Mental health and professional outcomes in parents of children with chronic kidney disease

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Methods This cross-sectional study compared parents of CKD patients (0–18 years) with a matched control group of parents of healthy children. Both groups completed the Parenting Stress Index – Short Form, the Hospital Anxiety and Depression Scale, and a sociodemographic questionnaire. Results The study group consisted of 45 parents (median age 39; 32 mothers) of CKD patients (median age 8; 36% female). Nearly 75% of children had CKD stage 2, 3, or 4, and 44.5% had congenital anomaly of the kidney and urinary tract. Five children (11%) were on dialysis, and 4 (9%) had a functioning kidney graft. Compared with parents of healthy children, more stress and anxiety symptoms were reported. Since the CKD diagnosis, 47% of parents perceived a deterioration of their own health, and 40% reduced work on a structural basis. Higher levels of stress, anxiety and depression symptoms were associated with a more negative perception of own health, and more child medical comorbidities and school absence. Conclusions This study showed higher levels of stress and anxiety symptoms in parents of children with CKD compared with parents of healthy children. This was associated with a less positive perception of the own health, especially if the child had more medical comorbidities or more absence from school. Psychosocial interventions to reduce the parental burden should be integrated in the standard care of pediatric nephrology departments. Children Chronic Kidney Disease Parents Health Stress Anxiety Depression Professional Figures Figure 1 Figure 2 Figure 3 Introduction Chronic kidney disease (CKD) has a significant impact on the psychosocial development of a child. Compared with healthy peers, lower quality of life (QoL) and more psychological problems are reported in children with mild to advanced stages of CKD or after kidney transplantation [ 1 – 5 ]. Like numerous other chronic diseases in childhood, these children depend on their primary caregivers, mainly parents, for the challenging disease management, which heightens the risk of stress among these parents [ 1 , 6 ]. Despite medical advances resulting in higher survival rates [ 7 , 8 ], parents have to face a far above average mortality risk in their child [ 7 ]. Furthermore, parents are faced with the daily challenges of coping with their child’s dietary and fluid restrictions, complex and time-intensive medical treatments, frequent outpatient visits or hospitalizations, and lifelong consequences of the disease [ 9 , 10 ]. The impact of parenting a child with a chronic illness on parents’ mental health has been a focus in several studies and systematic reviews. Compared with parents of healthy children, lower QoL [ 11 ], higher parental stress [ 12 , 6 , 13 , 14 ] and more frequent symptoms of anxiety and depression [ 15 , 16 ] were found in parents caring for a chronically ill child in general. Also more difficulties with employment [ 17 ] and a higher financial burden [ 6 , 18 ] have been reported in these parents. Less is known about the impact on parents specifically in a CKD population, although Bignall et al stated that the persistent nature of this chronic disease affects parents in such a way that it could be said that when a child is diagnosed with CKD, the whole family develops a “chronic condition” as well [ 19 ]. Reducing the impact of CKD on parents’ mental health seems essential, not only for the parents themselves but also to improve the psychosocial functioning and physical health of the child, as parental stress was found to be associated with lower QoL scores in the child [ 20 , 21 ], a higher presence of behavioral problems, and lower adherence to immunosuppressant medications [ 22 , 23 ]. Also, parental stress can negatively affect the children’s and parents’ perceptions of the child’s CKD management [ 24 ], health and well-being [ 8 ]. Most studies with parents in a CKD population have focused on either parental stress, anxiety or depression, and only a minority has been focusing on how these mental health outcomes are associated with parent and child characteristics. A recent systematic review revealed that studies exploring physical health in parents of chronically ill children are scarce [ 16 ] and to our knowledge nonexistent specifically for a CKD population. Also studies exploring child variables such as comorbid medical diagnoses or developmental disorders are scarce. Such studies are however needed to improve our understanding and to set up tailored interventions, as these parents are chronically exposed to these additional stressors [ 19 , 25 ]. To address these research gaps, this study aims to 1/ compare the prevalence and clinical scores of both stress, anxiety and depression symptoms in parents of children with CKD with a matched control group of parents of healthy children, and 2/ explore the associations of these three mental health outcomes with several characteristics of the parent (e.g. parent’s own health perception, structural work reduction, additional work leave) and the child with CKD (e.g. medical comorbidities, developmental disorders, school absence). Additionally, we sought to identify predictors of parental stress, anxiety and depression symptoms. Methods Study Population This exploratory study consecutively included parents of children aged 0–18 years with CKD stages 1 to 5D or after transplantation managed at the Pediatric Nephrology Departments of three University Hospitals in Belgium, namely Ghent, Leuven, and Antwerp, between 2015 to 2017 (Table 1). CKD was defined according to the KDIGO guidelines and classified in different stages (1 to 5) according to the estimated glomerular filtration rate (eGFR), determined by the updated bedside Schwartz formula (eGFR = 0.413*length/creatinin) [ 26 , 27 ]. As this study is part of the multicentric UToPaed study, we refer to El Amouri et al for more detailed information concerning the methods [ 28 ]. The control group of parents of healthy children was recruited from the general population by snowball sampling and was individually matched by parent’s gender and child’s gender and age. Parents of children with a chronic medical condition were excluded for this control group. Exclusion criteria for both groups were related to the possibility of adequate completion of questionnaires, such as severe cognitive disability or an insufficient knowledge of Dutch. This study was approved by the Ethics Committee of the Ghent University Hospital (B670201524922 and B670201731893). A written informed consent was obtained from all parents. Participation was voluntary and no payments or other rewards were provided. After informed consent had been provided, all parents were asked to complete the Parenting Stress Index - Short Form (PSI-SF), the Hospital Anxiety and Depression Scale (HADS), and a self-developed sociodemographic questionnaire. Additional medical information of the CKD patients was obtained from the medical files. Measures Clinical and sociodemographic data Sociodemographic information such as the parent’s age, gender, marital status, country of birth, education level and number of children living at home was collected from all parents. Also, parents provided the following information about their child: age, gender, developmental disorders (e.g., autism spectrum disorder, attention problems or learning disabilities), psychosocial support (e.g., psychologist) or developmental support (physiotherapist, speech therapist, …), special educational needs, and absence from school (recall of number of days in the past 6 months). Additionally, parents of children with CKD were asked to indicate if they had reduced their professional activities on a regular basis since the CKD diagnosis, and to report the number of additional days they had taken off from work in the past 6 months to care for their child with CKD. Also, we asked these parents how they perceived their own health since the diagnosis of their child (equal/better/worse). Finally, parents were asked to report any medical comorbidities 1 in their child. Additional relevant clinical information was obtained from the child’s medical chart such as underlying kidney disease, CKD stage, current treatment, kidney transplantation, and duration of CKD. Parenting Stress Index – Short Form (PSI-SF) The short version of the Dutch Parenting Stress Index (PSI-SF) is a 25-item screening questionnaire for parenting stress [ 29 , 30 ]. Parents rate the items on a six-point Likert scale ranging from 1 (‘totally disagree’) to 6 (‘totally agree’). The PSI-SF total score is the sum score of the 25 items (maximum score 150), with higher scores indicating higher levels of parenting stress. Hospital Anxiety & Depression Scale (HADS) Symptoms of anxiety and depression in parents were assessed with the HADS [ 31 ]. This 14-item self-report screening tool is divided into two 7-item scales; anxiety and depression. The questions are answered on a four-point Likert scale (0–3) resulting in scores on each scale from 0 to 21. Higher scores indicate more symptoms of anxiety respectively depression in the past week. A scale score of 8 (cut-off score) or above is considered as an indicator for clinically significant anxiety or depression [ 31 ]. The Dutch version of the HADS showed satisfactory validity and reliability [ 32 ]. Statistical methods All statistical analyses were examined by using SPSS 25.0. Normality was checked with the Shapiro-Wilk test. Parents’ and children’s characteristics in the CKD group and the non-clinical control group were compared using independent samples t-tests and Chi-square tests (as appropriate). Mann–Whitney U-tests were performed to compare the median levels, and Chi-square tests to compare the proportions in the clinical range. Correlations were calculated using Spearman correlations. Linear regression analyses were performed to explore which parental and child variables were associated with parental stress and symptoms of anxiety and depression. Due to the small sample size and to maximize the reliability of the analyses, only 5 predictors were included in the regression model (i.e., parents’ own health perception, child age, CKD stage, child’s medical comorbidities, child’s developmental disorders). In order to determine multicollinearity between two or more predictor variables, variance inflation factors (VIF) were used. No problematic multicollinearity was detected, as all VIF values were lower than 2. To correct for multiple testing, Bonferroni correction was performed. Results Clinical and sociodemographic data The characteristics of the included parents of children with CKD (N = 45) and parents of healthy children (N = 45) are shown in Table 1. In the CKD group, the majority of parents (median age 39) who completed the questionnaires were mothers (71%), and most families had 2 to 3 children (60%). Parents in the CKD group did not differ from the parents in the control group with respect to their age, gender, or number of children ( P > 0.05). Compared with the control group, less parents were born in Belgium (87% versus 98% in the control group; P = 0.01), were married or living together (76% versus 93% in the control group; P = 0.04) or completed higher education (56% versus 78% in the control group; P = 0.01). In the CKD group, 40% of parents reduced work on a structural basis since the CKD diagnosis in order to take care for their child. On average, parents had taken 4 additional days off from work in the past 6 months (median 4 days [0.5; 13]), with a maximum of 90 days. Also, 47% of parents perceived a deterioration of their own health since the CKD diagnosis of their child. Children with CKD (median age 8; 36% female) did not differ from the healthy controls with respect to their age or gender ( P > 0.05). In the CKD group, nearly 75% of children were categorized in CKD stage 2 (N = 24) , 3 (N = 24) or 4 (N = 24), and 44.5% was diagnosed with congenital anomaly of kidney and urinary tract (CAKUT). Five children (11%) were on dialysis, 4 children (9%) had undergone a kidney transplantation. The time since CKD diagnosis was on average 6 years. For 14 children (31%), parents reported one or more comorbid medical conditions. We refer to the Appendix for more information about these medical comorbidities. In this study sample, parent reports showed no significant differences in the presence of developmental disorders or absence from school. However, children in the CKD group made more use of professional psychosocial or developmental support on a regular basis (38% versus 9%; P < 0.001), and more often got special education versus the children in the control group (20% versus 2%; P = 0.01). Differences in parental stress and symptoms of anxiety and depression In the present study sample, Cronbach’s alpha for the total PSI-SF score was 0.93 in the CKD group and 0.88 in the control group, showing good internal consistency. Similar good internal consistency was observed in the HADS with a Cronbach’s alpha score of 0.82 for the depression scale in the CKD group and 0.77 in the control group, and 0.84 for the anxiety scale in both groups. Differences in stress, anxiety and depression symptoms between parents of CKD patients and parents of healthy children are presented in Table 2. Parents of children with CKD reported significantly higher levels of stress ( P < 0.001) and anxiety symptoms ( P < 0.01) compared with parents of healthy children. Considering symptoms of depression, no significant differences could be detected between both parent groups. Boxplots visualizing these comparisons are added as Supplemental Figures 1 to 3. The proportions in the clinical range for stress, anxiety and depression are also shown in Table 2. No significant differences were found between parents of children with CKD and parents of healthy children. Correlations Scatterplots of the correlations between parental stress, anxiety and depression symptoms in parents of children with CKD are presented in Figures 1 to 3. Additionally, Table 3 shows the correlations of these 3 mental health outcomes with parental and child characteristics. Correlation analyses indicated significantly positive correlations between parental stress, anxiety and depression symptoms (Figures 1 to 3). Table 3 shows that parental stress, anxiety and depression symptoms were negatively correlated with the parent’s own health perception ( P < 0.01), and positively correlated with the child’s medical comorbidities ( P < 0.01). Also, parental stress was positively correlated with child’s absence from school ( P < 0.05). Predictors of parental stress and symptoms of anxiety and depression Linear regression analyses indicated that parents of children with CKD who perceived their own health as less positive, reported more symptoms of anxiety (β = -0.51; t = -3.48; P = 0.001) and depression (β = -0.46; t = -3.16; P = 0.003) (Table 4). The explained variance was 14 % for parental stress (F(5) = 2.43; P = 0.05 ) , 27 % for anxiety symptoms (F(5) = 4.26; P = 0.004), and 29 % for depression (F(5) = 4.48; P = 0.003 ) . Discussion The primary objective of this study was to compare the levels of stress, anxiety and depression symptoms between parents of children with chronic kidney disease (CKD) and parents of healthy children. Additionally, we aimed to investigate the associations of various parental and child variables with these mental health outcomes. Furthermore, we sought to identify predictors of parental stress, anxiety and depression symptoms. First, we showed that parents of children with CKD reported higher levels of stress and anxiety symptoms. These findings are consistent with earlier research reporting more stress and anxiety symptoms in parents of CKD patients when compared with parents of healthy children [ 33 – 36 , 24 ]. Also studies with caregivers of children diagnosed with other chronic illnesses reported higher levels of parental stress [ 6 , 13 , 14 ], anxiety or depression [ 15 , 16 ]. Even after kidney transplantation, which may lead to a substantial improvement in the child’s health condition, parents still report more psychological distress compared with parents of non-transplants or healthy controls [ 37 , 38 , 20 ]. As possible explanations, however not questioned in this study, other studies often refer to the high responsibility for the child’s health, the enduring insecurity about the child’s future [ 37 ], fear for kidney loss [ 39 ], and the challenging transition to adulthood [ 40 , 21 ]. Tong et al also refer to the traumatizing effect on parents of watching their child undergo invasive medical procedures [ 41 ]. Second, we found the presence of medical comorbidities in the child being associated with more parental stress, anxiety and depression symptoms. Also a more negative perception of the own health was associated with higher levels of parental stress, anxiety and depression symptoms, and 47% of our parents perceived a deterioration of their own health since the CKD diagnosis of their child. It can be considered as a limitation that this study only used a subjective health measurement, as parents rated their own health since their child’s diagnosis in terms of equal, better or worse. Also, it is possible that parent’s perception of health deterioration might be predicted by parental stress, anxiety or depression symptoms, rather than otherwise. Nevertheless, these study findings can already shed some light on the possible physical impact of caring for a child with CKD, even in an early stage, as CKD stage was not found to be a significant predictor for parental stress, anxiety or depression in our study. To our knowledge, the impact of a child’s illness on the parents’ physical health had not been examined in a CKD population before, although more research exists in other chronic diseases. For instance, a large study involving patients with cerebral palsy found that caregivers experienced lower levels of psychological and physical health when the child exhibited more behavioral problems. Conversely, less caregiving demands were associated with better physical and psychological well-being among caregivers [ 42 ]. Also, two meta-analyses reported greater levels of parental stress [ 18 ] and poorer physical health among parents of children with developmental disabilities (e.g., autism spectrum disorder, Down syndrome, vision/hearing loss, or epilepsy) and chronic health conditions (such as growth deficiencies, asthma, feedings problems, congenital heart diseases) [ 18 , 43 ]. Concerning the professional impact, 40% of the parents reduced work on a structural basis to care for their child with CKD. In addition to the structural work reduction, parents had taken a median of 4 days off from work in the last 6 months. However, 20% of parents reported more than 15 days of work leave, and even up to 90 days, in these past 6 months, showing that some parents reported a much larger professional impact than others. This finding is consistent with Grootenhuis et al who reported that parents taking care of a chronically ill child have greater difficulties with employment in general [ 17 ]. In another study using focus-group methodology, parents of chronically ill children expressed their struggles with balancing between work, life and caring for their child, next to other issues like transport, financial management, and the child’s school [ 33 ]. Specifically in a CKD population, frequent and sometimes long distance clinic visits, dialysis treatments, and medical and non-medical expenses result in a great burden for parents with lost time, income from work and financial stress [ 44 ]. According to Tsai et al [ 45 ], caregivers of children on peritoneal dialysis were less likely to hold a full-time job and had lower average earnings. They also revealed that these caregivers were found to have threefold higher likelihood of experiencing symptoms of depression compared with caregivers of healthy children [ 45 ]. Future research should further explore these additional social and financial variables, as this financial stress may contribute to the worse mental health outcomes in these parents [ 24 , 37 , 44 ]. As a limitation it can be addressed that our study group of parents of children with CKD consisted of mainly mothers being married or living together with a partner. Future research should aim to explore larger and more representative sample sizes that include both mothers and fathers in various marital states, as the levels of stress, anxiety and depression might be lower in fathers compared with mothers based on earlier studies with parents of children with a chronic illness or developmental disorders [ 18 , 46 , 15 ]. Furthermore, considering the possibility of higher stress and anxiety/depression levels in single parent families, particularly in single mothers, could provide valuable insights [ 17 , 47 ]. Also, the majority of parents were born in Belgium and we excluded parents with an insufficient knowledge of Dutch, whereas more inclusion of non-native speaking parents (e.g. refugees and migrants) could result in even worse mental health outcomes due to additional burden [ 48 , 18 ]. Finally, compared with the control group, in the CKD group less parents completed higher education, which may have influenced our worse mental health outcomes in this parent group. Evidence for this hypothesis can be found in earlier studies reporting a negative impact of lower socioeconomic status on the physical and psychological health in parents of children with chronic conditions or developmental disabilities [ 43 , 18 ]. Despite the limitations of the study, this research has several strengths. This study is - to our knowledge - the first to compare both parental stress, anxiety and depression symptoms in parents of CKD patients with a matched control group of parents of healthy children. Also, no earlier research explored the association of these mental outcomes with variables such as parent’s own health perception and professional background, or child’s medical and developmental comorbidities. In conclusion, this study has provided valuable insights into the mental health and professional burden experienced by parents of children with CKD. Our findings revealed that these parents face higher levels of parental stress and anxiety symptoms compared with parents of healthy children. These outcomes were primarily associated with the child’s medical comorbidities and the parents’ negative perception of their own health, and secondly with the child’s absence from school. In addition to addressing the psychological and physical health of parents, this study also shed light on the professional challenges they face. Therefore, it is crucial to incorporate psychosocial interventions as an integral part of the comprehensive care provided to these families. By doing so, we can potentially reduce parental stress and improve the overall health outcomes for both parents and their children. Abbreviations CKD: chronic kidney disease QoL: quality of life eGFR: estimated glomerular filtration rate CAKUT: congenital anomaly of kidney and urinary tract Declarations Funding This study was part of a larger project (IWT-TBM 150195), funded by the Agency for Innovation by Science and Technology (IWT) of Flanders (Belgium). Conflicts of interest/Competing interests The authors have no conflicts of interest to declare that are relevant to the content of this article. Availability of data and material The datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request. Ethics approval The questionnaires and methodology for this study were approved by the Ethics Committee of the Ghent University Hospital (Ethics approval number: B670201524922 and B670201731893). Consent to participate A written informed consent was obtained from all parents included in the study. Acknowledgments First of all, we would like to thank the families who participated in this study. We would also like to thank Charlotte Van Herzeele for the design and initiation of the study, and Els Holvoet, Katty Van Cauwenberge, Joris Van Helleputte, Sofie Vermeire and Maria Van Dijck for their help in the follow-up and data-collection. Thank you to Dimitri van Ryckeghem, Wouter Bosmans and Dries Debeer from Ghent University for their support in developing our online survey and statistical support. Finally, we would like to thank our multidisciplinary teams for their help in recruiting study patients. We appreciate the support of all caregivers for their daily care of children with CKD, with the goal to optimize the well-being of these patients and their families. 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Child Care Health and Development 43 (6):831-838. https://doi.org/10.1111/cch.12476 Aldridge MD (2008) How do families adjust to having a child with chronic kidney failure? A systematic review. Nephrology nursing journal : journal of the American Nephrology Nurses' Association 35 (2):157-162 Lima AGT, Sales C, Serafim WFL (2019) Burden, depression and anxiety in primary caregivers of children and adolescents in renal replacement therapy. J Bras Nefrol 41 (3):356-363. https://doi.org/10.1590/2175-8239-jbn-2018-0039 Adejumo OA, Iyawe IO, Akinbodewa AA, Abolarin OS, Alli EO (2019) Burden, psychological well-being and quality of life of caregivers of end stage renal disease patients. Ghana Med J 53 (3):190-196. https://doi.org/10.4314/gmj.v53i3.2 Walker RC, Naicker D, Kara TT, Palmer SC (2019) parents' perspectives and experiences of kidney transplantation in children: A qualitative interview study. Journal of Renal Care 45 (3):193-200. https://doi.org/10.1111/jorc.12292 Kärrfelt HM, Berg UB, Lindblad FI (2000) Renal transplantation in children: psychological and donation-related aspects from the parental perspective. Pediatr Transplant 4 (4):305-312. https://doi.org/10.1034/j.1399-3046.2000.00135.x Mantulak A, Nicholas DB (2016) "We're not going to say it's suffering; we're going to say it's an experience": The lived experience of maternal caregivers in pediatric kidney transplantation. Soc Work Health Care 55 (8):580-594. https://doi.org/10.1080/00981389.2016.1208712 Tong A, Lowe A, Sainsbury P, Craig JC (2008) Experiences of parents who have children with chronic kidney disease: A systematic review of qualitative studies. Pediatrics 121 (2):349-360. https://doi.org/10.1542/peds.2006-3470 Tong A, Lowe A, Sainsbury P, Craig JC (2010) Parental perspectives on caring for a child with chronic kidney disease: an in-depth interview study. Child Care Health and Development 36 (4):549-557. https://doi.org/10.1111/j.1365-2214.2010.01067.x Raina P, O'Donnell M, Rosenbaum P, Brehaut J, Walter SD, Russell D, Swinton M, Zhu B, Wood E (2005) The health and well-being of caregivers of children with cerebral palsy. Pediatrics 115 (6):e626-636. https://doi.org/10.1542/peds.2004-1689 Masefield SC, Prady SL, Sheldon TA, Small N, Jarvis S, Pickett KE (2020) The Caregiver Health Effects of Caring for Young Children with Developmental Disabilities: A Meta-analysis. Matern Child Health J 24 (5):561-574. https://doi.org/10.1007/s10995-020-02896-5 Medway M, Tong A, Craig JC, Kim S, Mackie F, McTaggart S, Walker A, Wong G (2015) Parental Perspectives on the Financial Impact of Caring for a Child With CKD. Am J Kidney Dis 65 (3):384-393. https://doi.org/10.1053/j.ajkd.2014.07.019 Tsai TC, Liu SI, Tsai JD, Chou LH (2006) Psychosocial effects on caregivers for children on chronic peritoneal dialysis. Kidney Int 70 (11):1983-1987. https://doi.org/10.1038/sj.ki.5001811 Van Oers H, Haverman L, Limperg P, Van Dijk-Lokkart A, Maurice-Stam H, Grootenhuis M (2012) Anxiety and depression in fathers and mothers of children with a chronic disease. Qual Life Res 21:77-77 Olhaberry M, Farkas C (2012) Maternal Stress and Family Constitution: Comparative Study on Chilean, Single-Mother and Nuclear, Low-Income Families. Universitas Psychologica 11 (4):1317-1326 Sekkarie MA, Abdel-Rahman EM (2017) Cultural Challenges in the Care of Refugees with End-Stage Renal Disease: What Western Nephrologists Should Know. Nephron 137 (2):85-90. https://doi.org/10.1159/000477362 Footnotes Parents were asked if their child with CKD had any other diagnoses (yes/no), not related to CKD. In case of yes, parents were asked to specify how many and which medical comorbidities their child had. For all statistical analyses the researchers used the total number of medical comorbidities. We refer to Appendix 1 for more detailed information. Tables Table 1. Clinical and sociodemographic data CKD (N=45) Healthy (N=45) Median (IQR) Median (IQR) χ 2 (df) P Parents Age 39 (11) 41 (9) 26.55 (28) 0.54 Work leave past 6 months (in days) minimum – maximum 25pc – 75pc 4 (12.5) 0 - 90 0.5 – 13 - - - Children Age 8 (9.5) 8 (9.5) 6.89 (16) 0.97 Duration of CKD (years) 6 (9) - - - N (%) N (%) t (df) P Parents Gender (female) 32 (71) 35 (78) 0.69 (85) 0.49 Country of birth (outside Belgium) 6 (13) 1 (2) 2.60 (88) 0.01 Two to 3 children 27 (60) 36 (80) -0.73 (85) 0.47 Married/living together 34 (76) 42 (93) 2.04 (88) 0.04 Higher education 25 (56) 35 (78) -2.58 (88) 0.01 Structural work reduction since child’s CKD diagnosis (= yes) 18 (40) - - - Perception of own health deterioration since child’s CKD diagnosis (= yes) 21 (47) - - - Children Gender (female) Stages of CKD Stage 1 (>90mL/min/1.73m²) Stage 2 (60-89mL/min/1.73m²) Stage 3 (30-59mL/min/1.73m²) Stage 4 (15-29mL/min/1.73m²) Stage 5 (<14mL/min/1.73m²) ESKD, on peritoneal dialysis ESKD, on hemodialysis Missing 16 (36) 3 (7) 11 (24) 11 (24) 11 (24) 3 (7) 2 (4) 3 (7) 1 (2) 17 (38) 0.22 (88) 0.83 Underlying kidney disease Cystic disease CAKUT Glomerulonephritis Other/unknown Proximal tubular disease Missing 2 (4.5) 20 (44.5) 10 (22) 9 (20) 2 (4.5) 2 (4.5) - - - Kidney transplant in past Medical comorbidities (total) 4 (9) 14 (31) - - - - - Developmental disorders (total) Autism spectrum disorder Attention problems Learning disabilities Combination 11 (24) 1 1 5 4 6 (13) 0 2 3 1 1.35 (88) 0.18 Psychosocial/developmental support 17 (38) 4 (9) -3.41 (88) <0.01 Special education 9 (20) 1 (2) -2.79 (80) 0.01 Part-time school attendance 5 (11) 1 (2) -1.71 (80) 0.09 CKD: chronic kidney disease; N: number; IQR: interquartile range; χ 2: Chi-square test; df: degrees of freedom; P : p-value; 25pc: 25 th percentile; 75pc: 75 th percentile; t : independent samples t-test; ESKD: end stage kidney disease; CAKUT: congenital anomalies of kidney and urinary tract. Statistically significant p-values (p<0.05) are highlighted in bold. Table 2. Stress, anxiety and depression symptoms in parents of children with CKD and parents of healthy children Parents of children with CKD (N=45) Parents of healthy children (N=45) Symptoms Median (IQR) Median (IQR) U (df) Stress a 55 (29) 39 (24) 578.5 (88)*** Anxiety b 8 (6) 5 (6) 624.5 (88)** Depression b 4 (6) 3 (4) 817.5 (88) Proportions in clinical range N (%) N (%) χ 2 (df) Stress a 17 (38) 5 (11) 8.7 (1) Anxiety b 23 (51) 12 (27) 5.7 (1) Depression b 12 (27) 5 (11) 3.5 (1) * p< 0.05; ** p< 0.01; *** p< 0.001. Statistically significant p-values are highlighted in bold. Higher median scores represent higher levels of stress, or more symptoms of anxiety or depression. a According to the Parenting Stress Index – Short Form; normal scores range from 43 to 61. b According to the Hospital Anxiety and Depression Scale; normal scores range from 0 to 7. CKD: chronic kidney disease; N: number; IQR: interquartile range; U : Mann-Whitney test; df: degrees of freedom; χ 2: :Chi-square test. Table 3. Spearman correlations between parental stress, anxiety and depression symptoms, and clinical and sociodemographic variables in parents of children with CKD (N=45) Parental stress a Anxiety symptoms b Depression symptoms b Age parent 0.03 -0.14 -0.08 Age child 0.10 0.01 -0.14 Number of children 0.18 0.23 0.24 Perception own health -0.40** -0.66** -0.54** Work leave 0.12 0.26 0.12 Duration CKD 0.13 0.01 -0.08 Comorbidities Med. comorb. Child 0.43** 0.44** 0.39** Developm. dis. Child 0.12 0.23 0.15 School absence 0.30* 0.18 -0.07 * p< 0.05; ** p< 0.01; *** p< 0.001. Statistically significant p-values are highlighted in bold. a According to the Parenting Stress Index – Short Form; b According to the Hospital Anxiety and Depression Scale. CKD: chronic kidney disease; N: number; Perception own health: parent’s perception of own health since child’s CKD diagnosis; Work leave: days of work leave in addition to structural work reduction past 6 months due to child’s health problems; Med. comorb. child: Medical comorbidities in child (number); Developm. Dis child: developmental disorders in child (number); School absence: School absence past 6 months (days). Table 4. Standardized regression coefficients for parental stress and symptoms of anxiety and depression predicted by clinical and sociodemographic variables of parents and children with CKD Parental stress a Anxiety symptoms b Depression symptoms b β t β t β t Perception own health -0.12 -0.79 -0.51 -3.48** -0.46 -3.16** Age child 0.09 0.59 -0.15 -1.11 -0.32 -2.36 CKD stage 0.12 0.80 0.07 0.49 0.07 0.49 Med. comorb. child 0.36 2.37 0.19 1.35 0.23 1.65 Developm. dis. child 0.03 0.20 -0.02 -0.18 -0.04 -0.26 * p< 0.05; ** p< 0.01; *** p< 0.001. Statistically significant p-values are highlighted in bold. a According to the Parenting Stress Index – Short Form; b According to the Hospital Anxiety and Depression Scale. CKD: chronic kidney disease; Perception own health: perception of own health since child’s CKD diagnosis; Med. comorb. child: medical comorbidities in child (number); Developm. dis. child: developmental disorders in child (number); β : standardized regression coefficient; t : t-value. Supplementary Files APPENDIXDeBruyneUnivHospGhent.docx SUPPLEMMATERIALDeBruyneUnivHospGhent.docx Cite Share Download PDF Status: Published Journal Publication published 22 Apr, 2024 Read the published version in Pediatric Nephrology → Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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10:08:54","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3375535/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3375535/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00467-024-06372-y","type":"published","date":"2024-04-23T00:48:50+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":44034443,"identity":"78bf45c7-cae9-4b09-9eec-ed3e553cb7f0","added_by":"auto","created_at":"2023-10-03 17:43:56","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":144265,"visible":true,"origin":"","legend":"\u003cp\u003eScatterplot of Spearman’s correlations between total scores of the Parenting Stress Index – Short Form and the Anxiety scale scores of the Hospital Anxiety and Depression Scale in parents of children with CKD (N=45)\u003c/p\u003e\n\u003cp\u003eCKD: chronic kidney disease; N: number; \u003cem\u003eρ \u003c/em\u003e: Spearman’s correlation coefficient; \u003cem\u003eP\u003c/em\u003e: p-value.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-3375535/v1/58ef6a7a31b77a9ed51a3a66.jpeg"},{"id":44034440,"identity":"29c6b987-1e3b-47bf-81ce-ff148f5a815d","added_by":"auto","created_at":"2023-10-03 17:43:56","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":145665,"visible":true,"origin":"","legend":"\u003cp\u003eScatterplot of Spearman’s correlations between total scores of the Parenting Stress Index – Short Form and the Depression scale scores of the Hospital Anxiety and Depression Scale in parents of children with CKD (N=45)\u003c/p\u003e\n\u003cp\u003eCKD: chronic kidney disease; N: number;\u003cem\u003e ρ\u003c/em\u003e: Spearman’s correlation coefficient; \u003cem\u003eP\u003c/em\u003e: p-value.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-3375535/v1/801b5294b58704f230f48265.jpeg"},{"id":44035267,"identity":"1a694fe2-5fdd-4878-8482-b78bfa9ba9d8","added_by":"auto","created_at":"2023-10-03 17:51:56","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":146350,"visible":true,"origin":"","legend":"\u003cp\u003eScatterplot of Spearman’s correlations between the Anxiety scale scores and the Depression scale scores of the Hospital Anxiety and Depression Scale in parents of children with CKD (N=45)\u003c/p\u003e\n\u003cp\u003eCKD: chronic kidney disease; N: number;\u003cem\u003e ρ\u003c/em\u003e: Spearman’s correlation coefficient; \u003cem\u003eP\u003c/em\u003e: p-value.\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-3375535/v1/b5d84f03dd56454b1a436e28.jpeg"},{"id":55196995,"identity":"b9d293de-ffd7-42a9-9115-984bc9507c6b","added_by":"auto","created_at":"2024-04-24 00:48:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":492669,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3375535/v1/d9315446-51b3-45b7-9a33-59c095b83029.pdf"},{"id":44034426,"identity":"f60a3b83-964a-4d77-b82f-b4adfb142229","added_by":"auto","created_at":"2023-10-03 17:43:55","extension":"docx","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":39310,"visible":true,"origin":"","legend":"","description":"","filename":"APPENDIXDeBruyneUnivHospGhent.docx","url":"https://assets-eu.researchsquare.com/files/rs-3375535/v1/61f889b2f5a47c4ad506e945.docx"},{"id":44035266,"identity":"caede695-54bd-4836-9af4-860f6be135b4","added_by":"auto","created_at":"2023-10-03 17:51:56","extension":"docx","order_by":7,"title":"","display":"","copyAsset":false,"role":"supplement","size":85557,"visible":true,"origin":"","legend":"","description":"","filename":"SUPPLEMMATERIALDeBruyneUnivHospGhent.docx","url":"https://assets-eu.researchsquare.com/files/rs-3375535/v1/4efffcb1b19d764d1c582ea4.docx"}],"financialInterests":"","formattedTitle":"Mental health and professional outcomes in parents of children with chronic kidney disease","fulltext":[{"header":"Introduction","content":"\u003cp\u003eChronic kidney disease (CKD) has a significant impact on the psychosocial development of a child. Compared with healthy peers, lower quality of life (QoL) and more psychological problems are reported in children with mild to advanced stages of CKD or after kidney transplantation [\u003cspan additionalcitationids=\"CR2 CR3 CR4\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Like numerous other chronic diseases in childhood, these children depend on their primary caregivers, mainly parents, for the challenging disease management, which heightens the risk of stress among these parents [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Despite medical advances resulting in higher survival rates [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], parents have to face a far above average mortality risk in their child [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Furthermore, parents are faced with the daily challenges of coping with their child\u0026rsquo;s dietary and fluid restrictions, complex and time-intensive medical treatments, frequent outpatient visits or hospitalizations, and lifelong consequences of the disease [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e The impact of parenting a child with a chronic illness on parents\u0026rsquo; mental health has been a focus in several studies and systematic reviews. Compared with parents of healthy children, lower QoL [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], higher parental stress [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] and more frequent symptoms of anxiety and depression [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] were found in parents caring for a chronically ill child in general. Also more difficulties with employment [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] and a higher financial burden [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] have been reported in these parents.\u003c/p\u003e \u003cp\u003eLess is known about the impact on parents specifically in a CKD population, although Bignall \u003cem\u003eet al\u003c/em\u003e stated that the persistent nature of this chronic disease affects parents in such a way that it could be said that when a child is diagnosed with CKD, the whole family develops a \u0026ldquo;chronic condition\u0026rdquo; as well [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Reducing the impact of CKD on parents\u0026rsquo; mental health seems essential, not only for the parents themselves but also to improve the psychosocial functioning and physical health of the child, as parental stress was found to be associated with lower QoL scores in the child [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], a higher presence of behavioral problems, and lower adherence to immunosuppressant medications [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Also, parental stress can negatively affect the children\u0026rsquo;s and parents\u0026rsquo; perceptions of the child\u0026rsquo;s CKD management [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], health and well-being [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e Most studies with parents in a CKD population have focused on either parental stress, anxiety or depression, and only a minority has been focusing on how these mental health outcomes are associated with parent and child characteristics. A recent systematic review revealed that studies exploring physical health in parents of chronically ill children are scarce [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] and to our knowledge nonexistent specifically for a CKD population. Also studies exploring child variables such as comorbid medical diagnoses or developmental disorders are scarce. Such studies are however needed to improve our understanding and to set up tailored interventions, as these parents are chronically exposed to these additional stressors [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. To address these research gaps, this study aims to 1/ compare the prevalence and clinical scores of both stress, anxiety and depression symptoms in parents of children with CKD with a matched control group of parents of healthy children, and 2/ explore the associations of these three mental health outcomes with several characteristics of the parent (e.g. parent\u0026rsquo;s own health perception, structural work reduction, additional work leave) and the child with CKD (e.g. medical comorbidities, developmental disorders, school absence). Additionally, we sought to identify predictors of parental stress, anxiety and depression symptoms.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Population\u003c/h2\u003e \u003cp\u003e This exploratory study consecutively included parents of children aged 0\u0026ndash;18 years with CKD stages 1 to 5D or after transplantation managed at the Pediatric Nephrology Departments of three University Hospitals in Belgium, namely Ghent, Leuven, and Antwerp, between 2015 to 2017 (Table\u0026nbsp;1). CKD was defined according to the KDIGO guidelines and classified in different stages (1 to 5) according to the estimated glomerular filtration rate (eGFR), determined by the updated bedside Schwartz formula (eGFR\u0026thinsp;=\u0026thinsp;0.413*length/creatinin) [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. As this study is part of the multicentric UToPaed study, we refer to El Amouri \u003cem\u003eet al\u003c/em\u003e for more detailed information concerning the methods [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe control group of parents of healthy children was recruited from the general population by snowball sampling and was individually matched by parent\u0026rsquo;s gender and child\u0026rsquo;s gender and age. Parents of children with a chronic medical condition were excluded for this control group.\u003c/p\u003e \u003cp\u003eExclusion criteria for both groups were related to the possibility of adequate completion of questionnaires, such as severe cognitive disability or an insufficient knowledge of Dutch.\u003c/p\u003e \u003cp\u003e This study was approved by the Ethics Committee of the Ghent University Hospital (B670201524922 and B670201731893). A written informed consent was obtained from all parents. Participation was voluntary and no payments or other rewards were provided.\u003c/p\u003e \u003cp\u003e After informed consent had been provided, all parents were asked to complete the Parenting Stress Index - Short Form (PSI-SF), the Hospital Anxiety and Depression Scale (HADS), and a self-developed sociodemographic questionnaire. Additional medical information of the CKD patients was obtained from the medical files.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eMeasures\u003c/h2\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003eClinical and sociodemographic data\u003c/h2\u003e \u003cp\u003eSociodemographic information such as the parent\u0026rsquo;s age, gender, marital status, country of birth, education level and number of children living at home was collected from all parents. Also, parents provided the following information about their child: age, gender, developmental disorders (e.g., autism spectrum disorder, attention problems or learning disabilities), psychosocial support (e.g., psychologist) or developmental support (physiotherapist, speech therapist, \u0026hellip;), special educational needs, and absence from school (recall of number of days in the past 6 months).\u003c/p\u003e \u003cp\u003eAdditionally, parents of children with CKD were asked to indicate if they had reduced their professional activities on a regular basis since the CKD diagnosis, and to report the number of additional days they had taken off from work in the past 6 months to care for their child with CKD. Also, we asked these parents how they perceived their own health since the diagnosis of their child (equal/better/worse). Finally, parents were asked to report any medical comorbidities\u003csup\u003e1\u003c/sup\u003e in their child. Additional relevant clinical information was obtained from the child\u0026rsquo;s medical chart such as underlying kidney disease, CKD stage, current treatment, kidney transplantation, and duration of CKD.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eParenting Stress Index \u0026ndash; Short Form (PSI-SF)\u003c/h2\u003e \u003cp\u003eThe short version of the Dutch Parenting Stress Index (PSI-SF) is a 25-item screening questionnaire for parenting stress [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Parents rate the items on a six-point Likert scale ranging from 1 (\u0026lsquo;totally disagree\u0026rsquo;) to 6 (\u0026lsquo;totally agree\u0026rsquo;). The PSI-SF total score is the sum score of the 25 items (maximum score 150), with higher scores indicating higher levels of parenting stress.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eHospital Anxiety \u0026amp; Depression Scale (HADS)\u003c/h2\u003e \u003cp\u003eSymptoms of anxiety and depression in parents were assessed with the HADS [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. This 14-item self-report screening tool is divided into two 7-item scales; anxiety and depression. The questions are answered on a four-point Likert scale (0\u0026ndash;3) resulting in scores on each scale from 0 to 21. Higher scores indicate more symptoms of anxiety respectively depression in the past week. A scale score of 8 (cut-off score) or above is considered as an indicator for clinically significant anxiety or depression [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. The Dutch version of the HADS showed satisfactory validity and reliability [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical methods\u003c/h2\u003e \u003cp\u003eAll statistical analyses were examined by using SPSS 25.0. Normality was checked with the Shapiro-Wilk test.\u003c/p\u003e \u003cp\u003eParents\u0026rsquo; and children\u0026rsquo;s characteristics in the CKD group and the non-clinical control group were compared using independent samples t-tests and Chi-square tests (as appropriate). Mann\u0026ndash;Whitney U-tests were performed to compare the median levels, and Chi-square tests to compare the proportions in the clinical range. Correlations were calculated using Spearman correlations. Linear regression analyses were performed to explore which parental and child variables were associated with parental stress and symptoms of anxiety and depression. Due to the small sample size and to maximize the reliability of the analyses, only 5 predictors were included in the regression model (i.e., parents\u0026rsquo; own health perception, child age, CKD stage, child\u0026rsquo;s medical comorbidities, child\u0026rsquo;s developmental disorders). In order to determine multicollinearity between two or more predictor variables, variance inflation factors (VIF) were used. No problematic multicollinearity was detected, as all VIF values were lower than 2. To correct for multiple testing, Bonferroni correction was performed.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eClinical and sociodemographic data\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe characteristics of the included parents of children with CKD (N = 45) and parents of healthy children (N = 45) are shown in Table 1. In the CKD group, the majority of parents (median age 39) who completed the questionnaires were mothers (71%), and most families had 2 to 3 children (60%). Parents in the CKD group did not differ from the parents in the control group with respect to their age, gender, or number of children (\u003cem\u003eP\u003c/em\u003e \u0026gt; 0.05). Compared with the control group, less parents were born in Belgium (87% versus 98% in the control group; \u003cem\u003eP\u003c/em\u003e = 0.01), were married or living together (76% versus 93% in the control group; \u003cem\u003eP\u003c/em\u003e = 0.04) or completed higher education (56% versus 78% in the control group; \u003cem\u003eP\u003c/em\u003e = 0.01).\u003c/p\u003e\n\u003cp\u003eIn the CKD group, 40% of parents reduced work on a structural basis since the CKD diagnosis in order to take care for their child. On average, parents had taken 4 additional days off from work in the past 6 months (median 4 days [0.5; 13]), with a maximum of 90 days. Also, 47% of parents perceived a deterioration of their own health since the CKD diagnosis of their child.\u003c/p\u003e\n\u003cp\u003eChildren with CKD (median age 8; 36% female) did not differ from the healthy controls with respect to their age or gender (\u003cem\u003eP\u003c/em\u003e \u0026gt; 0.05). In the CKD group, nearly 75% of children were categorized in CKD stage 2 (N = 24) , 3 (N = 24) or 4 (N = 24), and 44.5% was diagnosed with congenital anomaly of kidney and urinary tract (CAKUT). Five children (11%) were on dialysis, 4 children (9%) had undergone a kidney transplantation. The time since CKD diagnosis was on average 6 years. For 14 children (31%), parents reported one or more comorbid medical conditions. We refer to the Appendix for more information about these medical comorbidities.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn this study sample, parent reports showed no significant differences in the presence of developmental disorders or absence from school. However, children in the CKD group made more use of professional psychosocial or developmental support on a regular basis (38% versus 9%; \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001), and more often got special education versus the children in the control group (20% versus 2%; \u003cem\u003eP\u003c/em\u003e = 0.01).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDifferences in parental stress and symptoms of anxiety and depression\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the present study sample, Cronbach\u0026rsquo;s alpha for the total PSI-SF score was 0.93 in the CKD group and 0.88 in the control group, showing good internal consistency. Similar good internal consistency was observed in the HADS with a Cronbach\u0026rsquo;s alpha score of 0.82 for the depression scale in the CKD group and 0.77 in the control group, and 0.84 for the anxiety scale in both groups.\u003c/p\u003e\n\u003cp\u003eDifferences in stress, anxiety and depression symptoms between parents of CKD patients and parents of healthy children are presented in Table 2. Parents of children with CKD reported significantly higher levels of stress (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001) and anxiety symptoms (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.01) compared with parents of healthy children. Considering symptoms of depression, no significant differences could be detected between both parent groups. Boxplots visualizing these comparisons are added as Supplemental Figures 1 to 3.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe proportions in the clinical range for stress, anxiety and depression are also shown in Table 2. No significant differences were found between parents of children with CKD and parents of healthy children.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCorrelations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eScatterplots of the correlations between parental stress, anxiety and depression symptoms in parents of children with CKD are presented in Figures 1 to 3. Additionally, Table 3 shows the correlations of these 3 mental health outcomes with parental and child characteristics.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCorrelation analyses indicated significantly positive correlations between parental stress, anxiety and depression symptoms (Figures 1 to 3). Table 3 shows that parental stress, anxiety and depression symptoms were negatively correlated with the parent\u0026rsquo;s own health perception (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.01), and positively correlated with the child\u0026rsquo;s medical comorbidities (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.01). Also, parental stress was positively correlated with child\u0026rsquo;s absence from school (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePredictors of parental stress and symptoms of anxiety and depression\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLinear regression analyses indicated that parents of children with CKD who perceived their own health as less positive, reported more symptoms of anxiety (\u0026beta; = -0.51; t = -3.48; \u003cem\u003eP\u003c/em\u003e = 0.001) and depression (\u0026beta; = -0.46; t = -3.16; \u003cem\u003eP\u003c/em\u003e = 0.003) (Table 4). The explained variance was 14 % for parental stress (F(5) = 2.43; \u003cem\u003eP\u003c/em\u003e = 0.05\u003cstrong\u003e)\u003c/strong\u003e, 27 % for anxiety symptoms (F(5) = 4.26; \u003cem\u003eP\u003c/em\u003e = 0.004), and 29 % for depression (F(5) = 4.48; \u003cem\u003eP\u003c/em\u003e = 0.003\u003cstrong\u003e)\u003c/strong\u003e. \u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe primary objective of this study was to compare the levels of stress, anxiety and depression symptoms between parents of children with chronic kidney disease (CKD) and parents of healthy children. Additionally, we aimed to investigate the associations of various parental and child variables with these mental health outcomes. Furthermore, we sought to identify predictors of parental stress, anxiety and depression symptoms.\u003c/p\u003e \u003cp\u003eFirst, we showed that parents of children with CKD reported higher levels of stress and anxiety symptoms. These findings are consistent with earlier research reporting more stress and anxiety symptoms in parents of CKD patients when compared with parents of healthy children [\u003cspan additionalcitationids=\"CR34 CR35\" citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Also studies with caregivers of children diagnosed with other chronic illnesses reported higher levels of parental stress [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], anxiety or depression [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Even after kidney transplantation, which may lead to a substantial improvement in the child\u0026rsquo;s health condition, parents still report more psychological distress compared with parents of non-transplants or healthy controls [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. As possible explanations, however not questioned in this study, other studies often refer to the high responsibility for the child\u0026rsquo;s health, the enduring insecurity about the child\u0026rsquo;s future [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], fear for kidney loss [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e], and the challenging transition to adulthood [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Tong \u003cem\u003eet al\u003c/em\u003e also refer to the traumatizing effect on parents of watching their child undergo invasive medical procedures [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSecond, we found the presence of medical comorbidities in the child being associated with more parental stress, anxiety and depression symptoms. Also a more negative perception of the own health was associated with higher levels of parental stress, anxiety and depression symptoms, and 47% of our parents perceived a deterioration of their own health since the CKD diagnosis of their child. It can be considered as a limitation that this study only used a subjective health measurement, as parents rated their own health since their child\u0026rsquo;s diagnosis in terms of equal, better or worse. Also, it is possible that parent\u0026rsquo;s perception of health deterioration might be predicted by parental stress, anxiety or depression symptoms, rather than otherwise. Nevertheless, these study findings can already shed some light on the possible physical impact of caring for a child with CKD, even in an early stage, as CKD stage was not found to be a significant predictor for parental stress, anxiety or depression in our study. To our knowledge, the impact of a child\u0026rsquo;s illness on the parents\u0026rsquo; physical health had not been examined in a CKD population before, although more research exists in other chronic diseases. For instance, a large study involving patients with cerebral palsy found that caregivers experienced lower levels of psychological and physical health when the child exhibited more behavioral problems. Conversely, less caregiving demands were associated with better physical and psychological well-being among caregivers [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Also, two meta-analyses reported greater levels of parental stress [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] and poorer physical health among parents of children with developmental disabilities (e.g., autism spectrum disorder, Down syndrome, vision/hearing loss, or epilepsy) and chronic health conditions (such as growth deficiencies, asthma, feedings problems, congenital heart diseases) [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eConcerning the professional impact, 40% of the parents reduced work on a structural basis to care for their child with CKD. In addition to the structural work reduction, parents had taken a median of 4 days off from work in the last 6 months. However, 20% of parents reported more than 15 days of work leave, and even up to 90 days, in these past 6 months, showing that some parents reported a much larger professional impact than others. This finding is consistent with Grootenhuis \u003cem\u003eet al\u003c/em\u003e who reported that parents taking care of a chronically ill child have greater difficulties with employment in general [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In another study using focus-group methodology, parents of chronically ill children expressed their struggles with balancing between work, life and caring for their child, next to other issues like transport, financial management, and the child\u0026rsquo;s school [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Specifically in a CKD population, frequent and sometimes long distance clinic visits, dialysis treatments, and medical and non-medical expenses result in a great burden for parents with lost time, income from work and financial stress [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. According to Tsai \u003cem\u003eet al\u003c/em\u003e [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e], caregivers of children on peritoneal dialysis were less likely to hold a full-time job and had lower average earnings. They also revealed that these caregivers were found to have threefold higher likelihood of experiencing symptoms of depression compared with caregivers of healthy children [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Future research should further explore these additional social and financial variables, as this financial stress may contribute to the worse mental health outcomes in these parents [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAs a limitation it can be addressed that our study group of parents of children with CKD consisted of mainly mothers being married or living together with a partner. Future research should aim to explore larger and more representative sample sizes that include both mothers and fathers in various marital states, as the levels of stress, anxiety and depression might be lower in fathers compared with mothers based on earlier studies with parents of children with a chronic illness or developmental disorders [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Furthermore, considering the possibility of higher stress and anxiety/depression levels in single parent families, particularly in single mothers, could provide valuable insights [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Also, the majority of parents were born in Belgium and we excluded parents with an insufficient knowledge of Dutch, whereas more inclusion of non-native speaking parents (e.g. refugees and migrants) could result in even worse mental health outcomes due to additional burden [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Finally, compared with the control group, in the CKD group less parents completed higher education, which may have influenced our worse mental health outcomes in this parent group. Evidence for this hypothesis can be found in earlier studies reporting a negative impact of lower socioeconomic status on the physical and psychological health in parents of children with chronic conditions or developmental disabilities [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite the limitations of the study, this research has several strengths. This study is - to our knowledge - the first to compare both parental stress, anxiety and depression symptoms in parents of CKD patients with a matched control group of parents of healthy children. Also, no earlier research explored the association of these mental outcomes with variables such as parent\u0026rsquo;s own health perception and professional background, or child\u0026rsquo;s medical and developmental comorbidities.\u003c/p\u003e \u003cp\u003eIn conclusion, this study has provided valuable insights into the mental health and professional burden experienced by parents of children with CKD. Our findings revealed that these parents face higher levels of parental stress and anxiety symptoms compared with parents of healthy children. These outcomes were primarily associated with the child\u0026rsquo;s medical comorbidities and the parents\u0026rsquo; negative perception of their own health, and secondly with the child\u0026rsquo;s absence from school. In addition to addressing the psychological and physical health of parents, this study also shed light on the professional challenges they face. Therefore, it is crucial to incorporate psychosocial interventions as an integral part of the comprehensive care provided to these families. By doing so, we can potentially reduce parental stress and improve the overall health outcomes for both parents and their children.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCKD: chronic kidney disease\u003c/p\u003e\n\u003cp\u003eQoL: quality of life\u003c/p\u003e\n\u003cp\u003eeGFR: estimated glomerular filtration rate\u003c/p\u003e\n\u003cp\u003eCAKUT: congenital anomaly of kidney and urinary tract\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e This study was part of a larger project (IWT-TBM 150195), funded by the Agency for Innovation by Science and Technology (IWT) of Flanders (Belgium).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest/Competing interests\u003c/strong\u003e The authors have no conflicts of interest to declare that are relevant to the content of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e The datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e The questionnaires and methodology for this study were approved by the Ethics Committee of the Ghent University Hospital (Ethics approval number: B670201524922 and B670201731893).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e A written informed consent was obtained from all parents included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFirst of all, we would like to thank the families who participated in this study. We would also like to thank Charlotte Van Herzeele for the design and initiation of the study, and Els Holvoet, Katty Van Cauwenberge, Joris Van Helleputte, Sofie Vermeire and Maria Van Dijck for their help in the follow-up and data-collection. Thank you to Dimitri van Ryckeghem, Wouter Bosmans and Dries Debeer from Ghent University for their support in developing our online survey and statistical support. Finally, we would like to thank our multidisciplinary teams for their help in recruiting study patients. We appreciate the support of all caregivers for their daily care of children with CKD, with the goal to optimize the well-being of these patients and their families.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMarciano RC, Soares CMB, Diniz JSS, Lima EM, Silva JMP, Canhestro MR, Gazzinelli A, Melo CCD, Dias CS, Silva A, Correa H, Oliveira EA (2011) Behavioral disorders and low quality of life in children and adolescents with chronic kidney disease. Pediatr Nephrol 26 (2):281-290. https://doi.org/10.1007/s00467-010-1683-y\u003c/li\u003e\n\u003cli\u003eDe Bruyne E, Eloot S, Vande Walle J, Raes A, Van Biesen W, Goubert L, Vervoort T, Snauwaert E, Van Hoecke E (2022) Validity and reliability of the Dutch version of the PedsQL (TM) 3.0 End Stage Renal Disease Module in children with chronic kidney disease in Belgium. 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Journal of Renal Care 45 (3):193-200. https://doi.org/10.1111/jorc.12292\u003c/li\u003e\n\u003cli\u003eK\u0026auml;rrfelt HM, Berg UB, Lindblad FI (2000) Renal transplantation in children: psychological and donation-related aspects from the parental perspective. Pediatr Transplant 4 (4):305-312. https://doi.org/10.1034/j.1399-3046.2000.00135.x\u003c/li\u003e\n\u003cli\u003eMantulak A, Nicholas DB (2016) \"We're not going to say it's suffering; we're going to say it's an experience\": The lived experience of maternal caregivers in pediatric kidney transplantation. Soc Work Health Care 55 (8):580-594. https://doi.org/10.1080/00981389.2016.1208712\u003c/li\u003e\n\u003cli\u003eTong A, Lowe A, Sainsbury P, Craig JC (2008) Experiences of parents who have children with chronic kidney disease: A systematic review of qualitative studies. 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Matern Child Health J 24 (5):561-574. https://doi.org/10.1007/s10995-020-02896-5\u003c/li\u003e\n\u003cli\u003eMedway M, Tong A, Craig JC, Kim S, Mackie F, McTaggart S, Walker A, Wong G (2015) Parental Perspectives on the Financial Impact of Caring for a Child With CKD. Am J Kidney Dis 65 (3):384-393. https://doi.org/10.1053/j.ajkd.2014.07.019\u003c/li\u003e\n\u003cli\u003eTsai TC, Liu SI, Tsai JD, Chou LH (2006) Psychosocial effects on caregivers for children on chronic peritoneal dialysis. Kidney Int 70 (11):1983-1987. https://doi.org/10.1038/sj.ki.5001811\u003c/li\u003e\n\u003cli\u003eVan Oers H, Haverman L, Limperg P, Van Dijk-Lokkart A, Maurice-Stam H, Grootenhuis M (2012) Anxiety and depression in fathers and mothers of children with a chronic disease. Qual Life Res 21:77-77\u003c/li\u003e\n\u003cli\u003eOlhaberry M, Farkas C (2012) Maternal Stress and Family Constitution: Comparative Study on Chilean, Single-Mother and Nuclear, Low-Income Families. Universitas Psychologica 11 (4):1317-1326\u003c/li\u003e\n\u003cli\u003eSekkarie MA, Abdel-Rahman EM (2017) Cultural Challenges in the Care of Refugees with End-Stage Renal Disease: What Western Nephrologists Should Know. Nephron 137 (2):85-90. https://doi.org/10.1159/000477362\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Footnotes","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e Parents were asked if their child with CKD had any other diagnoses (yes/no), not related to CKD. In case of yes, parents were asked to specify how many and which medical comorbidities their child had. For all statistical analyses the researchers used the total number of medical comorbidities. We refer to Appendix 1 for more detailed information.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"602\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.25956738768719%\" valign=\"top\"\u003e\n \u003cp\u003eTable 1. Clinical and sociodemographic data\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.143094841930116%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.803660565723792%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.306156405990016%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.487520798668885%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.25956738768719%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.143094841930116%\" valign=\"top\"\u003e\n \u003cp\u003eCKD (N=45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.803660565723792%\" valign=\"top\"\u003e\n \u003cp\u003eHealthy (N=45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.306156405990016%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.487520798668885%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.25956738768719%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.143094841930116%\" valign=\"top\"\u003e\n \u003cp\u003eMedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.803660565723792%\" valign=\"top\"\u003e\n \u003cp\u003eMedian\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(IQR)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.306156405990016%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026chi;\u003c/em\u003e\u003csup\u003e2\u0026nbsp;\u003c/sup\u003e(df)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.487520798668885%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.25956738768719%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eParents\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.143094841930116%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.803660565723792%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.306156405990016%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.487520798668885%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.25956738768719%\" valign=\"top\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.143094841930116%\" valign=\"top\"\u003e\n \u003cp\u003e39 (11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.803660565723792%\" valign=\"top\"\u003e\n \u003cp\u003e41 (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.306156405990016%\" valign=\"top\"\u003e\n \u003cp\u003e26.55 (28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.487520798668885%\" valign=\"top\"\u003e\n \u003cp\u003e0.54\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.25956738768719%\" valign=\"top\"\u003e\n \u003cp\u003eWork leave past 6 months (in days)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; minimum \u0026ndash; maximum\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 25pc \u0026ndash; 75pc\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.143094841930116%\" valign=\"top\"\u003e\n \u003cp\u003e4 (12.5)\u003c/p\u003e\n \u003cp\u003e0 - 90\u003c/p\u003e\n \u003cp\u003e0.5 \u0026ndash; 13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.803660565723792%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.306156405990016%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.487520798668885%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.25956738768719%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eChildren\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.143094841930116%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.803660565723792%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.306156405990016%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.487520798668885%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.25956738768719%\" valign=\"top\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.143094841930116%\" valign=\"top\"\u003e\n \u003cp\u003e8 (9.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.803660565723792%\" valign=\"top\"\u003e\n \u003cp\u003e8 (9.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.306156405990016%\" valign=\"top\"\u003e\n \u003cp\u003e6.89 (16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.487520798668885%\" valign=\"top\"\u003e\n \u003cp\u003e0.97\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.25956738768719%\" valign=\"top\"\u003e\n \u003cp\u003eDuration of CKD (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.143094841930116%\" valign=\"top\"\u003e\n \u003cp\u003e6\u0026nbsp;(9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.803660565723792%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.306156405990016%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.487520798668885%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.25956738768719%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.143094841930116%\" valign=\"top\"\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.803660565723792%\" valign=\"top\"\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.306156405990016%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003et\u0026nbsp;\u003c/em\u003e(df)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.487520798668885%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.25956738768719%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eParents\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eGender (female)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.143094841930116%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e32 (71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.803660565723792%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e35 (78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.306156405990016%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.69 (85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.487520798668885%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.49\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.25956738768719%\" valign=\"top\"\u003e\n \u003cp\u003eCountry of birth (outside Belgium)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.143094841930116%\" valign=\"top\"\u003e\n \u003cp\u003e6 (13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.803660565723792%\" valign=\"top\"\u003e\n \u003cp\u003e1 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.306156405990016%\" valign=\"top\"\u003e\n \u003cp\u003e2.60 (88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.487520798668885%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.25956738768719%\" valign=\"top\"\u003e\n \u003cp\u003eTwo to 3 children\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.143094841930116%\" valign=\"top\"\u003e\n \u003cp\u003e27 (60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.803660565723792%\" valign=\"top\"\u003e\n \u003cp\u003e36 (80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.306156405990016%\" valign=\"top\"\u003e\n \u003cp\u003e-0.73 (85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.487520798668885%\" valign=\"top\"\u003e\n \u003cp\u003e0.47\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.25956738768719%\" valign=\"top\"\u003e\n \u003cp\u003eMarried/living together\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.143094841930116%\" valign=\"top\"\u003e\n \u003cp\u003e34 (76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.803660565723792%\" valign=\"top\"\u003e\n \u003cp\u003e42 (93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.306156405990016%\" valign=\"top\"\u003e\n \u003cp\u003e2.04 (88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.487520798668885%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.04\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.25956738768719%\" valign=\"top\"\u003e\n \u003cp\u003eHigher education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.143094841930116%\" valign=\"top\"\u003e\n \u003cp\u003e25 (56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.803660565723792%\" valign=\"top\"\u003e\n \u003cp\u003e35 (78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.306156405990016%\" valign=\"top\"\u003e\n \u003cp\u003e-2.58 (88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.487520798668885%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.25956738768719%\" valign=\"top\"\u003e\n \u003cp\u003eStructural work reduction since child\u0026rsquo;s CKD diagnosis (= yes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.143094841930116%\" valign=\"top\"\u003e\n \u003cp\u003e18 (40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.803660565723792%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.306156405990016%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.487520798668885%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.25956738768719%\" valign=\"top\"\u003e\n \u003cp\u003ePerception of own health deterioration since child\u0026rsquo;s CKD diagnosis (= yes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.143094841930116%\" valign=\"top\"\u003e\n \u003cp\u003e21 (47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.803660565723792%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.306156405990016%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.487520798668885%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.25956738768719%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eChildren\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eGender (female)\u003c/p\u003e\n \u003cp\u003eStages of CKD\u003c/p\u003e\n \u003cp\u003eStage 1 (\u0026gt;90mL/min/1.73m\u0026sup2;)\u003c/p\u003e\n \u003cp\u003eStage 2 (60-89mL/min/1.73m\u0026sup2;)\u003c/p\u003e\n \u003cp\u003eStage 3 (30-59mL/min/1.73m\u0026sup2;)\u003c/p\u003e\n \u003cp\u003eStage 4 (15-29mL/min/1.73m\u0026sup2;)\u003c/p\u003e\n \u003cp\u003eStage 5 (\u0026lt;14mL/min/1.73m\u0026sup2;)\u003c/p\u003e\n \u003cp\u003eESKD, on peritoneal dialysis\u003c/p\u003e\n \u003cp\u003eESKD, on hemodialysis\u003c/p\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.143094841930116%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e16 (36)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3 (7)\u003c/p\u003e\n \u003cp\u003e11 (24)\u003c/p\u003e\n \u003cp\u003e11 (24)\u003c/p\u003e\n \u003cp\u003e11 (24)\u003c/p\u003e\n \u003cp\u003e3 (7)\u003c/p\u003e\n \u003cp\u003e2 (4)\u003c/p\u003e\n \u003cp\u003e3 (7)\u003c/p\u003e\n \u003cp\u003e1 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.803660565723792%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e17 (38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.306156405990016%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.22 (88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.487520798668885%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.83\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.25956738768719%\" valign=\"top\"\u003e\n \u003cp\u003eUnderlying kidney disease\u003c/p\u003e\n \u003cp\u003eCystic disease\u003c/p\u003e\n \u003cp\u003eCAKUT\u003c/p\u003e\n \u003cp\u003eGlomerulonephritis\u003c/p\u003e\n \u003cp\u003eOther/unknown\u003c/p\u003e\n \u003cp\u003eProximal tubular disease\u003c/p\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.143094841930116%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2 (4.5)\u003c/p\u003e\n \u003cp\u003e20 (44.5)\u003c/p\u003e\n \u003cp\u003e10 (22)\u003c/p\u003e\n \u003cp\u003e9 (20)\u003c/p\u003e\n \u003cp\u003e2 (4.5)\u003c/p\u003e\n \u003cp\u003e2 (4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.803660565723792%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.306156405990016%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.487520798668885%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.25956738768719%\" valign=\"top\"\u003e\n \u003cp\u003eKidney transplant in past\u003c/p\u003e\n \u003cp\u003eMedical comorbidities (total)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.143094841930116%\" valign=\"top\"\u003e\n \u003cp\u003e4 (9)\u003c/p\u003e\n \u003cp\u003e14 (31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.803660565723792%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.306156405990016%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.487520798668885%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.25956738768719%\" valign=\"top\"\u003e\n \u003cp\u003eDevelopmental disorders (total)\u003c/p\u003e\n \u003cp\u003eAutism spectrum disorder\u003c/p\u003e\n \u003cp\u003eAttention problems\u003c/p\u003e\n \u003cp\u003eLearning disabilities\u003c/p\u003e\n \u003cp\u003eCombination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.143094841930116%\" valign=\"top\"\u003e\n \u003cp\u003e11 (24)\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.803660565723792%\" valign=\"top\"\u003e\n \u003cp\u003e6 (13)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.306156405990016%\" valign=\"top\"\u003e\n \u003cp\u003e1.35 (88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.487520798668885%\" valign=\"top\"\u003e\n \u003cp\u003e0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.25956738768719%\" valign=\"top\"\u003e\n \u003cp\u003ePsychosocial/developmental support\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.143094841930116%\" valign=\"top\"\u003e\n \u003cp\u003e17 (38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.803660565723792%\" valign=\"top\"\u003e\n \u003cp\u003e4 (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.306156405990016%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-3.41 (88)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.487520798668885%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.25956738768719%\" valign=\"top\"\u003e\n \u003cp\u003eSpecial education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.143094841930116%\" valign=\"top\"\u003e\n \u003cp\u003e9 (20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.803660565723792%\" valign=\"top\"\u003e\n \u003cp\u003e1 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.306156405990016%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-2.79 (80)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.487520798668885%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"44.25956738768719%\" valign=\"top\"\u003e\n \u003cp\u003ePart-time school attendance\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.143094841930116%\" valign=\"top\"\u003e\n \u003cp\u003e5 (11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.803660565723792%\" valign=\"top\"\u003e\n \u003cp\u003e1 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.306156405990016%\" valign=\"top\"\u003e\n \u003cp\u003e-1.71 (80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.487520798668885%\" valign=\"top\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003eCKD: chronic kidney disease; N: number; IQR: interquartile range; \u0026chi;\u003csup\u003e2:\u0026nbsp;\u003c/sup\u003eChi-square test; df: degrees of freedom;\u003cem\u003e\u0026nbsp;P\u003c/em\u003e: p-value; 25pc: 25\u003csup\u003eth\u003c/sup\u003e percentile; 75pc: 75\u003csup\u003eth\u003c/sup\u003e percentile; \u003cem\u003et\u003c/em\u003e: independent samples t-test; ESKD: end stage kidney disease; CAKUT: congenital anomalies of kidney and urinary tract.\u0026nbsp;Statistically significant p-values (p\u0026lt;0.05) are highlighted in bold.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"623\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003eTable 2. Stress, anxiety and depression symptoms in parents of children with CKD and parents of healthy children\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.287319422150883%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.892455858747994%\" valign=\"top\"\u003e\n \u003cp\u003eParents of children\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ewith CKD (N=45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.187800963081862%\" valign=\"top\"\u003e\n \u003cp\u003eParents of healthy children (N=45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.63242375601926%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.243589743589745%\" valign=\"top\"\u003e\n \u003cp\u003eSymptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.846153846153847%\" valign=\"top\"\u003e\n \u003cp\u003eMedian (IQR) \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.153846153846153%\" valign=\"top\"\u003e\n \u003cp\u003eMedian (IQR) \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.71153846153846%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eU\u0026nbsp;\u003c/em\u003e(df)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.0448717948717947%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.243589743589745%\" valign=\"top\"\u003e\n \u003cp\u003eStress\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.846153846153847%\" valign=\"top\"\u003e\n \u003cp\u003e55 (29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.153846153846153%\" valign=\"top\"\u003e\n \u003cp\u003e39 (24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.71153846153846%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e578.5 (88)***\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.0448717948717947%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.243589743589745%\" valign=\"top\"\u003e\n \u003cp\u003eAnxiety\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.846153846153847%\" valign=\"top\"\u003e\n \u003cp\u003e8 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.153846153846153%\" valign=\"top\"\u003e\n \u003cp\u003e5 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.71153846153846%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e624.5 (88)**\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.0448717948717947%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.243589743589745%\" valign=\"top\"\u003e\n \u003cp\u003eDepression\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.846153846153847%\" valign=\"top\"\u003e\n \u003cp\u003e4 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.153846153846153%\" valign=\"top\"\u003e\n \u003cp\u003e3 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.71153846153846%\" valign=\"top\"\u003e\n \u003cp\u003e817.5 (88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.0448717948717947%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.243589743589745%\" valign=\"top\"\u003e\n \u003cp\u003eProportions in clinical range\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.846153846153847%\" valign=\"top\"\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.153846153846153%\" valign=\"top\"\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.71153846153846%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026chi;\u003c/em\u003e\u003csup\u003e2\u0026nbsp;\u003c/sup\u003e(df)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.0448717948717947%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.243589743589745%\" valign=\"top\"\u003e\n \u003cp\u003eStress\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.846153846153847%\" valign=\"top\"\u003e\n \u003cp\u003e17 (38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.153846153846153%\" valign=\"top\"\u003e\n \u003cp\u003e5 (11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.71153846153846%\" valign=\"top\"\u003e\n \u003cp\u003e8.7 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.0448717948717947%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.243589743589745%\" valign=\"top\"\u003e\n \u003cp\u003eAnxiety\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.846153846153847%\" valign=\"top\"\u003e\n \u003cp\u003e23 (51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.153846153846153%\" valign=\"top\"\u003e\n \u003cp\u003e12 (27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.71153846153846%\" valign=\"top\"\u003e\n \u003cp\u003e5.7 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.0448717948717947%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.243589743589745%\" valign=\"top\"\u003e\n \u003cp\u003eDepression\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.846153846153847%\" valign=\"top\"\u003e\n \u003cp\u003e12 (27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.153846153846153%\" valign=\"top\"\u003e\n \u003cp\u003e5 (11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.71153846153846%\" valign=\"top\"\u003e\n \u003cp\u003e3.5 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"3.0448717948717947%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e* p\u0026lt; 0.05; ** p\u0026lt; 0.01; *** p\u0026lt; 0.001. Statistically significant p-values are highlighted in bold.\u003c/p\u003e\n \u003cp\u003eHigher median scores represent higher levels of stress, or more symptoms of anxiety or depression.\u003c/p\u003e\n \u003cp\u003e\u003csup\u003ea\u003c/sup\u003eAccording to the Parenting Stress Index \u0026ndash; Short Form; normal scores range from 43 to 61.\u003c/p\u003e\n \u003cp\u003e\u003csup\u003eb\u003c/sup\u003eAccording to the Hospital Anxiety and Depression Scale; normal scores range from 0 to 7.\u003c/p\u003e\n \u003cp\u003eCKD: chronic kidney disease; N: number; IQR: interquartile range; \u003cem\u003eU\u003c/em\u003e: Mann-Whitney test; df: degrees of freedom; \u0026chi;\u003csup\u003e2:\u003c/sup\u003e:Chi-square test.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eTable 3. Spearman correlations between parental stress, anxiety and depression symptoms, and clinical and sociodemographic variables in parents of children with CKD (N=45)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eParental stress\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eAnxiety symptoms\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eDepression symptoms\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eAge parent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e-0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e-0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eAge child\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e-0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eNumber of children\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e0.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e0.24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003ePerception own health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-0.40**\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-0.66**\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-0.54**\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eWork leave \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e0.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eDuration CKD \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e-0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eComorbidities\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Med. comorb. Child\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.43**\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.44**\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.39**\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Developm. dis. Child\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e0.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eSchool absence\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.30*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e-0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e* p\u0026lt; 0.05; ** p\u0026lt; 0.01; *** p\u0026lt; 0.001. Statistically significant p-values are highlighted in bold.\u003c/p\u003e\n \u003cp\u003e\u003csup\u003ea\u003c/sup\u003eAccording to the Parenting Stress Index \u0026ndash; Short Form; \u003csup\u003eb\u003c/sup\u003eAccording to the Hospital Anxiety and Depression Scale.\u003c/p\u003e\n \u003cp\u003eCKD: chronic kidney disease; N: number; Perception own health: parent\u0026rsquo;s perception of own health since child\u0026rsquo;s CKD diagnosis; Work leave: days of work leave in addition to structural work reduction past 6 months due to child\u0026rsquo;s health problems; Med. comorb. child: Medical comorbidities in child (number); Developm. Dis child: developmental disorders in child (number); School absence: School absence past 6 months (days).\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"10\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Table 4. Standardized regression coefficients for parental stress and symptoms of anxiety and depression predicted by clinical and sociodemographic variables of parents and children with CKD\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.27574750830565%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.239202657807308%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eParental stress\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.900332225913623%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eAnxiety symptoms\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.58471760797342%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eDepression symptoms\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.24709784411277%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.096185737976782%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026beta;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.794361525704809%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003et\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.301824212271973%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.603648424543946%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026beta;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.45273631840796%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003et\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.794361525704809%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.603648424543946%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026beta;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.45273631840796%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003et\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.6533996683250414%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.24709784411277%\" valign=\"top\"\u003e\n \u003cp\u003ePerception\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eown health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.096185737976782%\" valign=\"top\"\u003e\n \u003cp\u003e-0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.794361525704809%\" valign=\"top\"\u003e\n \u003cp\u003e-0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.301824212271973%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.603648424543946%\" valign=\"top\"\u003e\n \u003cp\u003e-0.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.45273631840796%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-3.48**\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.794361525704809%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.603648424543946%\" valign=\"top\"\u003e\n \u003cp\u003e-0.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.45273631840796%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-3.16**\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.6533996683250414%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.24709784411277%\" valign=\"top\"\u003e\n \u003cp\u003eAge child\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.096185737976782%\" valign=\"top\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.794361525704809%\" valign=\"top\"\u003e\n \u003cp\u003e0.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.301824212271973%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.603648424543946%\" valign=\"top\"\u003e\n \u003cp\u003e-0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.45273631840796%\" valign=\"top\"\u003e\n \u003cp\u003e-1.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.794361525704809%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.603648424543946%\" valign=\"top\"\u003e\n \u003cp\u003e-0.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.45273631840796%\" valign=\"top\"\u003e\n \u003cp\u003e-2.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.6533996683250414%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.24709784411277%\" valign=\"top\"\u003e\n \u003cp\u003eCKD stage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.096185737976782%\" valign=\"top\"\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.794361525704809%\" valign=\"top\"\u003e\n \u003cp\u003e0.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.301824212271973%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.603648424543946%\" valign=\"top\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.45273631840796%\" valign=\"top\"\u003e\n \u003cp\u003e0.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.794361525704809%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.603648424543946%\" valign=\"top\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.45273631840796%\" valign=\"top\"\u003e\n \u003cp\u003e0.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.6533996683250414%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.24709784411277%\" valign=\"top\"\u003e\n \u003cp\u003eMed. comorb. child\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.096185737976782%\" valign=\"top\"\u003e\n \u003cp\u003e0.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.794361525704809%\" valign=\"top\"\u003e\n \u003cp\u003e2.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.301824212271973%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.603648424543946%\" valign=\"top\"\u003e\n \u003cp\u003e0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.45273631840796%\" valign=\"top\"\u003e\n \u003cp\u003e1.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.794361525704809%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.603648424543946%\" valign=\"top\"\u003e\n \u003cp\u003e0.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.45273631840796%\" valign=\"top\"\u003e\n \u003cp\u003e1.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.6533996683250414%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.24709784411277%\" valign=\"top\"\u003e\n \u003cp\u003eDevelopm. dis. child\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.096185737976782%\" valign=\"top\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.794361525704809%\" valign=\"top\"\u003e\n \u003cp\u003e0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.301824212271973%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.603648424543946%\" valign=\"top\"\u003e\n \u003cp\u003e-0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.45273631840796%\" valign=\"top\"\u003e\n \u003cp\u003e-0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.794361525704809%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.603648424543946%\" valign=\"top\"\u003e\n \u003cp\u003e-0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.45273631840796%\" valign=\"top\"\u003e\n \u003cp\u003e-0.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.6533996683250414%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"10\" valign=\"top\"\u003e\n \u003cp\u003e* p\u0026lt; 0.05; ** p\u0026lt; 0.01; *** p\u0026lt; 0.001. Statistically significant p-values are highlighted in bold.\u003c/p\u003e\n \u003cp\u003e\u003csup\u003ea\u003c/sup\u003eAccording to the Parenting Stress Index \u0026ndash; Short Form; \u003csup\u003eb\u003c/sup\u003eAccording to the Hospital Anxiety and Depression Scale.\u003c/p\u003e\n \u003cp\u003eCKD: chronic kidney disease; Perception own health: perception of own health since child\u0026rsquo;s CKD diagnosis; Med. comorb. child: medical comorbidities in child (number); Developm. dis. child: developmental disorders in child (number); \u003cem\u003e\u0026beta;\u003c/em\u003e: standardized regression coefficient; \u003cem\u003et\u003c/em\u003e: t-value.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Children, Chronic Kidney Disease, Parents, Health, Stress, Anxiety, Depression, Professional","lastPublishedDoi":"10.21203/rs.3.rs-3375535/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3375535/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThis study evaluated stress, anxiety and depression symptoms and their associated factors in parents of children with chronic kidney disease (CKD).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis cross-sectional study compared parents of CKD patients (0\u0026ndash;18 years) with a matched control group of parents of healthy children. Both groups completed the Parenting Stress Index \u0026ndash; Short Form, the Hospital Anxiety and Depression Scale, and a sociodemographic questionnaire.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe study group consisted of 45 parents (median age 39; 32 mothers) of CKD patients (median age 8; 36% female). Nearly 75% of children had CKD stage 2, 3, or 4, and 44.5% had congenital anomaly of the kidney and urinary tract. Five children (11%) were on dialysis, and 4 (9%) had a functioning kidney graft. Compared with parents of healthy children, more stress and anxiety symptoms were reported. Since the CKD diagnosis, 47% of parents perceived a deterioration of their own health, and 40% reduced work on a structural basis. Higher levels of stress, anxiety and depression symptoms were associated with a more negative perception of own health, and more child medical comorbidities and school absence.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThis study showed higher levels of stress and anxiety symptoms in parents of children with CKD compared with parents of healthy children. This was associated with a less positive perception of the own health, especially if the child had more medical comorbidities or more absence from school. Psychosocial interventions to reduce the parental burden should be integrated in the standard care of pediatric nephrology departments.\u003c/p\u003e","manuscriptTitle":"Mental health and professional outcomes in parents of children with chronic kidney disease","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-10-03 17:43:51","doi":"10.21203/rs.3.rs-3375535/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d22191d1-0db5-4b30-8d45-6058dcb015cc","owner":[],"postedDate":"October 3rd, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-04-24T00:48:50+00:00","versionOfRecord":{"articleIdentity":"rs-3375535","link":"https://doi.org/10.1007/s00467-024-06372-y","journal":{"identity":"pediatric-nephrology","isVorOnly":false,"title":"Pediatric Nephrology"},"publishedOn":"2024-04-23 00:48:50","publishedOnDateReadable":"April 23rd, 2024"},"versionCreatedAt":"2023-10-03 17:43:51","video":"","vorDoi":"10.1007/s00467-024-06372-y","vorDoiUrl":"https://doi.org/10.1007/s00467-024-06372-y","workflowStages":[]},"version":"v1","identity":"rs-3375535","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3375535","identity":"rs-3375535","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}