ACT for Parents of Children With Neurodevelopmental Comorbidities

The 7-item Chinese Version of Childhood Asthma Control Test (C-CACT; Chen et al., 2008) is based on the Global Asthma Initiative clinical guidelines to assess the level of asthma control in children clinically. The C-CACT is divided into two parts. The first part is rated by the child on his/her own or with the caregiver's guidance consisting of 4 response options on the perception of asthma control, limitation of activities, coughing, and awakenings at night. Each question of the first part has four options from 0 to 3. The second part of the questionnaire is filled by the parent or the primary caregiver consisting of 3 questions, including reporting daytime symptoms, daytime wheezing, and night awakenings, using a 6-point Likert scale from 0 (Everyday) to 5 (Not at all). The sum of all scores yields the total score ranging from 0 to 27, with higher scores indicating greater asthma control. A score less than 20 shows inadequately controlled asthma.

The Asthma Behavior Checklist (ABC; Morawska, Stelzer, \& Burgess, 2008) consists of 22 behaviors that parents with asthmatic children often have to manage and will be used to assess the degree of behavioral problems associated with asthma. Parents will provide each item with a score for his/her child's asthma-related behavioral problem, using a 7-point Likert scale, ranging from 1 (Not at all) to 7 (Very much) (ABC degree α=.93). Add all the 22 items together to get the total score. The higher the score, the more child's behavioral difficulties associated with asthma.

The 18-item Chinese Strengths and Weaknesses of ADHD-symptoms and Normal-Behavior (Chinese SWAN; Lai et al., 2013) will be used to measure the child's ability to focus attention, control activity, and inhibit impulses. SWAN is developed based on the DSM-IV standard of ADHD and has high sensitivity and specificity (clinical cut-off value >90%). Parents rated the items on a 7-point response scale (-3 = far above average; -2 = above average; -1 = somewhat above average; 0 = average; 1 = somewhat below average; 2 = below average; 3 = far below average). The mean score of all the 18 items provides the ADHD-Combined (ADHD-C) score, whereas Questions 1 to 9 constitute the ADHD-Inattentive (ADHD-I) score, and Questions 10 to 18 the ADHD-Hyperactivity/Impulsivity (ADHD-HI) score. According to their respective scales or subscales, higher scores indicate higher levels of ADHD symptoms or problem behaviors.

The 7-item Chinese version of the Acceptance and Action Questionnaire-II (AAQ-II; Chong et al., 2019) will be used to measure the participating parents' psychological inflexibility, the dominance of internal events over contingencies in determining value-directed actions preventing people from making full contact with the present moments. A 7-point Likert scale is used, ranging from 1 (never true) to 7 (always true). The item scores are added together to create a total score (range 7 to 49). The higher the total score, the poor psychological flexibility (more psychologically inflexible), and the lower the total score, the better the psychological flexibility. The AAQ-II demonstrated good internal consistencies (α = .88) and test-retest reliabilities (r = .79 - .81) among the Hong Kong adult population.

The 25-item Chinese Version of Parent Experience of Child Illness (PECI; Chong et al., 2019) scale will be used to capture the psychological adjustment of parents in caring for a child with chronic diseases on a 5-point Likert scale ranging from 0 (never) to 4 (always), with two scales, PECI Distress Scale (consisting of 3 subscales: Guilt and Worry, Unresolved Sorrow and Anger, and Long-term Uncertainty) and PECI Resources Scale (consisting of 1 subscale: Emotional Resources). The scores of each subscale are added and then divided by the number of items. The PECI Distress Score and Resources Score evaluate the distress and perceived resources of caregivers of children suffering from chronic diseases. Each PECI score had adequate internal consistencies (α=.72-.89) and test-retest reliabilities (r=.83-.86) in HK parents of children with asthma.

The 17-item Chinese Version of the Parenting Sense of Competency Scale (C-PSOC; Ngai, Chan,\& Holroyd E, 2007) will be used to assess parents' perceptions of their abilities to manage parenting needs. The PSOC comprises two subscales - the Efficacy subscale, and the Satisfaction subscale. The Efficacy subscale contains eight items measuring parents' perception of competence in the parenting role. Differently, the Satisfaction subscale contains nine items evaluating the satisfaction and comfort of parents with the parenting role. Each item is scored using a 6-point Likert scale, ranging from 1 (strongly disagree) to 6 (strongly agree). The total score ranges from 17 to 102, while subscale scores range for the Efficacy and Satisfaction subscales are 17 to 48 and 17 to 54, respectively. The higher the score, the higher sense of competence and satisfaction in parenting. The PSOC had adequate internal consistencies (α=.77-.85) and test-retest reliabilities (r=.87) among Hong Kong parents.

The 13-item Chinese Version of Parent Asthma Management Self-Efficacy (PAMSE; Chong et al., 2019) scale will be employed to assess parents' self-efficacy in preventing and managing childhood acute asthma exacerbations, using a 5-point Likert scale from 1 (not at all sure) to 5 (completely sure). The PAMSE comprises two subscales that measure attack prevention self-efficacy (6 items) and attack management self-efficacy (7 items). All scores are calculated by adding up all items and dividing by the number of items. A higher score indicates better self-efficacy in the respective scales. The PAMSE had adequate internal consistencies (α=.77 - .82) and test-retest reliabilities (ICC=.76 - .87) in Hong Kong parents of children with asthma.

The 36-item Chinese version of the Pediatric Quality of Life Inventory Family Impact Module (PedsQL FIM; Chen et al., 2011) will be adopted to assess the impact of pediatric asthma comorbid with ADHD on parent health-related quality of life and the family functioning. The PedsQL FIM consists of 8 subscales: Physical Functioning (6 items), Emotional Functioning (5 items), Social Functioning (4 items), Cognitive Functioning (5 items), Communication (3 items), Worry (5 items), Daily Activities (3 items) and Family Relationships (5 items). The former six subscales measure parents' overall functioning, while the latter two subscales measure parent-reported family functioning. Each item has five Likert response options, which are 0 (never a problem) to 4 (almost always a problem). Items are then linearly transformed to a 0-100 scale (0 = 100, 1 = 75, 2 = 50, 3 = 25, 4 = 0) and averaged by the number of items, so that higher scores indicate better health-related quality of life.