Adaptation and psychometric evaluation of the Brief Social Support Scale for Families (BS6-F)

Adaptation and psychometric evaluation of the Brief Social Support Scale for Families (BS6-F) | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Adaptation and psychometric evaluation of the Brief Social Support Scale for Families (BS6-F) Anne Geweniger, Thorsten Langer, Jana Willems This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8029850/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Social support is an important determinant of and resource for health and wellbeing of families. It positively affects health and wellbeing of both parents and children through different channels. Families with children with special healthcare needs (CSHCN) face complex caregiving demands and lower levels of mental wellbeing. Perceived social support is an important resource for these families and a structured assessment necessary to support healthcare providers and health policy. We here present the adaptation of the Brief Social Support Scale for Families (BS6-F) and its psychometric characteristics. Methods This study is based on data from the third of a series of cross-sectional online surveys assessing the situation of families with and without CSHCN in Germany during and after the COVID-19 pandemic, collected from December 2022 to March 2023. Caregivers of children ≤ 18 with and without CSHCN in Germany were eligible to participate. The BS6-F is a 6-item measure assessing perceived social support. It has two subscales, tangible and emotional-informational support. The adaptation of the original BS6 followed a structured consultation process involving representatives of a large patient organisation, the Kindernetzwerk e.V. Statistical analysis comprised descriptive item statistics, correlation analyses and exploratory factor analysis (EFA). Results The final study sample comprised 381 participants. Item-level analyses indicated good variability and no floor or ceiling effects. Inter-item correlations and EFA supported the expected two-factor structure of the BS6-F. explaining 78.8% of the variance. Both subscales demonstrated good to excellent reliability (α = .788 and .924). Correlations between subscales were moderate (r = .427). confirming them as related but distinct dimensions. Perceived social support was negatively associated with child disease complexity (r = –.354) and child mental health problems (r = –.240), and weakly positively associated with parental well-being (WHO-5; r = .275) and SES (r = .180). Conclusions The BS6-F is a brief assessment tool for social support adapted to the situation and needs of families and a valuable addition for assessment and research. While the clear two-factor structure and good reliability coefficients support the theoretical model, replication in diverse and representative samples is essential to establish the instrument's broader validity. The BS6-F is freely available and both the English and German versions can be found in the Additional file 1. social support assessment - families children with special healthcare needs children with chronic disease mental health mental wellbeing Background Social support is widely recognised as an important determinant of and resource for health and wellbeing of families. Social contacts among family members, friends and relatives as well as social networks can serve as sources of social support ( 1 ). Study findings indicate that perceived social support may be as important as actual support provided ( 2 ). Social support positively affects health and wellbeing of both parents and children through different channels. It may act as protective buffer against life stressors, promoting resilience and adaptive coping strategies ( 3 ); positively influence parenting self-efficacy and thus support children’s development ( 4 ); and promote parental and child mental health, particularly in times of crisis (5.6). Families with children with special healthcare needs (CSHCN) often face complex caregiving demands and lower levels of mental wellbeing ( 7 ). Associations of lower perceived social support with higher disease complexity of the child, lower caregiver wellbeing and low socioeconomic status have been described elsewhere ( 8 ). Therefore, access to reliable emotional, informational, and practical assistance is vital for maintaining parental mental health, enhancing caregiving capacity, and supporting optimal developmental outcomes for children with chronic health conditions. There are few brief instruments assessing social support which are available in both English and German. Existing measures such as the F-SozU K-6 and Brief Social Support Scale BS6 have demonstrated reliability and validity in rapidly assessing perceived social support, yet gaps remain (9.10). The F-SozU K-6, comprising only six items, primarily captures a unidimensional construct of general perceived support and thus does not differentiate well between types of support (e.g. emotional versus instrumental) nor does it contextualise support within specific settings like families ( 10 ). The BS6. despite its short form of six items still assesses emotional-informational and tangible support as well as overall perceived social support. However. it was developed for general population surveys rather than family-specific support needs. Tangible support, as assessed by the BS6, describes e.g. practical help with household tasks. Emotional-informational support encompasses e.g. provision of advice and empathy. The original version of the BS6 was validated in a population-based sample of 15.010 participants in a German cohort study showing good reliability, internal and external validity ( 9 ). The instrument is freely available through the open-access publication. In view of the importance of social support for families in general and particularly for those with CSHCN we adapted the original version of the BS6 to better reflect the situation and support needs of families. The psychometric characteristics of the Brief Social Support Scale for Families (BS6-F) were evaluated in a sample of 381 families with and without CSHCN. Further results of the study have been reported elsewhere ( 8 ). This study aims to assess the psychometric characteristics of the adapted Brief Social Support Scale for Families (BS6-F), in particular item distributions, factorial structure and reliability. Methods Study design This study analyses data from the third of a series of cross-sectional online surveys assessing the situation of families with and without CSHCN in Germany during and after the COVID-19 pandemic ( 8 , 11 , 12 ). The third survey collected data from December 2022 – March 2023 when most pandemic restrictions in Germany had been lifted. Caregivers of children ≤ 18 with and without CSHCN in Germany were eligible to participate. Recruitment was through convenience and non-probabilistic snowball sampling, study promotion via partner organisations, social and public media. and through free access websites. Representatives of the Kindernetzwerk e.V., a large German patient organisation for families with children with chronic disease and disabilities were actively involved in all stages of the study. Measures Brief Social Support Scale for Families (BS6-F) The original version of the Brief Social Support Scale (BS6) is a bi-factorial questionnaire that measures perceived overall social support, specifically distinguishing between emotional-informational and tangible aspects. It is derived from the MOS Social Support Survey ( 9 ). The scale comprises six items in total: three targeting tangible support and three focusing on emotional-informational support, each rated on a 4-point Likert scale. Total scores for perceived social support can range from 6 to 24. while each subscale can score between 3 and 12. The recommended interpretation divides the overall social support score into the categories low ( 6 – 11 ), moderate (12–17; indicating at least occasional support), high (18–23; meaning mostly supported), and very high (24; always supported). The scale was validated using data from 15.010 participants in a population-based German cohort study, demonstrating good reliability (Cronbach’s alpha = 0.86 for the total score) ( 9 ). For the purpose of this study, we adapted three of the six original BS6-Items to better reflect the situation and support needs of families. All three adapted items are part of the tangible support subscale. The adaptation process included several steps. First, members of the project team developed a draft version. The wording was carefully chosen to still match the original thematic area of tangible support represented by each item. Next, representatives of the patient organisation Kindernetzwerk e.V., which unites a network of 236 patient organisations for families of children with chronic diseases and disabilities, were invited to participate in a structured online consultation. During this stage, participants were asked to provide feedback on the wording, clarity, and cultural appropriateness of each item. Their suggestions informed the refinement of item phrasing and the inclusion of contextually relevant examples where necessary. After incorporating the recommendations from the patient representatives, a revised draft was circulated for final approval. Details of the item adaptations are shown in Table 1 . Table 1 BS6 original version and adapted Items for BS6-F BS6 original version (German) English BS6-F adapted Version (German) English Wie häufig steht Ihnen folgende Unterstützung durch andere Menschen zur Verfügung? If you needed it. how often is someone available… Tangible support Jemand, der Sie zum Arzt fährt, wenn es nötig ist To take you to the doctor if you need it Jemand, der Ihr Kind zu Terminen bringen oder aus der Betreuung abholen kann, wenn Sie verhindert sind To take your child to appointments or to pick them up from daycare/school if you’re not available Jemand, der Ihnen Essen zubereitet, wenn Sie dazu nicht in der Lage sind To prepare your meals if you are unable to do it yourself Jemand, der Sie bei der Kinderbetreuung unterstützt To support you in child care duties Jemand, der Ihnen bei alltäglichen Arbeiten hilft, wenn Sie krank sind To help with daily chores if you were sick Jemand, der Ihnen bei alltäglichen Arbeiten (z.B. Besorgungen oder im Haushalt) hilft To help with daily chores (e.g. shopping. household duties) Emotional-informational support Jemand, der Ihnen in schwierigen Situationen gute Ratschläge gibt To give you good advice about a crisis unverändert no changes made Jemand, dem Sie sich anvertrauen oder mit dem Sie über persönliche Probleme sprechen können To confide in or talk to about yourself or your problems Jemand, der Ihre Probleme versteht Who understands your problems Rating options: 1 = never. 2 = occasionally. 3 = mostly. 4 = always Antwortoptionen: 1 = nie. 2 = manchmal. 3 = meist. 4 = immer Children with special healthcare needs (CSHCN) Comprising five items, the CSHCN-Screener is a parent-report measure to identify children with chronic physical, mental, behavioural or other conditions who require more health care support than the average of their peers ( 13 ). Scores can be used to stratify according to disease complexity and healthcare needs with higher scores indicating higher complexity ( 14 , 15 ): no special healthcare needs (CSHCN score = 0), chronic conditions (CSHCN score ≤ 2) and complex chronic conditions (CSHCN score ≥ 3). WHO-5 wellbeing index The WHO-5 Wellbeing Index is a brief, five-item screening instrument designed to assess adult mental health, and it has demonstrated strong validity and reliability ( 16 ). The total score ranges from 0 to 100, with 100 representing the best imaginable mental wellbeing. A score of 50 or below serves as the threshold for identifying individuals at risk of depression ( 16 ). Strengths and Difficulties Questionnaire (SDQ) Strengths and Difficulties Questionnaire (SDQ) The Strengths and Difficulties Questionnaire (SDQ) is a widely used, validated screening tool for identifying mental health issues in children and adolescents. It assesses behaviours exhibited over the previous six months. The standard parent-report version is intended for children aged 4 to 16 years, while the preschool version—differing by three items—targets younger children ( 17 , 18 ). The Total Difficulties score, which sums four subscales (hyperactivity/inattention, emotional symptoms, conduct problems, and peer relationship problems), ranges from 0 to 40; higher scores reflect greater mental health problems. Both the German parent-report and preschool versions have demonstrated validity and reliability ( 19 , 20 ). For this study, caregivers of children older than 2 years completed the age-appropriate SDQ version. The SDQ is freely available through the official website ( https://www.sdqinfo.org ). We applied a cut-off of 13 or higher on the Total Difficulties score ( 21 ). Socioeconomic status As described in the German National Health Interview and Examination Survey for Children and Adolescents (KiGGS) ( 22 ), socioeconomic status (SES) was assessed using a composite index based on three components: household net equivalent income, parental education, and parental occupation. Household net equivalent income was determined by adjusting the total monthly net household income for household size according to a modified Organisation for Economic Cooperation and Development (OECD) scale ( 22 ). In this scale, the household head was weighted as 1, each additional adult as 0.5, and each child as 0.3; the income was then divided by the sum of these weights. For education and occupation, the higher value from either parent was used. Each SES component was rated on a scale from 1 to 7, resulting in a total SES index score ranging from 3 to 21, where lower scores reflect lower socioeconomic status. Sociodemographic measures These included age and gender, relationship status, education, occupation, monthly household income, household size, area of residence and country of birth. Caregiver education was categorised according to the international CASMIN classification ( 23 ). Sociodemographic characteristics are presented in Table 2 . Table 2 Sociodemographic characteristics (N = 381); SD : standard deviation; percentages reported as row percentages Mean (SD) Range Age in years responding parent (N = 333) 42.7 (6.4) 23–64 all children (N = 355) 9.3 (4.6) 1–18 children with SHCN (N = 275) 9.6 (4.7) 1–18 Number of children per household 2.0 (0.9) 1–5 Household size (N = 342) 4.0 (1.1) 1–8 Household net equivalent income ( N = 342 ; monthly. in Euros) 2127 (856) (486–6190) Partner living in the same household (n = 301) 2228 (845) (536–6190) Partner living in a different household (n = 9) 1487 (533) (852–2277) No partner (n = 29) 1294 (482) (486–2692) n % Gender of respondent (N = 338) male 37 10.9 female 301 89.1 Gender of child ( N = 354 ) male 179 50.6 female 173 48.9 diverse 2 0.6 Relationship status (N = 339) With partner. in same household 301 88.8 With partner. not in same household 9 2.7 No partner 29 8.6 Country of birth of parents (N = 341) Both in Germany 304 89.1 One parent in Germany. one elsewhere 28 8.2 Both elsewhere 9 2.6 Place of residence (N = 341) City (> 100 000 inhabitants) 137 40.2 Surroundings of a city with > 100 000 inhabitants 26 7.6 Town (20 000- 100 000 inhabitants) 59 17.3 Small town (5000–20 000 inhabitants) 48 14.1 Rural municipality (< 5000 inhabitants) 71 20.8 Disease complexity of child No special healthcare needs (CSHCN = 0) 89 23.4 Chronic disease (CSHCN ≤ 2 criteria) 55 14.4 Complex chronic disease (CSHCN ≥ 3 criteria) 237 62.2 Educational level according to CASMIN-Classification (N = 341) 1a: Inadequately completed general education 0 1b: General elementary education 4 1.2 1c: General elementary education and vocational qualification 8 2.3 2a: Intermediate general qualification and vocational qualification 70 20.5 2b: Intermediate general qualification 4 1.2 2c_gen: General maturity certificate 4 1.2 2c_voc: General maturity certificate and vocational qualification 76 22.3 3a: Lower tertiary education 37 10.9 3b: Higher tertiary education 141 41.3 Employment status of respondent (N = 339) Inactive or unemployed 40 11.8 Short term or temporary employment 19 5.6 Part-time 208 61.4 Full-time 72 21.2 Statistical analysis Descriptive statistics were first computed to inspect item distributions, with means and standard deviations calculated for each item. All items showed sufficient variability and met distributional assumptions for factor analysis (skewness and kurtosis < |2|; ( 24 )). Due to the content adjustment of the BS6-F, we refrained from confirmatory testing and conducted an exploratory factor analysis to examine the underlying factorial structure of the six items. We chose principal component extraction, followed by orthogonal varimax rotation with Kaiser normalization to aid interpretability and achieve a simple structure. The number of retained factors was determined according to theoretical (original BS6 factor structure) and statistical criteria (Kaiser-Guttman criterion, eigenvalue > 1). Kaiser-Mayer-Olkin (KMO) coefficient and Bartlett sphericity test were used to analyse the data suitability for exploratory factor analysis. Furthermore, internal consistency for the resulting subscales were estimated using Cronbach’s alpha. To examine expected associations of perceived social support and its subscales with mental wellbeing, SES and complexity of healthcare needs, Pearson correlations were calculated. Primary variables included social support total score, tangible and emotional-informational support. Secondary variables comprised SES, caregiver wellbeing as measured by the WHO-5, parent-reported child mental health problems as measured by the SDQ total problem score, age of child and caregiver. Statistical analysis was performed using IBM SPSS Version 29.0. Results Study sample The final study sample consisted of 381 participants. The majority was female, lived with a partner in the same household and had two children. 76.6% (n = 292) of children had special healthcare needs. Further details are shown in Table 2 . Descriptive item statistics Descriptive statistics for individual items are presented in Table 3 . Item variances ranged from .733 to .961, indicating adequate variability across all items with no evidence of floor or ceiling effects. Skewness values ranged from − 1.141 to 1.140, with four items showing negative skew (items 1, 2, 5, 6) and two items showing positive skew (items 3, 4). Kurtosis values ranged from − 1.035 to .529. All skewness and kurtosis values fell within acceptable ranges (< |2|) for factor analytic procedures. supporting the appropriateness of the analytical approach. Table 3 Descriptive item statistics (N = 381) Item Mean SD Variance Skewness SE Curtosis SE 1 1.92 .883 .780 .689 .125 − .294 .249 2 2.06 .856 .733 .638 .125 − .061 .249 3 1.70 .873 .762 1.140 .125 .529 .249 4 2.71 .980 .961 − .141 .125 -1.035 .249 5 2.61 .910 .829 .060 .125 − .863 .249 6 2.45 .929 .864 .207 .125 − .813 .249 Inter-item correlations The inter-item correlation matrix (Table 4 ) revealed a clear pattern supporting the two-factor structure of the BS6-F. Items within the tangible support subscale (Items 1–3) demonstrated good internal consistency, with correlations ranging from .491 to .637. The emotional-informational support subscale (Items 4–6) showed even stronger internal consistency, with correlations ranging from .771 to .821. Importantly, the correlations between items from different subscales were consistently lower (.275 to .378), providing evidence for discriminant validity. The moderate cross-subscale correlations suggest that tangible and emotional-informational support are conceptually related but empirically distinguishable dimensions of social support. Table 4 Inter-item correlation matrix (N = 381) Item 1 Item 2 Item 3 Item 4 Item 5 Item 6 Item 1 1.000 .637 .491 .358 .349 .371 Item 2 .637 1.000 .536 .295 .275 .289 Item 3 .491 .536 1.000 .378 .359 .323 Item 4 .358 .295 .378 1.000 .820 .771 Item 5 .349 .275 .359 .820 1.000 .821 Item 6 .371 .289 .323 .771 .821 1.000 Factor analysis The prerequisites for factor analysis were met. The Kaiser-Meyer-Olkin coefficient of sampling adequacy was good (KMO = .795), and Bartlett's test of sphericity was significant (χ² = 1311.287. df = 15. p < .001), indicating that the data were suitable for factor analysis. Kaiser-Guttman criterion suggests a two-factor solution, confirming the theoretically expected factor structure of the original BS6. All items loaded clearly on the theoretically expected factor with loadings ranging from .753 to .926. Cross-loadings were consistently low (< .24), indicating clear factorial separation (Table 5 ). The two extracted factors explained 78.8% of the total variance. Table 5 Rotated factor loadings (N = 381) Factor 1 Factor 2 Item 1 0.216 0.821 Item 2 0.106 0.877 Item 3 0.235 0.753 Item 4 0.899 0.219 Item 5 0.926 0.190 Item 6 0.904 0.197 The tangible support subscale (items 1–3) showed acceptable reliability (α = .788), while the emotional-informational subscale (items 4–6) demonstrated very good internal consistency (α = .924). These findings support the theoretically postulated two-factor structure and confirm the psychometric quality of both subscales. Correlation analysis Results are presented in Table 6 . Perceived social support demonstrated strong positive correlations with its constituent subscales: tangible support (r = .812. p < .001) and emotional-informational support (r = .874. p < .001), confirming the internal consistency of the social support construct. The moderate correlation between the two subscales (r = .427. p < .001) indicates they represent related but distinct dimensions of support. Lower social support was associated with higher disease complexity of the child (CSHCN: r = − .354. p < .001) and higher scores on the SDQ (SDQ total problem score: r = − .240. p < .001). There was strong evidence for a negative correlation between child age and social support (r = − .123. p < .05), indicating that families with older children reported lower levels of social support. Notably. social support demonstrated only a weak positive correlation with parental well-being as measured by WHO-5 (r = .275. p < .001) and a weak positive correlation with SES (r = .180. p < 0.001). Table 6 Correlations of social support and selected sociodemographic variables tangible support emotional-informational support social support total score CSHCN screener WHO-5 SES caregiver age age of child SDQ total difficulties score tangible support r 1.000 .397 ** .756 ** − .228 ** 0.104 .157 ** − .212 ** − .125 * − .117 * p ≤ 0.001 ≤ 0.001 ≤ 0.001 0.055 0.004 ≤ 0.001 0.019 0.029 N 381 381 381 381 343 341 333 355 345 emotional-informational support r .397 ** 1.000 .886 ** − .315 ** .350 ** .130 * − .135 * -0.082 − .242 ** p ≤ 0.001 ≤ 0.001 ≤ 0.001 ≤ 0.001 0.016 0.013 0.122 ≤ 0.001 N 381 381 381 381 343 341 333 355 345 social support total score r .756 ** .886 ** 1.000 − .327 ** .283 ** .165 ** − .194 ** − .115 * − .228 ** p ≤ 0.001 ≤ 0.001 ≤ 0.001 ≤ 0.001 0.002 ≤ 0.001 0.031 ≤ 0.001 N 381 381 381 381 343 341 333 355 345 CSHCN screener r − .228 ** − .315 ** − .327 ** 1.000 − .342 ** − .127 * .119 * 0.075 .420 ** p ≤ 0.001 ≤ 0.001 ≤ 0.001 ≤ 0.001 0.019 0.030 0.159 ≤ 0.001 N 381 381 381 404 343 341 333 355 345 WHO-5 r 0.104 .350 ** .283 ** − .342 ** 1.000 .115 * 0.095 .171 ** − .267 ** p 0.055 ≤ 0.001 ≤ 0.001 ≤ 0.001 0.034 0.082 0.001 ≤ 0.001 N 343 343 343 343 343 341 333 343 337 SES-Index r .157 ** .130 * .165 ** − .127 * .115 * 1.000 0.020 -0.044 -0.091 p 0.004 0.016 0.002 0.019 0.034 0.722 0.421 0.095 N 341 341 341 341 341 341 332 341 336 caregiver age r − .212 ** − .135 * − .194 ** .119 * 0.095 0.020 1.000 .662 ** 0.070 p ≤ 0.001 0.013 ≤ 0.001 0.030 0.082 0.722 ≤ 0.001 0.207 N 333 333 333 333 333 332 333 333 328 age of child r − .125 * -0.082 − .115 * 0.075 .171 ** -0.044 .662 ** 1.000 0.090 p 0.019 0.122 0.031 0.159 0.001 0.421 ≤ 0.001 0.096 N 355 355 355 355 343 341 333 355 345 SDQ total difficulties score r − .117 * − .242 ** − .228 ** .420 ** − .267 ** -0.091 0.070 0.090 1.000 p 0.029 ≤ 0.001 ≤ 0.001 ≤ 0.001 ≤ 0.001 0.095 0.207 0.096 N 345 345 345 345 337 336 328 345 345 ** p ≤ 0.01 * p ≤ 0.05 Discussion Psychometric quality and reliability The present psychometric evaluation of the adapted Brief Social Support Scale for Families (BS6-F) provides strong evidence of its reliability and construct validity as a concise measure of perceived social support among families with CSHCN. Exploratory factor analysis confirmed a distinct two-factor structure, capturing tangible and emotional-informational support with high factor loadings and minimal cross-loadings, indicating robust structural integrity. Furthermore, both subscales demonstrated strong internal consistency (α = .788-.924). 78.8% of total variance was explained, highlighting efficient assessment of perceived social support with minimal respondent burden (only six items). Item distribution and variance analyses supported measurement precision across diverse support profiles. Key Correlations and interpretative insights Associations of different types of social support, special healthcare needs of the child, child and parent mental health as well as socioeconomic factors could be described. In particular, there was strong evidence for a moderate association of parent-reported child mental health problems and caregiver mental wellbeing with low overall social support and low emotional-informational support. Parents of children with more complex healthcare needs reported lower social support on all three scales. Besides, families with older children reported lower levels of social support, which may suggest potential gaps in support systems as CSHCN transition through developmental stages. These results echo the findings of previous studies and underscore the importance of social support for vulnerable populations such as children with special healthcare needs and their families ( 8 , 12 , 25 , 26 ). Furthermore they add to the external validity of the BS6-F by confirming expected associations between social support and determinants of mental wellbeing and vulnerability ( 5 , 27 , 28 ). Surprisingly, we only found a weak correlation of social support and SES. This leads to several possible explanations. First, this might be due to sampling bias as participants in the study were not representative of the general population in Germany and families with low SES might be underrepresented. Second, the BS6-F captures perceived availability of social support rather than resource-intensive forms of assistance that would be expected to correlate more strongly with SES. Third, families across different socioeconomic levels may have access to similar levels of social support, indicating that supportive relationships are not necessarily tied to financial resources. Families with higher SES might tend to access formal, professional support services while families with lower SES may rely more on informal networks within the family or community, resulting in similar overall support levels. This warrants further research into the complex interrelations of SES, social support and the situation of families. Practical implications for clinical and research settings The brevity and explicit differentiation of support domains make the BS6-F highly applicable to routine pediatric and family-centered clinical settings. Its targeted measurement of tangible and emotional-informational support enables practitioners and researchers to identify specific support gaps, track changes over time, and tailor interventions accordingly. Sensitivity to family circumstances. particularly complexity of care and age-related transitions strengthens its utility for monitoring and outcome evaluation across diverse contexts. Limitations Several limitations must be considered. The non-representative nature of the sample limits the generalizability of these findings. Cross-validation in representative samples is needed to confirm the factorial structure and reliability estimates. The study benefited from direct stakeholder involvement in item development, which enhanced both contextual and content validity. Nevertheless - because item adaptations may influence measurement sensitivity - further investigation into measurement invariance and responsiveness to change across diverse subpopulations is critical. Conclusion and implications for future research Considering the scarcity of brief assessment tools for social support that are adapted to the situation and needs of families, the BS6-F is a valuable addition for assessment and research. While the clear two-factor structure and good reliability coefficients support the theoretical model, replication in diverse and representative samples is essential to establish the instrument's broader validity. Reliance on caregiver self-report potentially limits the breadth of perspectives captured, hence future research on social support measures should consider multi-informant and longitudinal studies employing mixed methods. The BS6-F is freely available and both the English and German versions can be found in Additional file 1. Declarations Ethics approval and consent to participate This study was conducted in accordance with the Declaration of Helsinki. Informed consent to participate was obtained from all study participants. Ethics approval was granted by the ethics committee of Freiburg University (Approval number 377/20). Consent for publication Not applicable. Data availabilty statement The dataset used during the current study is available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding The primary study was funded by the Volkswagen Foundation. grant number Az 990622. Author contributions AG: Conceptualisation. Methodology. Software. Formal analysis. Investigation. Data curation. Writing – Original Draft. Writing – Review and Editing. Visualisation. JW: Conceptualisation. Methodology. Writing – Review and Editing. Supervision. TL: Conceptualisation. Writing – Review and Editing. Supervision. Project administration. Funding acquisition. All authors read and approved the final manuscript. Acknowledgements The authors would like to thank Annette Mund. 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Psychother Psychosom. 2015;84(3):167–76. Goodman R. The strengths and difficulties questionnaire: A research note. J Child Psychol Psychiatry Allied Discip. 1997;38(5). Croft S, Stride C, Maughan B, Rowe R. Validity of the strengths and difficulties questionnaire in preschool-aged children. Pediatrics. 2015;135(5). Klein AM, Otto Y, Fuchs S, Zenger M, Von Klitzing K. Psychometric properties of the parent-rated SDQ in preschoolers. Eur J Psychol Assess. 2013;29(2). Woerner W, Becker A, Rothenberger A. Normative data and scale properties of the German parent SDQ. Eur Child Adolesc Psychiatry Suppl. 2004;13(2). Rothenberger A, Becker A, Erhart M, Wille N, Ravens-Sieberer U. Psychometric properties of the parent strengths and difficulties questionnaire in the general population of German children and adolescents: Results of the BELLA study. Eur Child Adolesc Psychiatry. 2008;17(SUPPL 1):99–105. Lampert T, Hoebel J, Kuntz B, Müters S, Kroll LE. Messung des sozioökonomischen Status und des subjektiven sozialen Status in KiGGS Welle 2. J Heal Monit [Internet]. 2018;3(1):114–33. Available from: www.kiggs-studie.de. Brauns H, Steinmann S. Educational reform in France. West-Germany and the United Kingdom: updating the CASMIN educational classification. ZUMA Nachrichten [Internet]. 1999;23(44):7–44. Available from: https://nbn-resolving.org/urn:nbn:de:0168-%0Assoar-208169%0A Tabachnick B, Fidell L. Using Multivariate Statistics. sixth edit. Boston. Munich: Pearson; 2013. p. 1060. Wang C. Mental health and social support of caregivers of children and adolescents with ASD and other developmental disorders during COVID-19 pandemic. J Affect Disord Reports [Internet]. 2021;6:100242. Available from: https://doi.org/10.1016/j.jadr.2021.100242 Heubeck BG, Richardson A, Lauth G. Parent stress and social support in a randomized controlled trial of individual versus group parent training for children with HKD/ADHD. Br J Clin Psychol. 2025;64(2):148–65. Hosokawa R, Katsura T. Association between parents’ perceived social support and children’s psychological adjustment: a cross-sectional study. BMC Pediatr [Internet]. 2024;24(1). Available from: https://doi.org/10.1186/s12887-024-05235-7 Reiss F, Meyrose AK, Otto C, Lampert T, Klasen F, Ravens-Sieberer U. Socioeconomic status. stressful life situations and mental health problems in children and adolescents: Results of the German BELLA cohort-study. PLoS One [Internet]. 2019;14(3):1–16. Available from: http://dx.doi.org/10.1371/journal.pone.0213700 Additional Declarations No competing interests reported. Supplementary Files Additionalfile1BriefSocialSupportScaleforFamiliesBS6F.docx Cite Share Download PDF Status: Posted 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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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8029850","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":555757076,"identity":"74d90d32-6a21-4988-af5d-67526b028af6","order_by":0,"name":"Anne Geweniger","email":"data:image/png;base64,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","orcid":"","institution":"University of Freiburg. 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Social contacts among family members, friends and relatives as well as social networks can serve as sources of social support (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Study findings indicate that perceived social support may be as important as actual support provided (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSocial support positively affects health and wellbeing of both parents and children through different channels. It may act as protective buffer against life stressors, promoting resilience and adaptive coping strategies (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e); positively influence parenting self-efficacy and thus support children\u0026rsquo;s development (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e); and promote parental and child mental health, particularly in times of crisis (5.6).\u003c/p\u003e\u003cp\u003eFamilies with children with special healthcare needs (CSHCN) often face complex caregiving demands and lower levels of mental wellbeing (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Associations of lower perceived social support with higher disease complexity of the child, lower caregiver wellbeing and low socioeconomic status have been described elsewhere (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Therefore, access to reliable emotional, informational, and practical assistance is vital for maintaining parental mental health, enhancing caregiving capacity, and supporting optimal developmental outcomes for children with chronic health conditions.\u003c/p\u003e\u003cp\u003eThere are few brief instruments assessing social support which are available in both English and German. Existing measures such as the F-SozU K-6 and Brief Social Support Scale BS6 have demonstrated reliability and validity in rapidly assessing perceived social support, yet gaps remain (9.10). The F-SozU K-6, comprising only six items, primarily captures a unidimensional construct of general perceived support and thus does not differentiate well between types of support (e.g. emotional versus instrumental) nor does it contextualise support within specific settings like families (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe BS6. despite its short form of six items still assesses emotional-informational and tangible support as well as overall perceived social support. However. it was developed for general population surveys rather than family-specific support needs. Tangible support, as assessed by the BS6, describes e.g. practical help with household tasks. Emotional-informational support encompasses e.g. provision of advice and empathy. The original version of the BS6 was validated in a population-based sample of 15.010 participants in a German cohort study showing good reliability, internal and external validity (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). The instrument is freely available through the open-access publication.\u003c/p\u003e\u003cp\u003eIn view of the importance of social support for families in general and particularly for those with CSHCN we adapted the original version of the BS6 to better reflect the situation and support needs of families. The psychometric characteristics of the \u003cem\u003eBrief Social Support Scale for Families (BS6-F)\u003c/em\u003e were evaluated in a sample of 381 families with and without CSHCN. Further results of the study have been reported elsewhere (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThis study aims to assess the psychometric characteristics of the adapted Brief Social Support Scale for Families (BS6-F), in particular item distributions, factorial structure and reliability.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design\u003c/h2\u003e\u003cp\u003eThis study analyses data from the third of a series of cross-sectional online surveys assessing the situation of families with and without CSHCN in Germany during and after the COVID-19 pandemic (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The third survey collected data from December 2022 \u0026ndash; March 2023 when most pandemic restrictions in Germany had been lifted.\u003c/p\u003e\u003cp\u003eCaregivers of children\u0026thinsp;\u0026le;\u0026thinsp;18 with and without CSHCN in Germany were eligible to participate. Recruitment was through convenience and non-probabilistic snowball sampling, study promotion via partner organisations, social and public media. and through free access websites. Representatives of the Kindernetzwerk e.V., a large German patient organisation for families with children with chronic disease and disabilities were actively involved in all stages of the study.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003eBrief Social Support Scale for Families (BS6-F)\u003c/h2\u003e\u003cp\u003eThe original version of the Brief Social Support Scale (BS6) is a bi-factorial questionnaire that measures perceived overall social support, specifically distinguishing between emotional-informational and tangible aspects. It is derived from the MOS Social Support Survey (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). The scale comprises six items in total: three targeting tangible support and three focusing on emotional-informational support, each rated on a 4-point Likert scale. Total scores for perceived social support can range from 6 to 24. while each subscale can score between 3 and 12. The recommended interpretation divides the overall social support score into the categories low (\u003cspan additionalcitationids=\"CR7 CR8 CR9 CR10\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), moderate (12\u0026ndash;17; indicating at least occasional support), high (18\u0026ndash;23; meaning mostly supported), and very high (24; always supported). The scale was validated using data from 15.010 participants in a population-based German cohort study, demonstrating good reliability (Cronbach\u0026rsquo;s alpha\u0026thinsp;=\u0026thinsp;0.86 for the total score) (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eFor the purpose of this study, we adapted three of the six original BS6-Items to better reflect the situation and support needs of families. All three adapted items are part of the tangible support subscale. The adaptation process included several steps. First, members of the project team developed a draft version. The wording was carefully chosen to still match the original thematic area of tangible support represented by each item. Next, representatives of the patient organisation Kindernetzwerk e.V., which unites a network of 236 patient organisations for families of children with chronic diseases and disabilities, were invited to participate in a structured online consultation. During this stage, participants were asked to provide feedback on the wording, clarity, and cultural appropriateness of each item. Their suggestions informed the refinement of item phrasing and the inclusion of contextually relevant examples where necessary. After incorporating the recommendations from the patient representatives, a revised draft was circulated for final approval. Details of the item adaptations are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBS6 original version and adapted Items for BS6-F\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBS6 original version (German)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEnglish\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBS6-F adapted Version (German)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eEnglish\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWie h\u0026auml;ufig steht Ihnen folgende Unterst\u0026uuml;tzung durch andere Menschen zur Verf\u0026uuml;gung?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIf you needed it. how often is someone available\u0026hellip;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003eTangible support\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJemand, der Sie zum Arzt f\u0026auml;hrt, wenn es n\u0026ouml;tig ist\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTo take you to the doctor if you need it\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eJemand, der Ihr Kind zu Terminen bringen oder aus der Betreuung abholen kann, wenn Sie verhindert sind\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTo take your child to appointments or to pick them up from daycare/school if you\u0026rsquo;re not available\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJemand, der Ihnen Essen zubereitet, wenn Sie dazu nicht in der Lage sind\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTo prepare your meals if you are unable to do it yourself\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eJemand, der Sie bei der Kinderbetreuung unterst\u0026uuml;tzt\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTo support you in child care duties\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJemand, der Ihnen bei allt\u0026auml;glichen Arbeiten hilft, wenn Sie krank sind\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTo help with daily chores if you were sick\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eJemand, der Ihnen bei allt\u0026auml;glichen Arbeiten (z.B. Besorgungen oder im Haushalt) hilft\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTo help with daily chores (e.g. shopping. household duties)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003eEmotional-informational support\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJemand, der Ihnen in schwierigen Situationen gute Ratschl\u0026auml;ge gibt\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTo give you good advice about a crisis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eunver\u0026auml;ndert\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eno changes made\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJemand, dem Sie sich anvertrauen oder mit dem Sie \u0026uuml;ber pers\u0026ouml;nliche Probleme sprechen k\u0026ouml;nnen\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTo confide in or talk to about yourself or your problems\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJemand, der Ihre Probleme versteht\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWho understands your problems\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eRating options: 1 = never. 2 = occasionally. 3 = mostly. 4 = always\u003c/h3\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eAntwortoptionen: 1\u0026thinsp;=\u0026thinsp;nie. 2\u0026thinsp;=\u0026thinsp;manchmal. 3\u0026thinsp;=\u0026thinsp;meist. 4\u0026thinsp;=\u0026thinsp;immer\u003c/h2\u003e\u003cdiv id=\"Sec8\" class=\"Section3\"\u003e\u003ch2\u003eChildren with special healthcare needs (CSHCN)\u003c/h2\u003e\u003cp\u003eComprising five items, the CSHCN-Screener is a parent-report measure to identify children with chronic physical, mental, behavioural or other conditions who require more health care support than the average of their peers (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Scores can be used to stratify according to disease complexity and healthcare needs with higher scores indicating higher complexity (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e): no special healthcare needs (CSHCN score\u0026thinsp;=\u0026thinsp;0), chronic conditions (CSHCN score\u0026thinsp;\u0026le;\u0026thinsp;2) and complex chronic conditions (CSHCN score\u0026thinsp;\u0026ge;\u0026thinsp;3).\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\n\u003ch3\u003eWHO-5 wellbeing index\u003c/h3\u003e\n\u003cp\u003eThe WHO-5 Wellbeing Index is a brief, five-item screening instrument designed to assess adult mental health, and it has demonstrated strong validity and reliability (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). The total score ranges from 0 to 100, with 100 representing the best imaginable mental wellbeing. A score of 50 or below serves as the threshold for identifying individuals at risk of depression (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eStrengths and Difficulties Questionnaire (SDQ)\u003c/h3\u003e\n\u003cdiv class=\"Heading\"\u003eStrengths and Difficulties Questionnaire (SDQ)\u003c/div\u003e\u003cp\u003eThe Strengths and Difficulties Questionnaire (SDQ) is a widely used, validated screening tool for identifying mental health issues in children and adolescents. It assesses behaviours exhibited over the previous six months. The standard parent-report version is intended for children aged 4 to 16 years, while the preschool version\u0026mdash;differing by three items\u0026mdash;targets younger children (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). The Total Difficulties score, which sums four subscales (hyperactivity/inattention, emotional symptoms, conduct problems, and peer relationship problems), ranges from 0 to 40; higher scores reflect greater mental health problems. Both the German parent-report and preschool versions have demonstrated validity and reliability (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). For this study, caregivers of children older than 2 years completed the age-appropriate SDQ version. The SDQ is freely available through the official website (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.sdqinfo.org\u003c/span\u003e\u003cspan address=\"https://www.sdqinfo.org\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). We applied a cut-off of 13 or higher on the Total Difficulties score (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eSocioeconomic status\u003c/h2\u003e\u003cp\u003eAs described in the German National Health Interview and Examination Survey for Children and Adolescents (KiGGS) (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), socioeconomic status (SES) was assessed using a composite index based on three components: household net equivalent income, parental education, and parental occupation. Household net equivalent income was determined by adjusting the total monthly net household income for household size according to a modified Organisation for Economic Cooperation and Development (OECD) scale (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). In this scale, the household head was weighted as 1, each additional adult as 0.5, and each child as 0.3; the income was then divided by the sum of these weights. For education and occupation, the higher value from either parent was used. Each SES component was rated on a scale from 1 to 7, resulting in a total SES index score ranging from 3 to 21, where lower scores reflect lower socioeconomic status.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eSociodemographic measures\u003c/h2\u003e\u003cp\u003eThese included age and gender, relationship status, education, occupation, monthly household income, household size, area of residence and country of birth. Caregiver education was categorised according to the international CASMIN classification (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Sociodemographic characteristics are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003eSociodemographic characteristics (N\u0026thinsp;=\u0026thinsp;381); SD\u003c/b\u003e: standard deviation; percentages reported as row percentages\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean (SD)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRange\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge in years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eresponding parent \u003cem\u003e(N\u0026thinsp;=\u0026thinsp;333)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e42.7 (6.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23\u0026ndash;64\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eall children \u003cem\u003e(N\u0026thinsp;=\u0026thinsp;355)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9.3 (4.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u0026ndash;18\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003echildren with SHCN \u003cem\u003e(N\u0026thinsp;=\u0026thinsp;275)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9.6 (4.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u0026ndash;18\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of children per household\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.0 (0.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u0026ndash;5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHousehold size (N\u0026thinsp;=\u0026thinsp;342)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.0 (1.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u0026ndash;8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHousehold net equivalent income (\u003cem\u003eN\u0026thinsp;=\u0026thinsp;342\u003c/em\u003e; \u003cem\u003emonthly. in Euros)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2127 (856)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(486\u0026ndash;6190)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePartner living in the same household (n\u0026thinsp;=\u0026thinsp;301)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2228 (845)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(536\u0026ndash;6190)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePartner living in a different household (n\u0026thinsp;=\u0026thinsp;9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1487 (533)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(852\u0026ndash;2277)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo partner (n\u0026thinsp;=\u0026thinsp;29)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1294 (482)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(486\u0026ndash;2692)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender of respondent \u003cem\u003e(N\u0026thinsp;=\u0026thinsp;338)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003emale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003efemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e301\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e89.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender of child (\u003cem\u003eN\u0026thinsp;=\u0026thinsp;354\u003c/em\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003emale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e179\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e50.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003efemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e173\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e48.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ediverse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRelationship status \u003cem\u003e(N\u0026thinsp;=\u0026thinsp;339)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWith partner. in same household\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e301\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e88.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWith partner. not in same household\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo partner\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCountry of birth of parents \u003cem\u003e(N\u0026thinsp;=\u0026thinsp;341)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBoth in Germany\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e304\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e89.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOne parent in Germany. one elsewhere\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBoth elsewhere\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePlace of residence \u003cem\u003e(N\u0026thinsp;=\u0026thinsp;341)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCity (\u0026gt;\u0026thinsp;100 000 inhabitants)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e137\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e40.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSurroundings of a city with \u0026gt;\u0026thinsp;100 000 inhabitants\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTown (20 000- 100 000 inhabitants)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSmall town (5000\u0026ndash;20 000 inhabitants)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRural municipality (\u0026lt;\u0026thinsp;5000 inhabitants)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDisease complexity of child\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo special healthcare needs (CSHCN\u0026thinsp;=\u0026thinsp;0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChronic disease (CSHCN\u0026thinsp;\u0026le;\u0026thinsp;2 criteria)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComplex chronic disease (CSHCN\u0026thinsp;\u0026ge;\u0026thinsp;3 criteria)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e237\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e62.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEducational level according to CASMIN-Classification \u003cem\u003e(N\u0026thinsp;=\u0026thinsp;341)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1a: Inadequately completed general education\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1b: General elementary education\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1c: General elementary education and vocational qualification\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2a: Intermediate general qualification and vocational qualification\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2b: Intermediate general qualification\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2c_gen: General maturity certificate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2c_voc: General maturity certificate and vocational qualification\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3a: Lower tertiary education\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3b: Higher tertiary education\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e141\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e41.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmployment status of respondent \u003cem\u003e(N\u0026thinsp;=\u0026thinsp;339)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInactive or unemployed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eShort term or temporary employment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePart-time\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e208\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e61.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFull-time\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eDescriptive statistics were first computed to inspect item distributions, with means and standard deviations calculated for each item. All items showed sufficient variability and met distributional assumptions for factor analysis (skewness and kurtosis \u0026lt; |2|; (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e)).\u003c/p\u003e\u003cp\u003eDue to the content adjustment of the BS6-F, we refrained from confirmatory testing and conducted an exploratory factor analysis to examine the underlying factorial structure of the six items. We chose principal component extraction, followed by orthogonal varimax rotation with Kaiser normalization to aid interpretability and achieve a simple structure. The number of retained factors was determined according to theoretical (original BS6 factor structure) and statistical criteria (Kaiser-Guttman criterion, eigenvalue\u0026thinsp;\u0026gt;\u0026thinsp;1). Kaiser-Mayer-Olkin (KMO) coefficient and Bartlett sphericity test were used to analyse the data suitability for exploratory factor analysis. Furthermore, internal consistency for the resulting subscales were estimated using Cronbach\u0026rsquo;s alpha.\u003c/p\u003e\u003cp\u003eTo examine expected associations of perceived social support and its subscales with mental wellbeing, SES and complexity of healthcare needs, Pearson correlations were calculated. Primary variables included social support total score, tangible and emotional-informational support. Secondary variables comprised SES, caregiver wellbeing as measured by the WHO-5, parent-reported child mental health problems as measured by the SDQ total problem score, age of child and caregiver.\u003c/p\u003e\u003cp\u003eStatistical analysis was performed using IBM SPSS Version 29.0.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eStudy sample\u003c/h2\u003e\u003cp\u003eThe final study sample consisted of 381 participants. The majority was female, lived with a partner in the same household and had two children. 76.6% (n\u0026thinsp;=\u0026thinsp;292) of children had special healthcare needs. Further details are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eDescriptive item statistics\u003c/h2\u003e\u003cp\u003eDescriptive statistics for individual items are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Item variances ranged from .733 to .961, indicating adequate variability across all items with no evidence of floor or ceiling effects. Skewness values ranged from \u0026minus;\u0026thinsp;1.141 to 1.140, with four items showing negative skew (items 1, 2, 5, 6) and two items showing positive skew (items 3, 4). Kurtosis values ranged from \u0026minus;\u0026thinsp;1.035 to .529. All skewness and kurtosis values fell within acceptable ranges (\u0026lt; |2|) for factor analytic procedures. supporting the appropriateness of the analytical approach.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDescriptive item statistics (N\u0026thinsp;=\u0026thinsp;381)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eItem\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eVariance\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSkewness\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eSE\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eCurtosis\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eSE\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.883\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.780\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.689\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.125\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.294\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e.249\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e2\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.856\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.733\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.638\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.125\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.061\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e.249\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e3\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1.70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.873\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.762\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.140\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.125\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.529\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e.249\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e4\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.980\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.961\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.141\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.125\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-1.035\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e.249\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e5\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2.61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.910\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.829\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.060\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.125\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.863\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e.249\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e6\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.929\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.864\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.207\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.125\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.813\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e.249\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eInter-item correlations\u003c/h2\u003e\u003cp\u003eThe inter-item correlation matrix (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e) revealed a clear pattern supporting the two-factor structure of the BS6-F. Items within the tangible support subscale (Items 1\u0026ndash;3) demonstrated good internal consistency, with correlations ranging from .491 to .637. The emotional-informational support subscale (Items 4\u0026ndash;6) showed even stronger internal consistency, with correlations ranging from .771 to .821.\u003c/p\u003e\u003cp\u003eImportantly, the correlations between items from different subscales were consistently lower (.275 to .378), providing evidence for discriminant validity. The moderate cross-subscale correlations suggest that tangible and emotional-informational support are conceptually related but empirically distinguishable dimensions of social support.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eInter-item correlation matrix (N\u0026thinsp;=\u0026thinsp;381)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eItem 1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eItem 2\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eItem 3\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eItem 4\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eItem 5\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eItem 6\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eItem 1\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.637\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.491\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.358\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.349\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.371\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eItem 2\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.637\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.536\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.295\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.275\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.289\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eItem 3\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.491\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.536\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.378\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.359\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.323\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eItem 4\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.358\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.295\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.378\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.820\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.771\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eItem 5\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.349\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.275\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.359\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.820\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.821\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eItem 6\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.371\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.289\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.323\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.771\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.821\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eFactor analysis\u003c/h2\u003e\u003cp\u003eThe prerequisites for factor analysis were met. The Kaiser-Meyer-Olkin coefficient of sampling adequacy was good (KMO\u0026thinsp;=\u0026thinsp;.795), and Bartlett's test of sphericity was significant (χ\u0026sup2; = 1311.287. df\u0026thinsp;=\u0026thinsp;15. p\u0026thinsp;\u0026lt;\u0026thinsp;.001), indicating that the data were suitable for factor analysis.\u003c/p\u003e\u003cp\u003eKaiser-Guttman criterion suggests a two-factor solution, confirming the theoretically expected factor structure of the original BS6. All items loaded clearly on the theoretically expected factor with loadings ranging from .753 to .926. Cross-loadings were consistently low (\u0026lt;\u0026thinsp;.24), indicating clear factorial separation (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). The two extracted factors explained 78.8% of the total variance.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eRotated factor loadings (N\u0026thinsp;=\u0026thinsp;381)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFactor 1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFactor 2\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eItem 1\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.216\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.821\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eItem 2\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.106\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.877\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eItem 3\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.235\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.753\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eItem 4\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.899\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.219\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eItem 5\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.926\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.190\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eItem 6\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.904\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.197\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe tangible support subscale (items 1\u0026ndash;3) showed acceptable reliability (α\u0026thinsp;=\u0026thinsp;.788), while the emotional-informational subscale (items 4\u0026ndash;6) demonstrated very good internal consistency (α\u0026thinsp;=\u0026thinsp;.924). These findings support the theoretically postulated two-factor structure and confirm the psychometric quality of both subscales.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eCorrelation analysis\u003c/h2\u003e\u003cp\u003eResults are presented in Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e. Perceived social support demonstrated strong positive correlations with its constituent subscales: tangible support (r\u0026thinsp;=\u0026thinsp;.812. p\u0026thinsp;\u0026lt;\u0026thinsp;.001) and emotional-informational support (r\u0026thinsp;=\u0026thinsp;.874. p\u0026thinsp;\u0026lt;\u0026thinsp;.001), confirming the internal consistency of the social support construct. The moderate correlation between the two subscales (r\u0026thinsp;=\u0026thinsp;.427. p\u0026thinsp;\u0026lt;\u0026thinsp;.001) indicates they represent related but distinct dimensions of support.\u003c/p\u003e\u003cp\u003eLower social support was associated with higher disease complexity of the child (CSHCN: r\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;.354. p\u0026thinsp;\u0026lt;\u0026thinsp;.001) and higher scores on the SDQ (SDQ total problem score: r\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;.240. p\u0026thinsp;\u0026lt;\u0026thinsp;.001). There was strong evidence for a negative correlation between child age and social support (r\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;.123. p\u0026thinsp;\u0026lt;\u0026thinsp;.05), indicating that families with older children reported lower levels of social support. Notably. social support demonstrated only a weak positive correlation with parental well-being as measured by WHO-5 (r\u0026thinsp;=\u0026thinsp;.275. p\u0026thinsp;\u0026lt;\u0026thinsp;.001) and a weak positive correlation with SES (r\u0026thinsp;=\u0026thinsp;.180. p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCorrelations of social support and selected sociodemographic variables\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"11\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003etangible support\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eemotional-informational support\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003esocial support total score\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eCSHCN screener\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eWHO-5\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eSES\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003ecaregiver age\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\"\u003e\u003cp\u003eage of child\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c11\"\u003e\u003cp\u003eSDQ total difficulties score\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003etangible support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003er\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.397\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.756\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.228\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.104\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e.157\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.212\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.125\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.117\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.055\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.004\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.019\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e0.029\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e381\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e381\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e381\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e381\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e343\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e341\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e333\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e355\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e345\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eemotional-informational support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003er\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.397\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.886\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.315\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.350\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e.130\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.135\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e-0.082\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.242\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.016\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.013\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.122\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e381\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e381\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e381\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e381\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e343\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e341\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e333\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e355\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e345\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003esocial support total score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003er\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.756\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.886\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.327\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.283\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" 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colname=\"c7\"\u003e\u003cp\u003e1.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e.115\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.095\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e.171\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.267\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.055\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd 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colname=\"c3\"\u003e\u003cp\u003e0.004\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.016\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.019\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.034\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.722\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.421\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e0.095\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e341\u003c/p\u003e\u003c/td\u003e\u003ctd 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colname=\"c3\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.212\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.135\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.194\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.119\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.095\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.020\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e1.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e.662\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" 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colname=\"c11\"\u003e\u003cp\u003e0.207\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e333\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e333\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e333\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e333\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e333\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e332\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e333\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e333\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e328\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eage of child\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003er\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.125\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.082\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.115\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.075\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.171\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-0.044\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e.662\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e1.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e0.090\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.019\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.122\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.031\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.159\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.421\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e0.096\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e355\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e355\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e355\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e355\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e343\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e341\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e333\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e355\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e345\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eSDQ total difficulties score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003er\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.117\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.242\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.228\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.420\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.267\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-0.091\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.070\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.090\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e1.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.029\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.095\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.207\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.096\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e345\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e345\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e345\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e345\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e337\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e336\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e328\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e345\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e345\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"11\" nameend=\"c11\" namest=\"c1\"\u003e\u003cp\u003e** p\u0026thinsp;\u0026le;\u0026thinsp;0.01\u003c/p\u003e\u003cp\u003e* p\u0026thinsp;\u0026le;\u0026thinsp;0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003ePsychometric quality and reliability\u003c/h2\u003e\u003cp\u003eThe present psychometric evaluation of the adapted Brief Social Support Scale for Families (BS6-F) provides strong evidence of its reliability and construct validity as a concise measure of perceived social support among families with CSHCN. Exploratory factor analysis confirmed a distinct two-factor structure, capturing tangible and emotional-informational support with high factor loadings and minimal cross-loadings, indicating robust structural integrity. Furthermore, both subscales demonstrated strong internal consistency (α\u0026thinsp;=\u0026thinsp;.788-.924). 78.8% of total variance was explained, highlighting efficient assessment of perceived social support with minimal respondent burden (only six items). Item distribution and variance analyses supported measurement precision across diverse support profiles.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003eKey Correlations and interpretative insights\u003c/h2\u003e\u003cp\u003eAssociations of different types of social support, special healthcare needs of the child, child and parent mental health as well as socioeconomic factors could be described.\u003c/p\u003e\u003cp\u003eIn particular, there was strong evidence for a moderate association of parent-reported child mental health problems and caregiver mental wellbeing with low overall social support and low emotional-informational support. Parents of children with more complex healthcare needs reported lower social support on all three scales. Besides, families with older children reported lower levels of social support, which may suggest potential gaps in support systems as CSHCN transition through developmental stages. These results echo the findings of previous studies and underscore the importance of social support for vulnerable populations such as children with special healthcare needs and their families (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Furthermore they add to the external validity of the BS6-F by confirming expected associations between social support and determinants of mental wellbeing and vulnerability (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSurprisingly, we only found a weak correlation of social support and SES. This leads to several possible explanations. First, this might be due to sampling bias as participants in the study were not representative of the general population in Germany and families with low SES might be underrepresented. Second, the BS6-F captures perceived availability of social support rather than resource-intensive forms of assistance that would be expected to correlate more strongly with SES. Third, families across different socioeconomic levels may have access to similar levels of social support, indicating that supportive relationships are not necessarily tied to financial resources. Families with higher SES might tend to access formal, professional support services while families with lower SES may rely more on informal networks within the family or community, resulting in similar overall support levels. This warrants further research into the complex interrelations of SES, social support and the situation of families.\u003c/p\u003e\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\u003ch2\u003ePractical implications for clinical and research settings\u003c/h2\u003e\u003cp\u003eThe brevity and explicit differentiation of support domains make the BS6-F highly applicable to routine pediatric and family-centered clinical settings. Its targeted measurement of tangible and emotional-informational support enables practitioners and researchers to identify specific support gaps, track changes over time, and tailor interventions accordingly. Sensitivity to family circumstances. particularly complexity of care and age-related transitions strengthens its utility for monitoring and outcome evaluation across diverse contexts.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\u003ch2\u003eLimitations\u003c/h2\u003e\u003cp\u003eSeveral limitations must be considered. The non-representative nature of the sample limits the generalizability of these findings. Cross-validation in representative samples is needed to confirm the factorial structure and reliability estimates. The study benefited from direct stakeholder involvement in item development, which enhanced both contextual and content validity. Nevertheless - because item adaptations may influence measurement sensitivity - further investigation into measurement invariance and responsiveness to change across diverse subpopulations is critical.\u003c/p\u003e\u003cdiv id=\"Sec25\" class=\"Section3\"\u003e\u003ch2\u003eConclusion and implications for future research\u003c/h2\u003e\u003cp\u003eConsidering the scarcity of brief assessment tools for social support that are adapted to the situation and needs of families, the BS6-F is a valuable addition for assessment and research. While the clear two-factor structure and good reliability coefficients support the theoretical model, replication in diverse and representative samples is essential to establish the instrument's broader validity. Reliance on caregiver self-report potentially limits the breadth of perspectives captured, hence future research on social support measures should consider multi-informant and longitudinal studies employing mixed methods. The BS6-F is freely available and both the English and German versions can be found in Additional file 1.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the Declaration of Helsinki. Informed consent to participate was obtained from all study participants. Ethics approval was granted by the ethics committee of Freiburg University (Approval number 377/20).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availabilty statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe dataset used during the current study is available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe primary study was funded by the Volkswagen Foundation. grant number Az 990622.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAG:\u003c/strong\u003e Conceptualisation. Methodology. Software. Formal analysis. Investigation. Data curation. Writing – Original Draft. Writing – Review and Editing. Visualisation. \u003cstrong\u003eJW:\u003c/strong\u003e Conceptualisation. Methodology. Writing – Review and Editing. Supervision. \u003cstrong\u003eTL:\u003c/strong\u003e Conceptualisation. Writing – Review and Editing. Supervision. Project administration. Funding acquisition. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank Annette Mund. Henriette Högl and Kathrin Jackel-Neusser from the steering committee of the Kindernetzwerk e.V. for their support in the recruitment process and their valuable contributions to the adaptation of the BS6-F.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBerkman LF, Glass T, Brissette I, Seeman TE. 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Psychometric properties of the parent strengths and difficulties questionnaire in the general population of German children and adolescents: Results of the BELLA study. Eur Child Adolesc Psychiatry. 2008;17(SUPPL 1):99\u0026ndash;105.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLampert T, Hoebel J, Kuntz B, M\u0026uuml;ters S, Kroll LE. Messung des sozio\u0026ouml;konomischen Status und des subjektiven sozialen Status in KiGGS Welle 2. J Heal Monit [Internet]. 2018;3(1):114\u0026ndash;33. Available from: www.kiggs-studie.de.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBrauns H, Steinmann S. Educational reform in France. West-Germany and the United Kingdom: updating the CASMIN educational classification. ZUMA Nachrichten [Internet]. 1999;23(44):7\u0026ndash;44. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://nbn-resolving.org/urn:nbn:de:0168-%0Assoar-208169%0A\u003c/span\u003e\u003cspan address=\"https://nbn-resolving.org/urn:nbn:de:0168-%0Assoar-208169%0A\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTabachnick B, Fidell L. Using Multivariate Statistics. sixth edit. Boston. Munich: Pearson; 2013. p. 1060.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWang C. Mental health and social support of caregivers of children and adolescents with ASD and other developmental disorders during COVID-19 pandemic. J Affect Disord Reports [Internet]. 2021;6:100242. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jadr.2021.100242\u003c/span\u003e\u003cspan address=\"10.1016/j.jadr.2021.100242\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHeubeck BG, Richardson A, Lauth G. Parent stress and social support in a randomized controlled trial of individual versus group parent training for children with HKD/ADHD. Br J Clin Psychol. 2025;64(2):148\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHosokawa R, Katsura T. Association between parents\u0026rsquo; perceived social support and children\u0026rsquo;s psychological adjustment: a cross-sectional study. BMC Pediatr [Internet]. 2024;24(1). 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Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://dx.doi.org/10.1371/journal.pone.0213700\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0213700\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"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":"social support, assessment - families, children with special healthcare needs, children with chronic disease, mental health, mental wellbeing","lastPublishedDoi":"10.21203/rs.3.rs-8029850/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8029850/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eSocial support is an important determinant of and resource for health and wellbeing of families. It positively affects health and wellbeing of both parents and children through different channels. Families with children with special healthcare needs (CSHCN) face complex caregiving demands and lower levels of mental wellbeing. Perceived social support is an important resource for these families and a structured assessment necessary to support healthcare providers and health policy. We here present the adaptation of the \u003cem\u003eBrief Social Support Scale for Families (BS6-F)\u003c/em\u003e and its psychometric characteristics.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis study is based on data from the third of a series of cross-sectional online surveys assessing the situation of families with and without CSHCN in Germany during and after the COVID-19 pandemic, collected from December 2022 to March 2023. Caregivers of children\u0026thinsp;\u0026le;\u0026thinsp;18 with and without CSHCN in Germany were eligible to participate. The BS6-F is a 6-item measure assessing perceived social support. It has two subscales, tangible and emotional-informational support. The adaptation of the original BS6 followed a structured consultation process involving representatives of a large patient organisation, the Kindernetzwerk e.V. Statistical analysis comprised descriptive item statistics, correlation analyses and exploratory factor analysis (EFA).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe final study sample comprised 381 participants. Item-level analyses indicated good variability and no floor or ceiling effects. Inter-item correlations and EFA supported the expected two-factor structure of the BS6-F. explaining 78.8% of the variance. Both subscales demonstrated good to excellent reliability (α\u0026thinsp;=\u0026thinsp;.788 and .924). Correlations between subscales were moderate (r\u0026thinsp;=\u0026thinsp;.427). confirming them as related but distinct dimensions. Perceived social support was negatively associated with child disease complexity (r = \u0026ndash;.354) and child mental health problems (r = \u0026ndash;.240), and weakly positively associated with parental well-being (WHO-5; r\u0026thinsp;=\u0026thinsp;.275) and SES (r\u0026thinsp;=\u0026thinsp;.180).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThe BS6-F is a brief assessment tool for social support adapted to the situation and needs of families and a valuable addition for assessment and research. While the clear two-factor structure and good reliability coefficients support the theoretical model, replication in diverse and representative samples is essential to establish the instrument's broader validity. The BS6-F is freely available and both the English and German versions can be found in the Additional file 1.\u003c/p\u003e","manuscriptTitle":"Adaptation and psychometric evaluation of the Brief Social Support Scale for Families (BS6-F)","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-08 19:35:35","doi":"10.21203/rs.3.rs-8029850/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":"f82aa198-77ff-4cb6-b1f2-eb918b51fcc0","owner":[],"postedDate":"December 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-13T02:38:51+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-08 19:35:35","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8029850","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8029850","identity":"rs-8029850","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}