Effects of a parental training program using group-based acceptance and commitment therapy for managing children with asthma : a randomized controlled trial

Abstract

Background: Efforts to control childhood asthma remains suboptimal. In the Asia-Pacific region, over half of the Asian children with asthma require emergency care services due to asthma exacerbations per year. Childhood asthma also imposes a heavy psychological burden on parents, which can adversely affect the child's health. Effective psychological interventions for these parents, however, are still lacking. Fostering parental psychological flexibility (PF) through Acceptance and Commitment Therapy (ACT) may help parents to accept their psychological difficulties and to improve their childhood asthma management in the service of their personally held values. Positive effects of ACT on the psycho-social outcomes of parents and their children with acquired brain injuries, cerebral palsy, and anorexia nervosa have been shown in a number of interventional studies. Aim: This study aimed to examine the efficacy of a parental training program using group-based ACT integrated with asthma education, in comparison with an asthma education talk as the usual care, on children's asthma management outcomes and their parents' psychological health outcomes measured at six months post-intervention in a randomized controlled trial (RCT) design. Methods: A two-arm RCT was conducted. Between 6th January 2016 and 26th May 2016, parents with children aged 3 to 12 years who had received a physician's diagnosis of asthma and without significant co-morbidities were consecutively recruited in a public hospital in Hong Kong. Eligible parent-child dyads were randomly assigned either to four weekly sessions of a training program using group-based ACT integrated with asthma education (ACT group) or to an asthma education talk as the usual care plus three weekly telephone follow-ups (Control group). The goal of ACT was to enhance the PF of the parents in caring for a child with asthma in the following ways: (i) to be aware of the thoughts and feelings of the present moment, (ii) to accept and to adapt flexibly to challenging situations, and (iii) to take actions to achieve valued goals in childhood asthma management. Throughout the four ACT sessions, six ACT therapeutic processes were applied interchangeably, which were contacting with the present moment, defusion, acceptance, self-as-context, values and committed action. An ACT-based Intervention Protocol was employed, which was developed according to the ACT model of PF by Professor Steven C. Hayes and colleagues (1999), as well as the findings from qualitative interviews of 14 Hong Kong Chinese parents to explore their psychological difficulties in taking care of a child with asthma. This protocol was tested in a pilot study of eleven parents of children with asthma to address their specific needs. The interventionist was the research investigator (Ms. Yuen-yu Chong, Ph.D candidate), who is a registered nurse in Hong Kong and had received ACT skills training, as well as supervisions by Chief Supervisor and a psychologist throughout the study period. The primary outcome of this study was the frequency of ED visits due to asthma exacerbations in children over a six-month follow-up period, measured at six months post-intervention. The secondary outcomes included the unscheduled health care service utilizations due to asthma exacerbations and asthma symptoms of the children. Other secondary outcomes included the PF, psychological adjustment in raising children with asthma, psychological symptoms in terms of anxiety, depression, and stress, asthma knowledge, asthma management self-efficacy and the quality of life of parents. All the outcomes were assessed by parental reports through validated questionnaires and the data collectors were blinded to the group assignments. Changes in the aforementioned outcomes between groups over time were analyzed using adjusted generalized estimating equations and in accordance with the intention-to-treat principle. Results: One hundred and sixty-eight parents (age M = 38.4, 88.1% mothers) and their children with asthma (age M = 6.8) participated in the RCT. Of these, six parent-child dyads were lost to follow-up by the end of the study. At six months post-intervention, when compared with the Control group, children whose parents were in the ACT group had significantly fewer ED visits (adjusted incidence rate ratio (IRR) = 0.20, 95% CI [0.08, 0.53], p = .001) and fewer private practitioners' clinic visits (adjusted IRR = 0.47, 95% CI [0.26, 0.85], p = .012) due to asthma exacerbations over the six-month follow-up period. In addition, these children exhibited fewer days of asthma symptoms during the daytime, fewer nights with disturbed sleep due to asthma symptoms and fewer days of using inhaled bronchodilators to relieve asthma symptoms (all ps ranged from <.001 to .001). There were no significant effects on the general outpatient visits (p = .063) and hospital admissions due to child's asthma exacerbations (p = .327). Significant time-by-group interactions were found in almost all parental psychological health outcomes (all ps ranged from <.001 to .025). Parents who were trained with ACT became more psychologically flexible (d = 0.80), reported with less negative emotional experiences such as guilt and worry (d = 0.46), sorrow and anger (d = 0.39), less anxiety (d = 0.47) and stress symptoms (d = 0.35), and attained a better quality of life (d = 0.36) at six months post-intervention when compared with those who attended an asthma education talk only. The time-by-group interaction effects on the parental asthma knowledge (p =.053) and the parental self-efficacy in preventing asthma exacerbations (p = .168) were non-significant. Significance: This RCT study is one of the first to test an innovative intervention, ACT, for helping parents to manage psychological difficulties aroused when taking care of their children with asthma. The results suggest that fostering the psychological flexibility of parents through ACT combined with asthma education improve their childhood asthma management and their psychological well-being. Given that the ACT intervention was delivered by a trained nurse, via a group-based approach and in brief sessions, it has its practical utility in clinical settings with less resource implications. In addition, this study raises the importance of incorporating an assessment of parental psychological difficulties in routine asthma care, which may help to identify those parents most in need for a psychological intervention like ACT. To conclude, helping parents to develop an unconditional acceptance of challenges and a consistent commitment to what they truly value may be particularly helpful to improve their management of a child's chronic disease.