Highlights
- Acceptance and Commitment Therapy-based parenting (ACT-PAM) reduces unscheduled asthma-related health care visits in children with asthma and ADHD.
- Significant improvement in asthma control, ADHD symptomatology, parental psychological flexibility, and asthma management self-efficacy at 12 months.
- ACT-PAM offers a holistic, feasible adjunct to standard care for families facing dual chronic conditions.
Study Background and Disease Burden
Co-occurring asthma and attention-deficit/hyperactivity disorder (ADHD) in pediatric populations present a unique and challenging clinical scenario. Children with both conditions often have worse disease control, elevated risk of exacerbations, and more frequent health care utilization compared to those with asthma alone. The burden extends to families, as caregivers must navigate complex behavioral and medical regimens, often with limited psychosocial support. Traditional asthma management typically does not address the psychosocial or behavioral comorbidities inherent to ADHD, underscoring the need for integrative interventions that target both child and caregiver well-being. Psychological inflexibility in parents—difficulty adapting to stressors and maintaining effective behavior under duress—can further compromise disease management.
Study Design
This assessor-blinded, randomized clinical trial was conducted at a major Hong Kong public hospital between April 2021 and August 2023. The study enrolled 118 parent-child dyads, where children (mean age 7.9 years) had physician-diagnosed asthma and comorbid ADHD. Parents (mean age 40.3 years; 92% female) were randomized to receive either:
- ACT-PAM: Six group sessions integrating acceptance, mindfulness, values-based parenting, and asthma management, plus standard asthma care (treatment as usual, TAU).
- TAU alone: Standard asthma care per prevailing guidelines.
Randomization was stratified and analyses followed the intention-to-treat principle, ensuring robust comparison of outcomes across arms.
Primary and secondary endpoints were prospectively defined:
- Primary outcome: Number of unscheduled health care visits for asthma exacerbations over 12 months.
- Secondary outcomes: Asthma control (Childhood Asthma Control Test, C-ACT), parent-rated ADHD symptoms (SWAN scale), parental psychological inflexibility, and parental asthma management self-efficacy.
Key Findings
The ACT-PAM intervention produced clinically meaningful benefits across multiple domains:
- Health Care Utilization: Children in the ACT-PAM group had significantly fewer unscheduled health care visits for asthma exacerbations over 12 months compared to TAU alone (adjusted mean difference -0.8 visits; 95% CI, -1.6 to -0.1; adjusted incidence rate ratio 0.33; 95% CI, 0.19-0.55), translating to a 67% relative reduction in acute care needs.
- Asthma Control: C-ACT scores improved substantially in the ACT-PAM arm (aMD, 4.4; 95% CI, 2.5-6.5; Cohen d, 1.40), indicating a large effect size and improved day-to-day asthma management.
- ADHD Symptomatology: Parent-rated SWAN scores on ADHD symptoms decreased more in the ACT-PAM group (aMD, -0.5; 95% CI, -0.8 to -0.3; Cohen d, -0.94), suggesting benefits not only for asthma but also for behavioral regulation.
- Parental Psychological Flexibility: The intervention significantly reduced parental psychological inflexibility (aMD, -10.0; 95% CI, -15.6 to -4.5; Cohen d, -1.08), a key mechanism by which ACT is theorized to impact health outcomes.
- Asthma Management Self-Efficacy: Parental confidence in managing asthma improved (aMD, 0.8; 95% CI, 0.4-1.2; Cohen d, 1.20), which is known to correlate with better adherence and child outcomes.
Importantly, these improvements were sustained over 12 months, supporting the durability of ACT-PAM’s effects. No significant adverse events related to the intervention were reported.
Expert Commentary
This trial is among the first to rigorously evaluate a psychological intervention targeting both clinical and behavioral comorbidities in pediatric asthma. The large effect sizes across primary and secondary outcomes are notable, especially given the complex interplay between asthma and ADHD. The program’s focus on acceptance, mindfulness, and values-based parenting likely addresses both parental stress and the practical challenges of disease management. These findings align with growing evidence that psychological flexibility in parents can buffer the impact of chronic illness on families and improve pediatric outcomes (Hayes et al., 2012; McCracken & Morley, 2014).
However, several limitations must be acknowledged. The study population was predominantly female parents, potentially limiting generalizability. While the single-center design ensures intervention fidelity, it may not capture variability across health systems. The relatively short duration of follow-up—though longer than many behavioral trials—means long-term sustainability of effects remains to be seen. Replication in diverse populations and health care settings will be important. Mechanistically, while improvements in parental psychological flexibility are plausible mediators, further mediation analyses could clarify causal pathways.
Conclusion
The ACT-PAM program represents a promising adjunct to standard asthma care for children with comorbid ADHD. By equipping parents with tools to navigate emotional and behavioral challenges, the intervention yields not only improved asthma control and reduced health care use, but also tangible benefits for ADHD symptoms and parental well-being. Holistic, family-centered models such as ACT-PAM warrant further integration into pediatric chronic care pathways and broader research to optimize implementation.
References
1. Chong YY, Chien WT, Fung KP, Leung SP, Lam SY. Acceptance and Commitment Therapy-Based Parenting Program in Children With Co-Occurring Asthma and ADHD: A Randomized Clinical Trial. JAMA Pediatr. 2025 Aug 1;179(8):846-856. doi: 10.1001/jamapediatrics.2025.1313. PMID: 40455452; PMCID: PMC12131174.
2. Hayes SC, Strosahl KD, Wilson KG. Acceptance and Commitment Therapy: The Process and Practice of Mindful Change. 2nd ed. New York: Guilford Press; 2012.
3. McCracken LM, Morley S. The psychological flexibility model: A basis for integration and progress in psychological approaches to chronic pain management. J Pain. 2014;15(3):221-234. doi:10.1016/j.jpain.2013.10.014.
