Is Parental Mindfulness Associated with Quality of Life and Itch Intensity in Children with Psoriasis and Eczema and Well-being in Parents?

The sample comprised children with psoriasis or eczema and/or their parents or carers. In total, 210 parents/carers (one per family) completed the questionnaires (females n=183; M age=39.97; SD=7.16). The children of 30 of these parents chose not to participate in the study. As a result, 180 children completed the questionnaires (females n=108; diagnosed with eczema n=125; M age=10.22, SD=0.29; see Table 1). Of the parent participants, 43 were recruited using social media, and 167 were recruited from 15 NHS hospital clinics based around the UK.

Parent–child dyads were recruited from two sources—NHS clinics and online via social media—using a convenience sampling method. Participants recruited from NHS clinics completed hard copies of questionnaires either directly before or after a clinic visit, or at home. Participants who were recruited online completed the questionnaire using the survey platform, Qualtrics (Provo, UT, USA). The questionnaires were also advertised using social media. Inclusion criteria were (i) child aged 4–17 years with psoriasis or eczema; (ii) parent of a child with psoriasis or eczema; and (iii) fluent English speaker. Each parent who completed the questionnaires was entered into a prize draw for the chance to win one of four £50 gift vouchers. Ethical approval was obtained from the Health Research Authority (NHS Yorkshire & The Humber—Sheffield Research Ethics Committee) and the study was pre-registered at https://​aspredicted.​org/​xf429.​pdf (see Supplementary Materials A). Participants completed questionnaires in the order presented below.

Parents reported their own age, gender, ethnicity, employment status, and education level, as well as their child’s age and gender. Parents provided medical information about their child, including comorbid medical conditions, duration of condition, and perceived skin condition severity (rated ‘mild’, ‘moderate’, or ‘severe’).

The Five-Factor Mindfulness Questionnaire (FFMQ; Baer et al., 2006) assessed parental dispositional mindfulness. This 39-item self-report questionnaire measures five facets of mindfulness: observing, describing, acting with awareness, non-judgement of inner experience, and non-reactivity to inner experience. Items are rated on 5-point Likert scales ranging from 1 (‘never or very rarely true’) to 5 (‘very often or always true’), and responses to each facet are summed. The FFMQ has demonstrated convergent validity in relation to a number of variables that are conceptually related to mindfulness (openness to experience, emotional intelligence, self-compassion), and divergent validity in relation to a number of variables that are conceptually unrelated to mindfulness (neuroticism, psychological symptoms, thought suppression) in a non-clinical sample (Baer et al., 2006). Previously, internal consistency for the FFMQ subscales was found to be good in a non-clinical sample (e.g. range α=0.75–0.91; Baer et al., 2006). In the current study, internal consistency for the full scale and subscales was also good (range α=0.80–0.91).

The Paediatric Inventory for Parents (PIP; Streisand et al., 2001) assessed levels of parental stress related to their child’s skin condition. This 42-item self-report questionnaire measures the frequency and difficulty of a range of scenarios that may be experienced by parents of children with an illness over the past week (Streisand et al., 2001). Items are rated on a 5-point Likert scale ranging from 1 (‘never’ or ‘not at all’) to 5 (‘very often’ or ‘extremely’), and responses for frequency and difficulty are summed separately. The PIP has demonstrated good psychometric properties in parents of children with a range of different health conditions (e.g. diabetes, Lewin et al., 2005; cancer, Streisand et al., 2001). For example, in a sample of parents of children with type 1 diabetes, the PIP demonstrated good internal consistency (frequency α=0.97; difficulty α=0.94) and convergent validity in relation to maternal anxiety and child mental health difficulties. In the current study, internal consistency for the frequency total score was α=0.96 and for the difficulty total score was α=0.95.

The Depression, Anxiety, and Stress Scale (DASS-21; Henry & Crawford, 2005; Lovibond & Lovibond, 1995) assessed parent’s levels of depression, anxiety, and general stress over the past week. This self-report questionnaire comprises 21-items, each rated on a 4-point Likert scale ranging from 0 (‘never’) to 3 (‘almost always’), and responses for each subscale are summed. The DASS-21 has demonstrated convergent and divergent validity in relation to other measures of depression and anxiety in non-clinical samples (e.g. Antony et al., 1998; Henry & Crawford, 2005). Previously, internal consistency for the DASS-21 total scale and subscales has been found to be good in non-clinical samples (e.g. range α=0.82–0.93; Henry & Crawford, 2005). In this study, the internal consistency of the DASS-21 total scores and subscale scores was also good (α=0.92–0.97).

The Family Dermatology Life Quality Index (FDLQI; Basra et al., 2007) assessed parental quality of life related to the child’s skin condition. This self-report measure comprises 10 items assessing a range of ways that a family member’s skin condition may affect an individual’s quality of life over the past month. For the current study, the phrase “relative/partner’s skin disease” was changed to “child’s skin disease”. Items are rated on 4-point Likert scales ranging from 0 (“not at all”) to 3 (“very much”), and responses were summed. The FDLQI has demonstrated convergent validity in relation to the family member skin-related quality of life score (Basra et al., 2007). The FDLQI has demonstrated good internal consistency (α=0.88) and test–retest reliability (intraclass correlation=0.94) in individuals with a range of skin conditions (Basra et al., 2007). In the current study, internal consistency of the FDLQI was α=0.91.

The Children’s Dermatology Life Quality Index (CDLQI; Lewis-Jones & Finlay, 1995) assessed children’s quality of life related to their skin condition. This self-report measure comprises 10 items assessing the extent to which a child’s skin condition has impacted different aspects of their life over the past week. Items are rated on a 4-point Likert scale ranging from 0 (“not at all”) to 3 (“very much”), and responses are summed. The CDLQI has demonstrated convergent validity in relation to a range of conceptually related variables (e.g. impact of the skin condition on family members, severity of skin condition), and divergent validity through higher scores in children with a skin condition than those without (see Salek et al., 2013, for a review). The cartoon version of the measure, which has demonstrated similar psychometric properties to the standard version (Holme et al., 2003), was used for those children in the current study who were 10 years old or younger. The CDLQI has demonstrated good internal consistency in children with a range of skin conditions (range α=0.82–0.92). Internal consistency for the CDLQI in this study was α=0.88.

Itch intensity was assessed by asking children to rate “how itchy is your psoriasis/eczema?” using a visual analogue scale ranging from 0 to 10 (‘0’=no itch; ‘10’=worst imaginable itch). This method of assessing itch has been recommended by the special interest group on scoring itch in clinical trials (Ständer et al., 2013).

Descriptive statistics were used to present demographic, medical, and well-being characteristics of the participants. Parents and children with psoriasis versus eczema were also compared on these variables using t-tests or chi-squared tests (see Supplementary Materials B).

Associations between the demographic variables (age, gender, employment status, ethnicity, education level), medical variables (duration of condition, skin condition severity, skin condition, other medical conditions), parental stress, psychological distress (anxiety, depression, general stress), quality of life (parent and child), and itch intensity were assessed using t-tests or correlations (see Supplementary Materials C, Table 1; these analyses were also run separately for those with eczema and those with psoriasis; see Supplementary Materials C, Tables 3 and 5).

Associations between parental dispositional mindfulness and measures of parental stress, psychological distress, quality of life (parent and child), and itch intensity were assessed using bivariate correlation analyses (Table 2; see Supplementary Materials C, Table 2, 4, and 6 for the full correlation matrices for the full sample, for those with eczema, and for those with psoriasis). Regression analyses were then conducted to examine the amounts of variance in the parent and child outcomes explained by mindfulness (four facets of the FFMQ) controlling for any significant demographic or medical variables (Tables 3 and 4). These analyses were repeated as moderated regression analyses using the PROCESS macro in SPSS, with skin condition as the moderator variable, to test whether relationships between the FFMQ subscales and parent and child outcomes differed for the two groups (see Supplementary Materials D). The observe subscale of the FFMQ was not included in the regression analyses as it had relatively small correlations with the FFMQ total scale (r=0.38 vs r=0.53–0.81 for the other subscales) and was differentially related to some of the well-being variables (e.g. positively related to anxiety; r=0.21). This is in line with research suggesting the observed facet may not be measuring mindful awareness in non-meditators and should be omitted from analyses (Baer et al., 2008; Cohen, 1988). Demographic or medical variables that were significantly associated with the dependent variables were controlled for in the regression analyses.

Multicollinearity among the independent variables was tested in two ways. First, correlations between the independent variables were examined. Second, collinearity statistics (i.e. tolerance, variance inflation factors) and collinearity diagnostics (i.e. condition index, variance proportions) were computed for all regression analyses. None of these tests indicated that multicollinearity was a cause for concern (i.e. coefficients <0.80; tolerance values >0.20; variance inflation factors <10; condition index <30; variance proportions, for each independent variable, only one value >0.50, Field, 2005; Tabachnick & Fidell, 1996).

Demographic, medical, and well-being variables are summarised in Table 1. T-tests and chi-squared tests comparing the two groups on demographic, medical, and well-being variables are reported in Supplementary Materials B.

Correlations and t-tests between demographic, medical, and well-being variables are summarised in Supplementary Materials C, Table 1.

Correlations between parental dispositional mindfulness and the parent and child well-being variables are summarised in Table 2 (see Supplementary Materials C, Table 2, for a full correlation matrix). The describe, acting with awareness, and non-judgement of inner experience subscales of the FFMQ were all significantly correlated with each of the following outcomes: parental stress, depression, anxiety, general stress, parental quality of life, and child quality of life. The acting with awareness and non-judgement subscale was also significantly correlated with itch intensity.

All interaction terms between the FFMQ subscales and skin condition were found to be non-significant (see Supplementary Materials D), thereby indicating that relationships between mindfulness and the child and parent outcomes did not differ by skin condition (i.e. psoriasis versus eczema).

There were some limitations to the current study. Only 55 children with psoriasis were recruited into the study, as opposed to 125 with eczema. As a result, it was not possible to run separate regression analyses due to low statistical power. Instead, moderated regression analyses tested whether skin condition moderated relationships between mindfulness and the child and parent outcomes. All moderation effects were non-significant, indicating that the relationships were similar across both skin conditions. The cross-sectional design means it cannot be assumed that increased mindfulness leads to improved well-being. It is possible that parents who are more stressed also have reduced capacity for mindful awareness. In addition, children were only assessed on quality of life and itch and it may have been useful to investigate the relationships between parental mindfulness and other child variables, such as depression and anxiety. It may have also been informative to assess the relationship between child dispositional mindfulness and parent and child well-being (including itch intensity). However, this would have been difficult in a large proportion of our sample, as current measures of dispositional mindfulness in children are validated for those aged 8 years and above (Goodman et al., 2017).

A further limitation of this study is that common method bias may have been introduced due to using self-report questionnaires to assess all constructs (Podsakoff et al., 2003, 2012). In other words, the likelihood of inflated or spurious correlations may have increased due to biases common to self-report measures, such as response styles or social desirability. We attempted to overcome this limitation by emphasising to participants that their responses were anonymous and there were no right or wrong answers to the questions. In addition, children completed questionnaires themselves, rather than their parents on their behalf. Nonetheless, future studies should seek to further overcome this limitation by introducing another sources of measurement, such as objective measures of parent mindfulness (e.g. see Wong et al., 2018) or clinical ratings of disease severity.

There were also some strengths to the current study that should be highlighted. In particular, a large diverse sample of participants was recruited from clinics and community settings in the UK. In addition, important clinical and demographic variables were measured and controlled for in the analyses.

Future studies could assess the relationship between child dispositional mindfulness and well-being in older children (i.e. 8 years or older) with skin conditions, as the relationship may be stronger than the relationship between parent dispositional mindfulness and child well-being. Future studies with this population could also assess how often parents practice mindfulness—particularly studies testing the efficacy of mindfulness interventions—as this can increase dispositional mindfulness (Kiken et al., 2015). Parents who practice mindfulness more regularly would be expected to have higher well-being than those who practice less regularly. Finally, future studies are needed to test whether mindfulness-based interventions improve well-being in children with skin conditions and their parents.