Acceptance and Commitment Therapyfor Parental Management of ChildhoodAsthma: An RCTYuen-yu Chong, PhD,a Yim-wah Mak, PhD,a Sui-ping Leung, MNurs (AdvPrac),b Shu-yan Lam, MD,b Alice Yuen Loke, PhDa

abstractBACKGROUND: Few trials have been conducted to address the psychological difficulties of parentsin managing their child’s asthma. Fostering parental psychological flexibility throughAcceptance and Commitment Therapy (ACT) may help parents to accept these psychologicaldifficulties and improve their management of childhood asthma.

METHODS: In this randomized controlled trial, a 4-session, group-based ACT plus asthmaeducation (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 careservices due to asthma exacerbations in children and the psychological well-being of theirparents were assessed before, immediately after, and at 6 months after the intervention.

RESULTS: A total of 168 parents and their children aged 3 to 12 years with asthma wereconsecutively recruited in a public hospital in Hong Kong. When compared with the controlgroup, children whose parents were in the ACT group made significantly fewer emergencydepartment visits (adjusted 6-month incidence rate ratio = 0.20; confidence interval [CI] 0.08to 0.53; P = .001) due to asthma exacerbations at 6 months postintervention. These parentsalso reported a decrease in psychological inflexibility (mean difference = 25.45; CI 27.71to 23.30; P = .014), less anxiety (mean difference = 22.20; CI 23.66 to 20.73; P = .003),and stress (mean difference = 22.50; CI 24.54 to 20.47; P = .016).

CONCLUSIONS: Integrating ACT into parental asthma education was effective at decreasingparental anxiety and stress and reducing the asthma-related emergency department visits ofchildren at 6 months postintervention.

WHAT’S KNOWN ON THIS SUBJECT: Many parentsexperience psychological difficulties in caring fora child with asthma. There is a paucity of research onthe link between how parents manage their ownpsychological difficulties and how this affects thehealth of their child with asthma.

WHAT THIS STUDY ADDS: This is the first study toinvestigate the efficacy of Acceptance and CommitmentTherapy for parental management of childhoodasthma. Use of emergency care services due tochildhood asthma exacerbations was reduced, and thepsychological health of the parents improved.

To cite: Chong Y, Mak Y, Leung S, et al. Acceptance andCommitment Therapy for Parental Management ofChildhood Asthma: An RCT. Pediatrics. 2019;143(2):e20181723

aSchool of Nursing, The Hong Kong Polytechnic University, Hong Kong, China; and bDepartment of Pediatrics andAdolescent Medicine, Tuen Mun Hospital, Hong Kong, China

Dr Chong was responsible for the conception and design of this study and for developing theintervention protocol, managing the randomized controlled trial, performing the analysis, anddrafting the manuscript; Dr Mak was responsible for the conception and design of the study, formonitoring the overall quality of the study, assessing the fidelity of the intervention, and supervisingthe implementation of the Acceptance and Commitment Therapy intervention, and reviewed andrevised the manuscript for intellectual content; Ms Leung and Dr Lam contributed to the design ofthe study and implemented the asthma education talk; Prof Loke reviewed and revised themanuscript for intellectual content; and all authors approved the final manuscript as submitted andagree to be accountable for all aspects of the work.

This trial has been registered at www.clinicaltrials.gov (identifier NCT02405962).

DOI: https://doi.org/10.1542/peds.2018-1723

Accepted for publication Nov 26, 2018

Address correspondence to Yim-wah Mak, PhD, School of Nursing, The Hong Kong PolytechnicUniversity, FG419, 11 Yuk Choi Road, Hung Hom, Kowloon, Hong Kong Special Administrative Region,China. E-mail: yw.mak@polyu.edu.hk

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Asthma remains the most commonchronic disease, affecting one-tenthof children worldwide.1 Theunpredictability and life-threateningnature of asthma imposes a heavypsychological burden on parents.2–4

Parents who find it difficult to copewith the burden may engage inavoidance or hypervigilance or maycatastrophize mildly threatening cuesrelated to asthma,5,6 which may affecthow they manage their child’sasthma.7–9 Studies have revealed thatpoor parental psychological health10

affects childhood asthma morbidity,as indicated by increased symptomseverity11 and frequent use of healthcare services.12,13 Hence, helpingparents manage their psychologicaldifficulties may improve theirmanagement of childhood asthma,leading to better child healthoutcomes.

Asthma management programs arefocused on self-managementeducation14–16 but do not addressparental psychological needs. Authorsof a recent Cochrane review17

identified 5 randomized controlledtrials (RCTs) of psychologicalinterventions for parents of childrenwith asthma. Family therapy,18–20

multisystemic therapy,21 andproblem-solving therapy22 wereinvestigated, but no beneficial effectswere found on the psychologicalhealth of the parents and the asthmasymptoms of their children17 whencompared with either those whoreceived the usual care18–20 or anactive control that included thosewho received family counseling21 andasthma education delivered throughhome visits.22 Importantly, the reviewfurther found that the quality of theevidence from these studies was lowor very low because of an unclear orhigh risk of attrition bias or reportingbias.17 Acceptance and CommitmentTherapy (ACT) is a third wave ofcognitive behavioral therapy aimed atfostering psychological flexibility(PF), which refers to acceptingpsychological experiences

nonjudgmentally and taking values-based actions toward goals leading tohealthy functioning.23 There isgrowing evidence that ACT can beused to help individuals with chronicdiseases to self-manage theirillnesses.24–26 Two recent RCTsdemonstrated that childrendiagnosed with acquired braininjuries27–29 and cerebral palsy,30,31

whose parents had undergone 2group sessions of ACT plus theStepping Stone Triple P parentingprogram, showed fewer behavioraland emotional problems than thosewho had received rehabilitationservices as the usual care.Furthermore, the therapeutic effectslasted for at least 3 to 6 monthspostintervention.27,28,30,31 Ina structural equation model of ourrecent study, a significant associationbetween the parents’ PF and theirchild’s asthma morbidity wasfound,32 implying that children withasthma may achieve better healthoutcomes if their parents becomemore psychologically flexible inmanaging their child’s asthmaconditions.

In this present study, an RCT wasemployed to examine the efficacy ofa parental training program usingACT integrated with asthmaeducation on the health outcomes ofparent-child dyads in comparisonwith the usual care of an asthmaeducation talk. We hypothesized thatchildren whose parents had receivedACT plus asthma education would usefewer health care services because ofasthma exacerbations and exhibitfewer asthma symptoms at 6 monthspostintervention when comparedwith those whose parents hadreceived asthma education only. Wealso hypothesized that parents whohad received additional ACT trainingwould be more psychologicallyflexible, exhibit better psychologicaladjustment 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 oflife).

METHODS

Settings and Participants

The study was conducted in 2pediatric respiratory outpatientclinics of a public hospital inHong Kong (see SupplementalInformation). Ethical approval for thestudy was obtained from the NewTerritories East Cluster ClinicalResearch Ethics Committee and TheHong Kong Polytechnic University.This trial has been registered at www.clinicaltrials.gov (identifierNCT02405962).

Parent-child dyads who fulfilled thefollowing eligibility criteria wererecruited: the parent should be eitherthe father or mother (18–65 years ofage) of the child with asthma, theprimary caregiver of a child withasthma, living together with the indexchild, able to communicate inCantonese, a Hong Kong permanentresident who planned to stay in HongKong for at least 6 months, andaccessible by phone or mail. Thechild of such a parent should be 3to 12 years old and have receiveda physician’s diagnosis of asthma(International Classification Diseases,10th Revision codes J45 and J46) asdocumented in the electronicmedical records. Those parentsand/or their children who werecurrently participating in anotherasthma-related interventionalstudy were excluded. Also excludedwere children who had beendiagnosed with congenitalproblems, oxygen-dependentconditions, autism, epilepsy,attention-deficit/hyperactivitydisorders, Down syndrome, cerebralpalsy, or psychomotor retardation.This was because the coexistenceof asthma with complicatedmorbidities has a significant impacton the health outcomes ofchildren.33,34

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Sample Size Estimation

We referred to the findings of otherRCTs examining the efficacy of ACTfor parents of children with chronicdiseases for improving their child’shealth outcomes when comparedwith the usual care.27,30,35 The effectsizes (ESs) of those trials ranged from0.47 to 1.33. Using G*Power version3.1.9.2 statistical software,36

considering the smallest ES (0.47),2-tailed tests of significance, and anattrition rate of 10%, it wasdetermined that a total of 160participants, with 80 in each group,was required for a power of 80% anda maximum error of 5% according toan independent-samples t test.

Recruitment

Consecutive sampling was employed.The first author (Y-y. C.) screened thelist of children who had appointmentsin the clinics and identified thosechildren who met the eligibilitycriteria of this study. Next, for everyeligible child who attended the clinicwith his or her accompanying parent,Y-y. C. or an advanced practice nursescreened the parent for eligibilitythrough face-to-face interviews. Thefirst author explained the study to theparents, obtained their writtenconsent to participate, and enrolledthem in the trial.

Randomization and AllocationConcealment

Randomization in permuted blocks of6 was conducted through a computer-generated list (www.randomizer.org)by using sequentially numbered,opaque, and sealed envelopes, whichwere prepared and kept by a nursingstudent with no other involvement inthis study. The envelopes wereopened only after the parents hadcompleted the baseline assessmentsand provided written consent. Thenurses in the clinics collected thequestionnaires, which were self-administered by the parents. Aresearch assistant entered the data.Neither the nurses nor the research

assistant was told about the randomassignment of the parents totreatment conditions.

Treatment Conditions

Parents in the control group receiveda 2-hour asthma education talk,which was the usual care, conductedby an advanced practice nurse fromthe clinics. Following the GlobalInitiative for Asthma guidelines,1 thetalk was focused on teaching parentsabout monitoring asthma symptoms,using medications, and managingasthma attacks. To ensure theequivalency of the assigned sessionsbetween groups and to approximatethe usual care that the parentsordinarily received in the clinics, theparents received in addition 3 weeklytelephone calls of 15 minutes each.One registered nurse from the clinics,who was not involved in the datacollection process, invited the parentsto report their child’s asthmaconditions over the past week.

Parents in the ACT group received 4weekly sessions of group-based ACTintegrated with asthma education.There is evidence that ACT in briefinterventions (eg, ,5 sessions) ismore efficacious than the usual care,with medium-to-large within-groupESs on the physical health conditionsof individuals with chronic diseases(eg, diabetes, epilepsy).24 A group-based approach helps to normalizea problem37 and leads to peersupport in coping with psychologicaldifficulties.38

The ACT intervention was deliveredaccording to an intervention protocol.This protocol was modified on thebasis of ACT training manuals used inprevious studies,39–41 whichdemonstrated positive effects forparents of children with anorexianervosa,42,43 acquired braininjuries,28,44 and chronic pain.35,45

These are diseases in which thechronicity and the complexity of careare similar to those of childhoodasthma. The protocol of the currentstudy was modified on the basis of

findings from interviews with HongKong Chinese parents of children whohad been diagnosed with asthma.These interviews were conducted toexplore the caregiving difficulties ofthese parents,6 with the aim ofdevising intervention materials thatwould be more relevant to theparents’ child care experiences. Theprotocol was reviewed by a team ofexperts in ACT and in childhoodasthma. The reviewed protocol wasthen pilot tested on a sample of 11parents of children with asthma whohad been recruited from a communitysetting. In the pilot study, muchimprovement was found in theparents’ PF after the ACT trainingwhen compared with the baseline(mean difference = 5.73; test-retestreliability coefficient r = 0.55).

In this study, for each session (2hours), a group of 6 to 8 parentsreceived 90 minutes of ACT followedby 30 minutes of asthma education,the content of which was identical tothat delivered to the control group. Ineach ACT session, multiple activitieswere conducted to foster parental PF.These included mindfulness exercisesto guide the parents in observingpainful emotions that they wereattempting to avoid when managingasthma and experiential exercises,such as the metaphor of tug-of-warwith a monster, so that parentswould realize that struggling withpsychological distress creates moredistress. We also facilitated the parentsin reflecting on whether their asthmamanagement and parenting strategieswere moving toward or away fromtheir values and in establishingvalues-based action plans. At the endof each session, parents receiveda handout on ACT and asthmaeducational materials (Table 1).

Treatment Fidelity

Y-y. C. was the interventionist. She isa registered nurse with experience inpatient counseling and pediatric care.She had also received a total of 5 daysof training in ACT skills. Throughout

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TABLE1SessionOutline

Them

eComponentsof

ACT

Componentsof

AsthmaEducation

Objective(s)

KeyActivities

Objective(s)

Content

Session1:welcome

andintroduction;

creative

hopelessness

Todiscover

thelong-term

costofstruggling

with

psychologicaldifficulties

inchildhood

asthmacare

(awareness)

Obtain

inform

edconsent,build

rapport,open

the

sessionwith

abriefexercise

onmindful

body

sensations;use

amindfulness

exercise

toallow

parentsto

review

thechallenges

involved

inmanagingtheirchild’sasthmaconditionsand

discussthelong-term

workabilityof

usingvarious

coping

strategies;use

ofan

ACTmetaphor,“a

man

inahole”metaphor,to

help

parentsto

review

the

impact

ofpsychologicaldifficulties

(eg,fear,w

orry,

guilt)on

theirow

nhealth

andthatoftheirchild;give

homew

orkon

themindful

parentingof

achild

with

asthma

Toprovidean

overview

ofasthmain

young

children

Prevalence

ofchildhood

asthmain

Hong

Kong;basic

etiology

ofasthma;typesof

asthmatriggers

Session2:watch

you

thinking

andexplore

acceptance

Toexploreacceptance

ofpsychological

difficulties

asan

alternativetoavoidance

coping

(awarenessandacceptance)

Open

thesessionwith

abriefexerciseon

mindfulbody

sensations;reviewhomew

orkby

usingdefusion

exercisesto

help

parentsto

detach

from

anunhelpfulself-evaluationthat

couldlead

topsychologicalbarriers

tocaring

fortheirchild;u

seof

ACTmetaphors,including

thetug-of-war

andthe

“passengerson

thebus”

metaphor,to

help

parents

toaccept

psychologicaldifficulties

nonjudgm

entally

whileworking

towardvalues

that

will

prom

ote

favorablehealth

outcom

esfortheirchild;give

homew

orkon

mindful

parentingby

practicing

acceptance

ofpsychologicaldifficulties

relatedto

caring

forachild

with

asthma

Toteachparentsaboutthe

strategies

for

monitoring

and

preventingasthma

symptom

s

Asthmasignsandsymptom

s;monitoring

asthma

symptom

s;triggeravoidancein

asthma;

demonstrationof

thecorrectwaysof

usingpeak

flow

meters

Session3:be

here

and

now,yourobserving

self,andclarify

values

Todevelopasenseof

selfas

anobserver

andto

explorepersonallyheldvalues

asaparent

ofachild

with

asthma

(awarenessandcommitm

entto

values-

basedactions)

Open

thesessionwith

abriefexerciseon

mindfulbody

sensations;use

the“eyes-on”exercise

toencourage

parentsto

experience

compassioneven

inthe

presence

ofdiscom

fort;use

the“storylineexercise”

tohelp

parentsto

developasenseof

selfas

anobserver

bytaking

note

ofthelifeexperiencesof

otherparentsfrom

different

perspectives;use

amindfulness

exercise

toguideparentsin

recalling

experiencesof

gettingalongwith

themost

unforgettableperson

intheirlifein

relationto

their

values

incaring

fortheirchild;givehomew

orkto

parentsto

setup

theirvalues-based

actionplan

incaring

fortheirchild

Toteachparentsaboutthe

useof

asthma

medications

Differences

betweencontrollers

(ie,ICS)

andrelievers

(ie,short-actingbronchodilators),thepotentialside

effectsof

asthmamedications;d

emonstrationof

thecorrectwaysof

usinginhalers

with

different

typesof

aerocham

bers,the

aftercare

ofusing

aerocham

bers

Session4:commityour

value-basedaction

Tomakeshort-term

andlong-term

values-

basedactionplansto

improvethe

managem

entof

childhood

asthma

Open

thesessionwith

abriefexerciseon

mindfulbody

sensations;reviewtheirhomew

orkby

using“The

StandandCommitexercise”to

helpparentsdeclare

theirvalues

andexplorewhether

actions

relatingto

managingchildhood

asthmacanmovethem

toward

oraw

ayfrom

thosevalues

Toteachparentsaboutthe

managem

entof

childhood

asthma

attacks

Managem

entof

asthmaattacks;useof

anasthma

actionplan

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the study, her ACT skills weresupervised by the correspondingauthor, an ACT researcher (Y-w. M.),and a psychologist. Theinterventionist completeda behavioral checklist40 to rate hercompetence in delivering ACT aftereach session. All sessions in the ACTgroup were videotaped afterobtaining written consent from theparents. The videotaped ACT sessionswere first reviewed independently byY-w. M. to assess Y-y. C.’s competenceand adherence to the protocol. Duringweekly meetings, Y-y. C. briefed Y-w.M. about anything noteworthy. Y-y.C.’stherapeutic stance and competence indelivering the ACT were mostly ratedas being “sometimes true” (score 4)to “frequently true” (score 5),indicating that the intervention thatwas delivered was consistent with theprinciples of ACT most of the time.

Child Measures

We assessed the frequency ofemergency department (ED) visits(primary outcome), unscheduledvisits to general outpatient clinics,private practitioners’ clinics, hospitaladmissions, and the number of daysof stay in the hospital due to asthmaexacerbations in children over thepast 6 months at baseline and at6 months after the completion of theintervention. The parents conductedassessments by completing a set ofself-administered, structuredquestionnaires when theyaccompanied their children forregular visits to the clinic. Follow-upsessions at the clinics are oftenarranged once every 3 months forchildren who have been diagnosedwith asthma. The question items wereretrieved from the consensus reportspublished by the National Institutesof Health in the United States.46,47

During their visits, we also invited theparents to report their child’s asthmasymptoms over the past 4 weeks atbaseline and at 3 and 6 monthspostintervention in the questionnaire.As recommended by the GlobalInitiative for Asthma,1 the average

number of days with asthmasymptoms, nights awakening due toasthma symptoms, days with activitylimitations due to asthma symptoms,and days requiring inhaledbronchodilators to relieve asthmasymptoms per week were assessed(see Supplemental Tables 6 and 7).

Parental Measures

We assessed the followingparental outcomes at baseline,postintervention, and at 6 monthspostintervention: PF via theAcceptance and Action Questionnaire-II,48 psychological adjustment to thechild’s illness via the ParentExperience of Child Illness (PECI)scale,49,50 psychological symptomsvia the Depression Anxiety StressScale-21 (DASS-21),51 asthmaknowledge via the AsthmaKnowledge Questionnaire (AKQ),52

asthma management self-efficacy viathe Parent Asthma ManagementSelf-Efficacy Scale (PAMSES),53

and quality of life via the PediatricAsthma Caregiver’s Quality of LifeQuestionnaire (PACQL)54 (seeSupplemental Information). All of theitems in these instruments weredemonstrated to have acceptableinternal consistency (Cronbach’s a

[a] = 0.74 to 0.90) and a moderatelevel of stability (intraclass correlationcoefficient = 0.76 to 1.00) over 2 weeksin our pilot sample of 49 parents ofchildren with asthma recruited in thestudy hospital. At baseline and at6 months postintervention, parents inboth groups completed thequestionnaires during their regularvisits to the clinic. At postintervention,parents in the ACT group completedthe questionnaires at the end of thefourth session, whereas those in thecontrol group were assessed throughtelephone interviews by a trainedresearch assistant using thequestionnaire.

Baseline Measures

Before random assignment, parentsreported their child’s demographicand asthma-related clinical

information, their sociodemographicdata, and their personal and familymembers’ history of asthma in thequestionnaires.

Statistical Analyses

The collected data were entered andanalyzed via SPSS (version 23.0; IBMSPSS Statistics, IBM Corporation)statistical software. P , .05 (2 tailed)was considered significant. Weexamined any group differences usingx2 tests, Fisher’s exact tests,independent-sample t tests, orMcNemar tests (as appropriate) forall randomly assigned participantsassessed at baseline, those who hadnot attended the sessions afterrandomization, and those who werelost to follow-up (if any).

Following intention-to-treatprinciples, in attempting to minimizethe missing data, we followed-up onthe trial participants, even on thosewho had not adhered to the allocatedintervention.55 We examined theeffect of the intervention on eachoutcome between groups over timeusing generalized estimatingequations56 (GEEs) with the first-order autoregressive workingcorrelation structure, taking intoaccount the extra covariance betweenrepeated measurements withincreased spacing across time.57,58

Given that no missing data werefound in any of the variablesmeasured at baseline, the proportionof missing data per variable duringthe follow-up period was small(0%–3.6%), and the missing datamechanism was applied completely atrandom (x2 = 63.61; degrees offreedom = 234; P = .99). Therefore,we used standard GEE models, whichallow missing data to be modeled bymaking use of all available data55

without the need to use imputationsto replace missing data.59

For child health outcomes (asthma-related events and asthma symptoms,count data), GEE models used tospecify a log-link function anda Poisson distribution were used to

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estimate the incidence rate ratios(IRRs) and 95% confidence intervals(CIs). The analyses were adjusted forthe parent’s relationship with thechild, the parent’s age, monthlyhousehold income, marital status, thechild’s age, the child’s sex, types ofinhaled corticosteroids (ICSs),1 andthe season of enrollment.60 Forparental outcomes (continuous data),GEE models used to specify a normaldistribution with a linear responsescale were employed to estimate theeffects of the intervention, adjustedfor the parents’ age, relationship withthe child, marital status, educationallevel, and monthly householdincome.7 Post hoc comparisons werethen conducted to examine whetherthere were any significant between-group differences based on theestimated marginal means derivedfrom the GEE models.

RESULTS

Characteristics of the Participants

We screened 1727 appointmentsmade in the pediatric clinics betweenJanuary 6 and May 26, 2016. Of the302 parent-child dyads who wereidentified as eligible and invited toparticipate in the study, 168 wereenrolled and randomly allocated toeither the control group (n = 84) orthe ACT group (n = 84) (Fig 1). Thesociodemographic characteristics ofthe parent-child dyads and the parentand child measures at baseline weresimilar between groups (P valuesrange from .073 to .968). The parentswere mainly mothers (88%). Aboutone-tenth of them reported moderatelevels of depressive symptoms (8%),stress symptoms (11%), or anxietysymptoms (17%). Their children(60% boys; age mean = 6.8)experienced at least 1 day withasthma symptoms per week, andaround 40% had visited EDs becauseof asthma over the past 6 months(Table 2).

Of those 168 randomly assignedparents, 19% (15 in ACT; 16 in

control) provided baselineinformation but did not attend anyof the intervention sessions. Nosignificant differences betweengroups were noted in thecharacteristics of these parents andtheir children (P values range from.131 to .921). Six participants (1 inACT; 5 in control; 3.6% attrition)were lost to follow-up, mainlybecause of work and/or familycommitments (Fig 1).

Child Health Outcomes

The effects of interventions on theuse of unscheduled health careservices due to asthma exacerbationsover a 6-month follow-up period,measured at 6 monthspostintervention, are summarized inTable 3. When compared with thecontrol group, children whoseparents were in the ACT group hadsignificantly fewer visits to the ED(adjusted IRR = 0.20; 95% CI [0.08 to0.53]; P = .001) and fewer visits toprivate practitioners’ clinics (adjustedIRR = 0.47; 95% CI [0.26 to 0.85];P = .012). No significant differenceswere found in visits to generaloutpatient clinics (P = .063) andhospital admissions due to a child’sasthma exacerbations (P = .327). Inaddition, these children experiencedfewer days and nights withasthma symptoms (P , .001)(Table 4).

Parental Outcomes

Significantly better parentaloutcomes were also found in the ACTgroup when compared with thecontrol group when taking the timeeffect into account (Table 5). Whencompared with parents who hadreceived asthma education only, thosewho had been trained in ACT becameless psychologically inflexible(Cohen’s d = 0.80), reported havingfewer negative emotional experiencessuch as guilt and worry (d = 0.46) andsorrow and anger (d = 0.39), lessanxiety (d = 0.47), and fewersymptoms of stress (d = 0.35) at6 months postintervention. Parents

who had been trained in ACT hada better quality of life at 6 monthspostintervention than those who hadreceived asthma education only(d = 0.36) (Table 5).

Significant time-by-groupinteractions were found in allsubscales measuring parentalquality of life (P = .001) but not inparental asthma knowledge(P = .053) and self-efficacy inpreventing asthma exacerbations(P = .168).

DISCUSSION

This is the first report of an RCTfor which ACT was used in theparental management of childhoodasthma. We demonstrated that a 4-session parental training programusing group-based ACT integratedwith asthma education was moreeffective than education alone forimproving childhood asthmamorbidity and reducing psychologicaldistress. For the children of parentswho had received ACT training, the6-month incidence of their ED visitsdue to asthma exacerbations wasonly one-fifth that of childrenwhose parents had attended anasthma education talk. Likewise,children whose parents had beentrained in ACT reported fewerasthma symptoms during daytimeand nighttime (0.5–0.6 days perweek) when compared withtheir counterparts (1.9–2.3 days perweek).

A growing number of RCTs havesupported the efficacy of parent-based interventions for improvingchildhood asthma morbiditythrough addressing practical issuesin managing childhood asthma,such as poor medicationadherence,61 family conflicts,62 andparenting difficulties.63 This trialwas an extension of previousstudies as the first RCT to use ACTcombined with evidence-basedasthma education1 to address thepsychological difficulties

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FIGURE 1The Consolidated Standards of Reporting Trials diagram used to indicate the flow of participants.

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TABLE 2 Baseline Characteristics of the Parents and Their Children by Group Assignment

Total (N = 168) ACT Group (n = 84) ControlGroup (n = 84)

Parents’ characteristicsRelationship 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 symptomsDASS-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 characteristicsSex, 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)

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experienced by parents who managetheir child’s asthma. Furthermore,our training program for parentswas brief (4 sessions), implying thatthis program would use fewerresources than would be requiredfor other asthma managementprograms, such as those offeringfrequent home visits tofamilies,18,64,65 and telephonecoaching for 12 months.66

Notably, parents who were trained inACT had better PF when comparedwith parents in the control groupstarting from postintervention, andthe reductions in a child’s asthmasymptoms and ED visits due toasthma exacerbations occurred at 3and 6 months postintervention,respectively. From such sequentialchanges, it could be posited that

fostering parental PF via ACT couldbe a way to improve parentalmanagement of childhood asthma,eventually leading to betterchildhood asthma outcomes. Afurther study exploring themediating role of parental PF iswarranted. Recent research hassuggested that parents mayinfluence their child’s interpretationof asthma-related threateningcues.67 Hence, parents who becomeless anxious after the ACT trainingmight reduce their child’s biasestoward their asthma symptoms andencourage adaptive coping for betterhealth outcomes.

Consistent with our earlier study,6

the parents in the current study feltgreat distress, with their meancombined DASS-21 scores being

close to those whose childrenpresented with disruptivebehavioral problems68 andattention-deficient/hyperactivitydisorders.69 Nevertheless, our ACTintervention yielded significantsmall-to-moderate between-groupESs in parental psychologicaladjustment to a child’s illness andin parental anxiety and stresssymptoms at 6 monthspostintervention. Although theefficacy of ACT on the psychologicalhealth outcomes of adult populationshas been shown,25,70,71 includingthose of parents of children withacquired brain injuries28 orcerebral palsy,31 our study is thefirst to indicate such a therapeuticeffect in parents of children withasthma.

TABLE 2 Continued

Total (N = 168) ACT Group (n = 84) ControlGroup (n = 84)

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 thepast 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 wk1.33 (1.93) 1.31 (1.79) 1.35 (2.07)

Days with activity limitation due to asthma symptomsper wk

0.61 (1.34) 0.60 (1.40) 0.62 (1.29)

Total No. emergency care visit(s) due to asthmaexacerbation(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 asthmaexacerbation(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.a 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-sizedhousehold of 2.9 (a Hong Kong couple with a child) was ∼$25 000 HKD.b 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 thepossible range of score as 0–42.

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In our trial, we found no significantdifferences between groups over timein visits to general outpatient clinics,hospital admissions due to a child’sasthma exacerbations, parentalasthma knowledge, and parentalself-efficacy in asthma management.The parents in both groups receivedasthma education with the samecontent and number of contact hours,

but the additional ACT components,as reflected in the improved parentalPF, might confer additional benefitson many other parental and childhealth outcomes. A 12-monthfollow-up study may capturerelatively rare or seasonal asthma-related events.47

This study has its limitations. Theextended amount of time devoted to

parents who were allocated to theACT group might have contributed to

the significant intervention effects.Nevertheless, we included PF, anACT-specific measure of therapeuticprocesses, specifically to assess theeffect of the ACT.23 In addition, ourfindings indicated that ACTsignificantly enhanced the PF ofparents who joined the ACT group.

TABLE 3 Effects of the Intervention on the Child’s Use of Unscheduled Health Care Services Due to Asthma Exacerbations Over the Past 6 Months byGroups 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-GroupEffect P

Exponential b(95% CI)

P

ED visit(s) — — ,.001 .002 .004 .20 (0.08 to 0.53) .001ACT 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) .063ACT 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) .012ACT 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) .327ACT 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) .921ACT 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.a 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.b For those children who had been hospitalized because of asthma exacerbations only (n = 7; 3 in ACT group; 4 in Control group).

TABLE 4 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-GroupEffect P

Exponential b(95% CI)

P

Day symptomsb — — — .681 .005 ,.001 .25 (0.15 to 0.43) ,.001ACT 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) ,.001ACT 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) .001ACT 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) ,.001ACT 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.a 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.b 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 chesttightness) during daytime.c Night symptoms refer to the average number of night(s) per week that the child was awakened because asthma symptoms during nighttime.d 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.e 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.

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TABLE 5 Effects of the Intervention on Parental Outcomes by Groups Across Time Using GEEs

Measures Mean (SE) Tests of Adjusted GEE ModelEffectsa

Between-Group Comparison

Baseline Postintervention 6MFU TimeEffect P

GroupEffect P

Time-by-GroupEffect P

Postintervention Mdiff(95% CI)

6MFU Mdiff (95% CI)

AAQ-II — — — ,.001 .036 ,.001 23.05 (25.49 to 20.62) 25.45 (27.71 to 23.30)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 ,.001ES (95% CI)c — — — — — — 0.41 (0.10 to 0.73) 0.80 (0.48 to 1.12)

PECI: guilt and worry — — — ,.001 .199 ,.001 20.16 (20.37 to 0.04) 20.28 (20.46 to 20.10)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 .002ES (95% CI)c — — — — — — 0.25 (20.06 to 0.56) 0.46 (0.15 to 0.78)

PECI: unresolvedsorrow and anger

— — — .001 .580 .002 20.03 (20.22 to 0.16) 20.22 (20.40 to 20.04)

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 .017ES (95% CI)c — — — — — — 0.05 (20.26 to 0.36) 0.39 (0.08 to 0.70)

PECI: long-termuncertainty

— — — .001 .601 .025 0.09 (20.13 to 0.30) 20.15 (20.34 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 .146ES (95% CI)c — — — — — — 0.12 (20.18 to 0.43) 0.24 (20.07 to 0.55)

PECI: emotionalresources

— — — .001 .827 .001 0.11 (20.11 to 0.32) 0.22 (20.04 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 .097ES (95% CI)c — — — — — — 0.22 (20.09 to 0.53) 0.32 (0.01 to 0.63)

DASS-21: depressiond — — — .002 .990 .055 0.13 (21.37 to 1.62) 21.18 (22.57 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 .095ES (95% CI)c — — — 0.03 (20.28 to 0.33) 0.31 (0.00 to 0.62)

DASS-21: anxietyd — — — ,.001 .486 .002 20.12 (21.70 to 1.46) 22.20 (23.66 to 20.73)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 .003ES (95% CI)c — — — — — — 0.06 (20.25 to 0.37) 0.47 (0.16 to 0.79)

DASS-21: stressd — — — .151 .218 .002 22.33 (24.92 to 0.27) 22.50 (24.54 to 20.47)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 .016ES (95% CI)c — — — — — — 0.27 (20.04 to 0.58) 0.35 (0.04 to 0.66)

DASS-21: totald — — — .003 .433 .003 22.76 (27.80 to 2.28) 26.05 (210.56 to 21.55)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 .008ES (95% CI)c — — — — — — 0.17 (20.14 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 (20.32 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 .243ES (95% CI)c — — — — — — 0.43 (0.12 to 0.75) 0.28 (20.03 to 0.59)

PAMSES: attackprevention

— — — ,.001 .409 .168 0.03 (20.18 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) — — — — —

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Thus, we believe that ACT, andnot merely clinical attention,contributed to the outcomes thatwere observed in this study. Anotherlimitation is that the expectations ofthe parents were not measured.Hence, we were unable to determinethe role played by treatmentexpectations in the outcomesbetween groups.

All of the data on child andparental outcomes were collected byparental reports in the questionnairesand not through blinded assessors;thus, there was a chance ofresponse bias. Nevertheless, somestudies have supported the argument

that parents can accurately reporttheir child’s asthma-related events ifthe recall period is #6 months.47,72,73

Young children present challengesfor spirometric measurements74;however, a self-report by parentson their child’s asthma symptomsand the use of rescue medicationsmay reflect even more closely theactual disease status of a child at thetime of data collection.75,76

Furthermore, the instruments forassessing parental outcomes were allvalidated.48–54

At baseline, 75% of the children hadnot been hospitalized because ofasthma exacerbations, and half

(52.4%) did not require ICS, implyingthat the children in this studygenerally had a low level of severityof asthma. Our sample is similar tothat of a recent study in which 45.1%of children with asthma recruited inanother local hospital in Hong Kongdid not require ICS.77 Our samplemay therefore be representative ofurban Asian families in general whoare rearing children with a lowseverity of asthma.78 Hence, wesuggest that ACT integrated withasthma education could beuniversally adopted to help parents toimprove their management ofchildhood asthma, regardless of the

TABLE 5 Continued

Measures Mean (SE) Tests of Adjusted GEE ModelEffectsa

Between-Group Comparison

Baseline Postintervention 6MFU TimeEffect P

GroupEffect P

Time-by-GroupEffect P

Postintervention Mdiff(95% CI)

6MFU Mdiff (95% CI)

Pb — — — — — — .775 .055ES (95% CI)c — — — — — — 0.08 (20.23 to 0.39) 0.34 (0.03 to 0.65)

PAMSES: attackmanagement

— — — ,.001 .940 .015 0.02 (20.22 to 0.26) 0.18 (20.05 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 .121ES (95% CI)c — — — — — — 0.09 (20.22 to 0.40) 0.31 (20.01 to 0.62)

PAMSES: total — — — ,.001 .753 .020 0.03 (20.17 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 .055ES (95% CI)c — — — — — — 0.11 (20.20 to 0.42) 0.35 (0.04 to 0.66)

PACQL: emotionalfunction

— — — ,.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 .039ES (95% CI)c — — — — — — 0.38 (0.07 to 0.69) 0.34 (0.03 to 0.65)

PACQL: activitylimitation

— — — ,.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 .014ES (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 .023ES (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.a Adjusted for parents’ age, relationship with the child, marital status, educational level, and monthly household income.b P value for the between-group difference measured at postintervention and at the 6-mo follow-up after the intervention.c 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 theintervention.d 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 thepossible range of scores being 0–42.

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severity of their child’s asthmasymptoms. There is a need toreplicate our study in othergeographical contexts and amongdifferent target populations, such asamong parents of children withasthma who need daily ICS and/orwho frequently need to behospitalized. It is expected that suchparents may shoulder a greaterpsychological burden in managingchildhood asthma and responddifferently to ACT. Future studiescould also explore whether trainingparents in the use of ACT promotesadherence to medications; authors ofa recent meta-analysis have reportedthat psychological interventionscould be used to promote adherenceto treatment of children with chronicillnesses.79

CONCLUSIONS

Our results suggest that a parentaltraining program using group-basedACT plus asthma education is more

efficacious than an asthma educationtalk alone in reducing the frequencyof ED visits due to asthmaexacerbations, as well as in improvingasthma symptoms in young children.Group-based ACT also helps parentsto deal with the psychologicaldifficulties of managing childhoodasthma.

ACKNOWLEDGMENTS

We thank Dr Allen Dorcas for hissubstantial contribution in providingthe interventionist with training inacceptance and mindfulness skills, aswell as group skills. We also thankDr Paul Lee for providing us withstatistical advice, Miss Pui Man Li andMiss Flora Wong for their assistancein managing the data, and the nursingstaff of the Department of Pediatricand Adolescent Medicine, Tuen MunHospital, for their assistance incollecting the data. We also thank allof the participants who took part inthis study.

ABBREVIATIONS

ACT: Acceptance and CommitmentTherapy

AKQ: Asthma KnowledgeQuestionnaire

CI: confidence intervalDASS-21: Depression Anxiety

Stress Scale-21ED: emergency departmentES: effect sizeGEE: generalized estimating

equationICS: inhaled corticosteroidIRR: incidence rate ratioPACQL: Pediatric Asthma

Caregiver’s Quality of LifeQuestionnaire

PAMSES: Parent AsthmaManagement Self-Efficacy Scale

PECI: Parent Experience of ChildIllness

PF: psychological flexibilityRCT: randomized controlled triala: Cronbach’s a

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2019 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

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).

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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DOI: 10.1542/peds.2018-1723 originally published online January 18, 2019; 2019;143;Pediatrics 

Yuen-yu Chong, Yim-wah Mak, Sui-ping Leung, Shu-yan Lam and Alice Yuen LokeAsthma: An RCT

Acceptance and Commitment Therapy for Parental Management of Childhood

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Yuen-yu Chong, Yim-wah Mak, Sui-ping Leung, Shu-yan Lam and Alice Yuen LokeAsthma: An RCT

Acceptance and Commitment Therapy for Parental Management of Childhood

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