. Correlation coefficients (see Table 4) showed that greater asthma-related behaviour difficulties (ABC Extent) were associated with lower parent self-efficacy for managing problem behaviours (ABC Confidence) and poorer parent adjustment (DASS Total). Likewise, greater eczema-related behaviour difficulties (EBC Extent) were not only associated with lower parent self-efficacy for managing problem behaviours (EBC Confidence) and poorer parent adjustment (DASS Total), but they also correlated with more severe eczema symptoms, lower parent self-efficacy for managing their child’s eczema care, lower parent self-efficacy for managing children’s emotional difficulties, dysfunctional parenting, and older child age.

Table 5.

Hierarchical regression analysis predicting children’s (1) asthma-related behaviour problems (n = 47) and (2) eczema-related behaviour problems (n = 84).

	Step 1		Step 2		Step 3		Step 4
	β	95% CI for β	β	95% CI for β	β	95% CI for β	β	95% CI for β
(1) DV: Asthma-related behaviour problems (ABC Extent)
Child age	0.12	−0.22, .47	0.14	−0.22, .52	0.21	−0.10, 0.56	0.12	−0.17, 0.44
Parent education	−0.28	−0.62, 0.04	−0.22	−0.57, 0.12	−0.23	−0.54, 0.07	−0.17	−0.45, 0.10
Early diagnosis			0.28	−0.08, 0.65	0.38*	0.07, 0.72	.38*	0.10, 0.69
Treatment intensity			0.10	−0.28, 0.50	0.10	−0.24, 0.46	0.10	−0.21, 0.42
Asthma severity			0.13	−0.22, 0.47	0.00	−0.32, .31	0.04	−0.24, 0.33
DASS Total					0.48**	0.17, 0.70	0.36*	0.08, 0.58
ABC Confidence							−.39**	−0.66, −0.12
R² (adjusted R²)	0.09 (0.04)		0.18 (0.06)		0.38 (0.27)		0.51 (0.41)
F for change in R²	1.82		1.21		10.88**		8.64**
(2) DV: Eczema-related behaviour problems (EBC Extent)
Child age	0.24*	0.01, 0.46	0.17	−0.05, 0.38	0.14	−0.06, 0.34	0.10	−0.10, 0.30
Parent education	0.12	−0.10, 0.33	0.18	−0.03, 0.38	0.17	−0.02, 0.36	0.12	−0.07, 0.31
Treatment intensity			0.05	−0.16, 0.26	0.07	−0.12, 0.26	0.09	−0.10, 0.28
Early diagnosis			0.09	−0.12, 0.31	0.11	−0.09, 0.31	0.05	−0.15, 0.25
Eczema severity			0.38**	0.16, 0.59	0.34**	0.14, 0.54	0.28**	0.07, 0.48
DASS Total					0.36***	0.16, 0.51	0.28**	0.07, 0.45
CEMQ Self-Efficacy							0.02	−0.22, 0.26
EBC Confidence							−0.31*	−0.56, −0.05
PS Total							−0.01	−0.22, 0.20
R² (adjusted R²)	0.06 (0.04)		0.23 (0.17)		0.36 (0.30)		0.43 (0.35)
F for change in R²	2.57		5.09**		14.22***		2.67

Note. β = standardised coefficient. CI = confidence intervals. Treatment intensity indicates the prescription and use of preventer for asthma, and topical steroids for eczema. Asthma severity indicates the mean asthma episodes per week. Eczema severity indicates the scores of Patient-Oriented Eczema Measure (POEM). ABC = Asthma Behaviour Checklist. EBC = Eczema Behaviour Checklist. DASS = Depression Anxiety Stress Scales. CEMQ = Child Eczema Management Questionnaire. PS = Parenting Scale. * p < 0.05. ** p < 0.01. *** p < 0.001.

For the model predicting extent of asthma-related child behaviour problems, there was no relationship between asthma-related child behaviour problems and sociodemographic variables (child age and parent education) entered at step 1, F(2,37) = 1.82, p = 0.176. Addition of illness variables (early diagnosis, treatment intensity, and asthma severity) at step 2 did not make a significant contribution to the model, F(5,34) = 1.47, p = 0.226. Addition of parent adjustment (DASS Total) at step 3 contributed significantly to the model, F(6,33) = 3.39, p = 0.010, and early diagnosis became a significant predictor once parent adjustment was accounted for. Finally, addition of parents’ self-efficacy with asthma-related behaviour management (ABC Confidence) at step 4 made a significant contribution to the model. Total variance explained by the model (adjusted R²) was 40.6%, F(7,32) = 4.81, p = 0.001. Parents’ self-efficacy with asthma-related behaviour management, early diagnosis, and parent adjustment all made significant contributions to the final model, explaining 13.1%, 11.2%, and 10.6% of variation in asthma-related behaviour difficulties, respectively.

For the model predicting the extent of eczema-related child behaviour problems, parents’ self-efficacy with eczema-related behaviour management (EBC Confidence) was selected for inclusion over parents’ self-efficacy with managing their child’s emotional difficulties (CAPES Confidence) to avoid problems with multicollinearity. The block of sociodemographic variables (child age and parent education) entered at step 1 did not make a significant contribution to the model, F(2,75) = 2.57, p = 0.083. In contrast, the addition of illness factors at step 2 did make a significant contribution to the model, F(5,72) = 4.25, p = 0.002, with eczema severity making the only significant unique contribution. Addition of parent adjustment (DASS Total) at step 3 also contributed significantly to the model, F(6,71) = 6.56, p < 0.001, and both parent adjustment and eczema severity were significant predictors. Parent self-efficacy with eczema management (CEMQ Self-Efficacy), self-efficacy with managing eczema-related behaviour problems (EBC Confidence), and dysfunctional parenting (PS Total) added at step 4 fell short of making a significant contribution to the model. Total variance explained by the model (adjusted R²) was 34.8%, F(9,68) = 5.57, p < 0.001. Parent adjustment, eczema severity, and parent confidence with eczema-related behaviour management made significant contributions to the final model, explaining 6.5%, 6.1%, and 4.7% of variation in children’s eczema-related behaviour difficulties, respectively.

Discussion

This study examined relationships between modifiable parenting factors, including parenting style, self-efficacy and adjustment, and general and illness-related child behaviour and emotional problems. Overall, five out of six of the modifiable parenting factors tested (parents’ self-efficacy with managing their child’s internalising, asthma-related, and eczema-related behaviours; parent adjustment; and use of ineffective parenting strategies) made significant contributions to the final models, each explaining between 4.7% and 36.1% of unique variance in child behaviour. In line with our prediction, parenting factors consistently explained greater proportions of variance in general and illness-related child behaviour difficulties than demographic and illness factors (i.e. comorbid asthma and eczema, early diagnosis, and symptom severity).

Correlations and regression models demonstrated differences in relationships between parenting factors and different domains of child behaviour. Use of ineffective parenting strategies was the strongest predictor of general behaviour problems, and low treatment intensity (i.e. no use of preventer or corticosteroid medication for asthma and/or eczema management) was the only other variable that contributed to the model explaining general behavioural difficulties. In contrast, scores for general emotional difficulties (internalising behaviours) did not correlate with the use of ineffective parenting strategies; rather, low self-efficacy with managing their child’s internalising behaviours was the only significant predictor.

Models predicting illness-related behaviour difficulties revealed that parents’ adjustment (depression, anxiety, and stress) and self-efficacy with managing their child’s illness-related behaviours were the strongest predictors of asthma- and eczema-related behaviour problems. These results extend the existing literature, which already recognises parents’ self-efficacy with managing their child’s chronic health condition as a key predictor of successful condition management and reduced disease and symptom severity (Mitchell et al., 2015; Grus et al., 2001; Barlow et al., 2000) and confirm the importance of parents’ self-efficacy to the management of children’s illness-related behaviour. This is important given that child behaviour difficulties and lack of cooperation are key contributors to treatment non-adherence and poorer chronic health condition management in the paediatric chronic illness context (Santer et al., 2013; LeBovidge et al., 2007; Burgess et al., 2008).

Previous research has highlighted the importance of assessing child behaviour not only at the general level but also at the domain-specific level of illness-related child behaviour, which likely has a greater influence over parents’ confidence and competence with treatment than more general child behaviour difficulties (Mitchell et al., 2017; Morawska et al., 2008). Our results extend knowledge in this area by confirming the unique value of condition-specific measures of parenting behaviour. Notably, measures of general parenting behaviour did not make a significant contribution to the models predicting asthma- and eczema-related child behaviour difficulties once condition-specific measures of parenting self-efficacy were included. This suggests that condition-specific measures of parenting and child behaviour – that is, measures that specifically examine the extent of parenting and child behaviour difficulties commonly faced by families of children with a particular chronic health condition – should be included in studies that seek to understand contributors to difficulties with paediatric chronic health condition management, and in intervention studies that aim to improve condition management.

Previous studies examining the effect of parenting intervention on paediatric chronic health condition management have generally relied on measures of general parenting and general child behaviour to assess intervention efficacy (Mitchell et al., 2020). While several studies have demonstrated pre- to post-intervention improvements using general parenting and child behaviour measures (Morawska et al., 2016; Westrupp et al., 2015), sometimes this was only for the subsample of children where general child behaviour difficulties were elevated at baseline (e.g. Westrupp et al., 2015). Studies in other paediatric populations have also demonstrated that domain-specific behaviour problems are not necessarily associated with more global behaviour problems (Adamson and Morawska, 2017; Berzinski et al., 2019). One may argue that illness-specific parenting and child behaviour measures are needed to assess whether the changes produced are relevant to the child’s condition and thereby likely to result in improved condition management and child health outcomes.

Although the use of ineffective parenting strategies was the strongest predictor of general child behaviour difficulties, correlations between ineffective parenting and illness-related behaviour difficulties, and parents’ confidence with managing illness-related behaviour difficulties, were only small. Parents of children with chronic health conditions tend to be more overprotective of their children (Pinquart, 2013a) and may have low or inconsistent expectations in terms of children’s behaviour, particularly when children are unwell (Ievers et al., 1994). This suggests that approaches to helping parents to develop effective disciplinary methods and reduce child behaviour difficulties should not only focus on building general parenting skills and confidence but should also help parents to apply them specifically to the illness management context. Building parents’ confidence and skills may not improve children’s condition management if parents are unable or reluctant to apply them when carrying out condition management activities such as monitoring, treatment, or managing a flare of symptoms.

Finally, parent adjustment was a significant predictor of illness-related child behaviour difficulties but not general externalising or internalising behaviour difficulties. These relationships remained evident even after children’s symptom severity and treatment intensity were accounted for. Parents reporting higher levels of distress were also more likely to report difficulties with illness-related behaviour problems. Greater parental distress also correlated with the use of ineffective parenting strategies and lower self-efficacy for managing internalising behaviour problems, eczema-related behaviour difficulties, and asthma treatment. Our results suggest that parents with high levels of psychological distress are therefore at risk of low parenting skill and confidence and greater child behaviour difficulties at both the general and illness-specific levels. This is in line with the broader literature linking parents’ depression, anxiety, and stress with low parenting self-efficacy in both the general (Jones and Prinz, 2005; Morawska and Sanders, 2007) and paediatric chronic illness (Mitchell et al., 2015, 2016) contexts.

Limitations

Limitations are acknowledged. The cross-sectional study design precludes inferences of causality, and longitudinal and experimental research designs are needed to establish mechanisms of effect. Our sample size was relatively small, limiting our power to detect effects in analyses. Measures of symptom severity and parent and child behaviour were limited by parent self-report, and more objective measures of these variables using clinician assessment and behavioural observation, respectively, may yield different results. Multi-modal assessment of symptom severity to take into account both objective and subjective experiences is important for future research.

Implications for practice

Supporting parents to maintain consistent and effective parenting despite the distress, discomfort, and demands of day-to-day illness management may be important in preventing and reducing child behaviour problems in the chronic illness context. Interventions should focus not only on appropriate general parenting skills and confidence but also on how to apply these in the context of their child’s condition. It is well established that parents of children with chronic health conditions are at higher risk of mental health difficulties than parents of healthy children (Cohn et al., 2020). Interventions that seek to support families to manage paediatric chronic health conditions should therefore recognise the importance of parental mental health to the parent–child relationship and family environment, and incorporate strategies to support parental mental health and self-care.

Conclusions

In conclusion, our results confirm the importance of modifiable parenting factors, such as parenting practices, self-efficacy, and parent adjustment, to general and illness-related behaviour difficulties for children with asthma and eczema. Development and testing of intervention approaches that help parents to develop effective parenting practices, boost parents’ self-efficacy for managing illness-related behaviour problems, and support parent mental health and self-care are warranted.

Footnotes

Declaration of Conflicting interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The Parenting and Family Support Centre is partly funded by royalties stemming from published resources of the Triple P – Positive Parenting Program, which is developed and owned by The University of Queensland (UQ). Royalties are also distributed to the Faculty of Health and Behavioural Sciences at UQ and contributory authors of published Triple P resources. Triple P International (TPI) Pty Ltd is a private company licensed by UQ, to publish and disseminate Triple P worldwide. The authors of this report have no share or ownership of TPI. Dr Morawska has received royalties from TPI. TPI had no involvement in the study design, collection, analysis or interpretation of data, or writing of this report. Drs Morawska and Mitchell are employees at UQ. Dr Etel was an employee at UQ at the time this research was conducted.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Australian Research Council (grant number DP110102449) and Children’s Hospital Foundation Early Career Fellowships (AEM; award ref. 50223, ECF0112020).

ORCID iDs

Alina Morawska

Evren Etel

Amy Mitchell

References

Adamson

Morawska

(2017) Early feeding, child behaviour and parenting as correlates of problem eating. Journal of Child and Family Studies 26(11): 3167–3178.

AIHW (2015) What Is the Health Burden of Asthma? Canberra: AIHW.

Al Ghriwati

Winter

Everhart

, et al. (2017) Family functioning and child asthma severity: a bio-behavioral approach. Families, Systems and Health 35(4): 439–449.

Arnold

O’Leary

Wolff

, et al. (1993) The parenting scale: a measure of dysfunctional parenting in discipline situations. Psychological Assessment 5: 137–144.

Barlow

Shaw

Wright

(2000) Development and preliminary validation of a self-efficacy measure for use among parents of children with juvenile idiopathic arthritis. Arthritis Care and Research 13(4): 227–236.

Berzinski

Morawska

Mitchell

, et al. (2019) Parenting and child behaviour as predictors of toothbrushing difficulties in young children. International Journal of Paediatric Dentistry 30(1): 75–84.

Blackman

Gurka

(2007) Developmental and behavioral comorbidities of asthma in children. Journal of Developmental and Behavioral Pediatrics 28(2): 92–99.

Brady

Deighton

Stansfeld

(2017) Psychiatric outcomes associated with chronic illness in adolescence: a systematic review. Journal of Adolescence 59: 112–123.

Burgess

Sly

Morawska

, et al. (2008) Assessing adherence and factors associated with adherence in young children with asthma. Respirology 13: 559–563.

10.

Catal

Topal

Soylu

, et al. (2016) Psychiatric disorders and symptoms severity in preschool children with atopic eczema. Allergologia et Immunopathologia 44(2): 120–124.

11.

Charman

Venn

Williams

(2004) The patient-qriented eczema measure: development and initial validation of a new tool for measuring atopic eczema severity from the patients’ perspective. Archives of Dermatology 140: 1513–1519.

12.

Cohn

Pechlivanoglou

Lee

, et al. (2020) Health outcomes of parents of children with chronic illness: a systematic review and meta-analysis. The Journal of Pediatrics 218: 166–177.

13.

Cooper

Metcalf

Versnel

, et al. (2015) Patient-reported side effects, concerns and adherence to corticosteroid treatment for asthma, and comparison with physician estimates of side-effect prevalence: a UK-wide, cross-sectional study. Npj Primary Care Respiratory Medicine 25: 15026.

14.

Davis

Delamater

Shaw

, et al. (2001) Brief report: parenting styles, regimen adherence, and glycemic control in 4- to 10-year-old children with diabetes. Journal of Pediatric Psychology 26(2): 123–129.

15.

de Vries

van Roon

Duiverman

(2008) Inhaled corticosteroids do not affect behaviour. Acta Paediatrica 97(6): 786–789.

16.

Eyberg

Pincus

(1999) Eyberg Child Behavior Inventory and Sutter-Eyberg Student Behavior Inventory - Revised: Professional Manual. Odessa, FL: Psychological Assessment Resources.

17.

Faught

Bierl

Barton

, et al. (2007) Stress in mothers of young children with eczema. Archives of Disease in Childhood 92(8): 683–686.

18.

Foronda

Kelley

Nadeau

, et al. (2020) Psychological and socioeconomic burdens faced by family caregivers of children with asthma: an integrative review. Journal of Pediatric Health Care 34(4): 366–376.

19.

Goodwin

Robinson

Sly

, et al. (2013) Severity and persistence of asthma and mental health: a birth cohort study. Psychological Medicine 43(6): 1313–1322.

20.

Grus

Lopez-Hernandez

DelAmAter

, et al. (2001) Parental self-efficacy and morbidity in pediatric asthma. The Journal of Asthma 38(1): 99–106.

21.

Hammer-Helmich

Linneberg

Obel

, et al. (2016) Mental health associations with eczema, asthma and hay fever in children: a cross-sectional survey. BMJ Open 6(10): e012637.

22.

Hill

Grundmeier

Ram

, et al. (2016) The epidemiologic characteristics of healthcare provider-diagnosed eczema, asthma, allergic rhinitis, and food allergy in children: a retrospective cohort study. BMC Pediatrics 16(1): 133.

23.

Ievers

Drotar

Dahms

, et al. (1994) Maternal child-rearing behavior in three groups: cystic fibrosis, insulin-dependent diabetes mellitus, and healthy children. Journal of Pediatric Psychology 19(6): 681–687.

24.

Jones

Prinz

(2005) Potential roles of parental self-efficacy in parent and child adjustment: a review. Clinical Psychology Review 25(3): 341–363.

25.

Klinnert

Kaugars

Strand

, et al. (2008) Family psychological factors in relation to children’s asthma status and behavioral adjustment at age 4. Family Process 47: 41–61.

26.

Klinnert

Mrazek

(1994) Early asthma onset: the interaction between family stressors and adaptive parenting. Psychiatry: Interpersonal and Biological Processes 57(1): 51–61.

27.

LeBovidge

Kelley

Lauretti

, et al. (2007) Integrating medical and psychological health care for children with atopic dermatitis. Journal of Pediatric Psychology 32(5): 617–625.

28.

Lovibond

(1995) Manual for the Depression Anxiety Stress Scales. Sydney: Psychology Foundation of Australia.

29.

Maes

Van den Noortgate

Fustolo-Gunnink

, et al. (2017) Loneliness in children and adolescents with chronic physical conditions: a meta-analysis. Journal of Pediatric Psychology 42(6): 622–635.

30.

McQuaid

Kopel

Nassau

(2001) Behavioral adjustment in children with asthma: a meta-analysis. Journal of Developmental and Behavioral Pediatrics 22(6): 430–439.

31.

Meldrum

D’Vaz

Dunstan

, et al. (2012) Allergic disease in the first year of life is associated with differences in subsequent neurodevelopment and behaviour. Early Human Development 88(7): 567–573.

32.

Mitchell

Fraser

Morawska

, et al. (2016) Parenting and childhood atopic dermatitis: a cross-sectional study of relationships between parenting behaviour, skin care management, and disease severity in young children. International Journal of Nursing Studies 64: 72–85.

33.

Mitchell

Fraser

Ramsbotham

, et al. (2015) Childhood atopic dermatitis: a cross-sectional study of relationships between child and parent factors, atopic dermatitis management, and disease severity. International Journal of Nursing Studies 52: 216–228.

34.

Mitchell

Fraser

(2011) Parents’ self-efficacy, outcome expectations, and self-reported task performance when managing atopic dermatitis in children: Instrument reliability and validity. International Journal of Nursing Studies 48(2): 215–226.

35.

Mitchell

Morawska

Fraser

, et al. (2017) Child behaviour problems and childhood illness: development of the Eczema Behaviour Checklist. Child: Care, Health and Development 43(1): 67–74.

36.

Mitchell

Morawska

Mihelic

(2020) A systematic review of parenting interventions for child chronic health conditions. Journal of Child Health Care 24(4): 603–628.

37.

Moore

David

Murray

, et al. (2006) Effect of childhood eczema and asthma on parental sleep and wellbeing: a prospective comparative study. The British journal of dermatology 154(3): 514–518.

38.

Morawska

Calam

Fraser

(2015) Parenting interventions for childhood chronic illness: a review and recommendations for intervention design and delivery. Journal of Child Health Care 19(1): 5–17.

39.

Morawska

Mitchell

Burgess

, et al. (2016) Effects of Triple P parenting intervention on child health outcomes for childhood asthma and eczema: randomised controlled trial. Behaviour Research and Therapy 83: 35–44.

40.

Morawska

Mitchell

Burgess

, et al. (2017) Randomized controlled trial of Triple P for parents of children with asthma or eczema: effects on parenting and child behavior. Journal of Consulting and Clinical Psychology 85(4): 283–296.

41.

Morawska

Sanders

(2007) Concurrent predictors of dysfunctional parenting and maternal confidence: implications for parenting interventions. Child: Care, Health and Development 33: 757–767.

42.

Morawska

Sanders

Haslam

, et al. (2014) Child adjustment and parent efficacy scale: development and initial validation of a parent report measure. Australian Psychologist 49: 241–252.

43.

Morawska

Stelzer

Burgess

(2008) Parenting asthmatic children: Identification of parenting challenges. The Journal of Asthma 45: 465–472.

44.

Penza-Clyve

Mansell

McQuaid

(2004) Why don’t children take their asthma medications? A qualitative analysis of children’s perspectives on adherence. The Journal of Asthma 41(2): 189–197.

45.

Pinquart

(2013a) Do the parent–child relationship and parenting behaviors differ between families with a child with and without chronic illness? A meta-analysis. Journal of Pediatric Psychology 38(7): 708–721.

46.

Pinquart

(2013b) Self-esteem of children and adolescents with chronic illness: a meta-analysis. Child: Care, Health and Development 39(2): 153–161.

47.

Pinquart

(2017) Systematic review: bullying involvement of children with and without chronic physical illness and/or physical/sensory disability—A meta-analytic comparison with healthy/nondisabled peers. Journal of Pediatric Psychology 42(3): 245–259.

48.

Pinquart

(2018) Parenting stress in caregivers of children with chronic physical condition—A meta-analysis. Stress and Health 34(2): 197–207.

49.

Pinquart

Shen

(2011a) Anxiety in children and adolescents with chronic physical illnesses: a meta-analysis. Acta Paediatrica 100(8): 1069–1076.

50.

Pinquart

Shen

(2011b) Behavior problems in children and adolescents with chronic physical illness: a meta-analysis. Journal of Pediatric Psychology 36(9): 1003–1016.

51.

Pinquart

Teubert

(2012) Academic, physical, and social functioning of children and adolescents with chronic physical illness: a meta-analysis. Journal of Pediatric Psychology 37(4): 376–389.

52.

Quak

Klok

Kaptein

, et al. (2012) Preschool children with high adherence to inhaled corticosteroids for asthma do not show behavioural problems. Acta Paediatrica 101(11): 1156–1160.

53.

Rapoff

(2010) Adherence to Pediatric Medical Regimens. New York: Springer.

54.

Sanders

Morawska

(2010) Family Background Questionnaire. Brisbane: Parenting and Family Support Centre.

55.

Santer

Burgess

Yardley

, et al. (2013) Managing childhood eczema: qualitative study exploring carers' experiences of barriers and facilitators to treatment adherence. Journal of Advanced Nursing 69(11): 2493–2501.

56.

Secinti

Thompson

Richards

, et al. (2017) Research review: childhood chronic physical illness and adult emotional health—A systematic review and meta-analysis. Journal of Child Psychology and PsychiatryCPPAD 58(7): 753–769.

57.

Stevenson

(2003) Relationship between behavior and asthma in children with atopic dermatitis. Psychosomatic Medicine 65(6): 971–975.

58.

Teasdale

Muller

Sivyer

, et al. (2021) Views and experiences of managing eczema: systematic review and thematic synthesis of qualitative studies. The British Journal of Dermatology 184(4): 627–637.

59.

Tegethoff

Belardi

Stalujanis

, et al. (2015) Association between mental disorders and physical diseases in adolescents from a nationally representative cohort. Psychosomatic Medicine 77(3): 319–332.

60.

Tibosch

Verhaak

Merkus

PJFM

(2011) Psychological characteristics associated with the onset and course of asthma in children and adolescents: a systematic review of longitudinal effects. Patient Education and Counseling 82(1): 11–19.

61.

Urban

Chu

Giesey

, et al. (2021) The global, regional, and national burden of atopic dermatitis in 195 countries and territories: an ecological study from the Global Burden of Disease Study 2017. JAAD International 2: 12–18.

62.

Van Cleave

Gortmaker

Perrin

(2010) Dynamics of obesity and chronic health conditions among children and youth. JAMA 303(7): 623–630.

63.

Verkleij

van de Griendt

Colland

, et al. (2015) Parenting stress related to behavioral problems and disease severity in children with problematic severe asthma. Journal of Clinical Psychology in Medical Settings 22(2–3): 179–193.

64.

Wamboldt

Schmitz

Mrazek

(1998) Genetic association between atopy and behavioral symptoms in middle childhood. Journal of Child Psychology and PsychiatryCPPAD 39(7): 1007–1016.

65.

Westrupp

Northam

Lee

, et al. (2015) Reducing and preventing internalizing and externalizing behavior problems in children with type 1 diabetes: a randomized controlled trial of the Triple P-Positive Parenting Program. Pediatric Diabetes 16(7): 554–563.

66.

Wood

Lim

Miller

, et al. (2007) Family emotional climate, depression, emotional triggering of asthma, and disease severity in pediatric asthma: examination of pathways of effect. Journal of Pediatric Psychology 32: 542–551.