Parenting stress level of children with allergic rhinitis ：Role of children's behavior and parental anxiety

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Parenting stess is closely related to the health of child patients and the anxiety levels of their parents. It is still unclear how the behavioral problems of these children and parental anxiety together affect parenting stress. Methods: A cross-sectional design and convenience sampling method were employed for 230 parents of children with allergic rhinitis. The Conners' Parent Symptom Questionnaire, Self-Rating Anxiety Scale, and the Simplified Parenting Stress Index were used for assessment. Data were analyzed using descriptive statistics and structural equation modeling with SPSS 27.0 and AMOS 26.0. Results : The parents of children with AR had a moderate level of parenting stress (31.95±9.41). In the mediating effects model, children’s behavioral problems could influence parenting stress directly (95% CI: 2.556, 3.990) or indirectly through parental anxiety (95% CI: 0.190, 0.759). Conclusions : Behavioral problems of children with AR can have both direct and indirect effects on parenting stress through the mediating factors of parental anxiety.Therefore, when designing supportive interventions, clinicians should consider both the children's clinical symptoms and behavioral issues, as well as the psychological state of their caregivers.On one hand, resources can be directly applied to the children. On the other hand, the utilization of psychological assessment and intervention for caregivers, can alleviate parenting stress and strengthen the family's ability to cope. Health sciences/Diseases Health sciences/Health care Health sciences/Medical research Biological sciences/Psychology Social science/Psychology Health sciences/Risk factors Allergic rhinitis patenting stess behavioral problems parental anxiety Figures Figure 1 Figure 2 1. Introduction Allergic rhinitis (AR) is a chronic, non-infectious inflammatory disease of the nasal mucosa mediated by immunoglobulin E (IgE) [1]. Triggered by exposure to allergens in atopic individuals, AR induces significant physical discomfort and substantially impairs daily life[2]. Driven by climate change, environmental pollution, and urbanization, the global incidence of AR is rising. The worldwide prevalence of AR in children is approximately 40%[3], while in China, it ranges from 18.10% to 49.68%[4,5]. Allergic Rhinitis not only imposes a physical burden on children, affecting their learning, social interaction, and quality of life[1], but also brings significant psychological stress and parenting burden to parents[6]. Surveys indicate that 36%-50% of parents express concerns regarding their children's health, behavioral development, and cognitive development[7]. Studies have shown that higher levels of parenting stress may lead parents to adopt low-quality parenting behaviors, which may, in turn,contribute to long-term behavioral and emotional problems in children[8-10]. Consequently, reducing the psychological and parenting stress of caregivers and enhancing their capacity to fulfill parenting roles effectively have emerged as pressing public health priorities. Allergic Rhinitis (AR) is one of the most common allergic diseases among children and adolescents, mainly characterized by symptoms such as nasal congestion, sneezing, runny nose and nasal itching. Owing to their chronicity and recurrence, AR symptoms have a profound negative impact on the quality of life of young individuals, which manifests not only physically but also in psychological and behavioral domains. Furthermore, studies have demonstrated that chronic AR can adversely affect sleep quality, resulting in issues including attention deficits, emotional dysregulation, and academic challenges[1]. Yamaguchi et al. (2017) reported that children with AR aged 2-6 years scored significantly higher on measures of emotional and behavioral problems than their healthy children[2].This finding suggests a strong association between chronic nasal symptoms of AR and behavioral issues in children, such as emotional lability, irritability, and heightened anxiety. Moreover, these behavioral problems tend to intensify during symptomatic exacerbations. AR is also linked to specific neuropsychological disorders. Studies indicate a higher prevalence of conditions like attention deficit hyperactivity disorder (ADHD) and learning disabilities in this population[11]. The underlying mechanism may involve the chronic inflammatory response associated with AR affecting central nervous system (CNS) function, thereby increasing the risk of concentration difficulties and maladaptive behaviors[11]. The cumulative effect of these psychological and behavioral challenges can further impair a child's academic performance and social functioning, ultimately compromising their mental health. This, in turn, increases the parenting burden and can negatively impact the parent-child relationship[12]. Based on the above reasons, we hypothesize that behavioral problems in children with AR directly contribute to parenting stress(Hypothesis 1). Studies have demonstrated that parents of children with AR often experience anxiety and helplessness attributable to the disease's chronicity and the child's frequent need for medical care. Consequently, these parents bear greater psychological and parenting burdens compared to parents of healthy children[13]. The high prevalence of comorbidities, such as asthma (approximately35%) in China[14],and allergic conjunctivitis (30-71%)[15] . Research by Tae-Yoon Hwang et al. confirmed that the number and frequency of a child's allergic symptoms are significant predictors of impaired parental quality of life, with a higher symptom load correlating with increased reports of parental anxiety and distress[13].This anxiety can, in turn, compromise a parent's capacity for positive emotional engagement and effective parenting practices, thereby fostering perceptions of parenting as more challenging[16]. Based on this evidence, we hypothesize that parental anxiety directly contributes to parenting stress (Hypothesis 2). Furthermore, behavioral problems in children with AR, such as emotional instability and irritability, can exacerbate parenting difficulties, thereby increasing stress levels[7]. The impact of AR extends beyond physical health to affect psychological well-being and social adaptation. Studies indicate that children with AR exhibit more emotional, behavioral, and academic challenges compared to their healthy children[3], Consequently, parents often invest considerable time and energy in monitoring their child's behavior and academic progress, a demand compounded by the child's condition.Given that parenting stress is closely linked to the child's physical and mental health, their behavioral issues, and the parents' own psychological state[7]. Therefor, we hypothesize that children's behavioral problems indirectly influence parenting stress through the mediation of parental anxiety (Hypothesis 3). Parenting stress refers to the negative emotional experience when parents perceive an imbalance between the demands of their role and their available resources to meet those demands[17].This study is grounded in Abidin's Parenting Stress Model, which posits that such stress originates from the dynamic interplay among parent domain, child domain, and contextual factors [17]. Within this framework, the parent's own psychological state(such as anxiety, depression, and self-efficacy) is considered a core determinant of their stress experience. Specifically, when parents experience psychological distress or emotional imbalance, their tolerance for child behavior and their perceived parenting efficacy are often diminished, thereby intensifying the subjective feeling of stress. Guided by this model, this study focuses on the influence paths of child domain behavior problems and parent domain anxiety on parental stress. Moreover, based on the above hypotheses 1, 2, and 3, this study aims to construct a structural equation model (SEM) to examine the effects of behavior problems and parental anxiety on parenting stress. The proposed conceptual model is shown in Figure 1. 2. Material and Methods 2.1. Setting and Participants This is a cross-sectional study to explore the influencing mechanisms and potential intervention strategies for parenting stress among parents of children with Allergic Rhinitis (AR).A convenience sampling method was employed to recruit participants from both the outpatient and inpatient departments of Renmin Hospital of Wuhan University between January 2023 and January 2024.Inclusion criteria were as follows:(1) children diagnosed with AR according to the Guidelines for Diagnosis and Treatment of Allergic Rhinitis developed by the Editorial Board of the Chinese Journal of Otorhinolaryngology Head and Neck Surgery and the Otolaryngology Branch of the Chinese Medical Association, with typical symptoms and signs of AR (e.g., clear rhinorrhea, sneezing, nasal congestion, nasal itching, pale and edematous nasal mucosa, and watery nasal discharge);(2) positive serum-specific IgE to Dermatophagoides pteronyssinus and/or Dermatophagoides farinae on allergen testing; (3) age ≤ 18 years; and(4) either parent (father or mother) provided informed consent and voluntarily participated in the study.Exclusion criteria included:(1) children with severe comorbidities such as congenital heart disease, hepatic or renal dysfunction, or malignancy;(2) presence of severe infectious diseases (e.g., respiratory or hematologic infections);(3) children or parents with psychiatric disorders that might affect cooperation; and(4) hearing or speech impairments in children or parents that could hinder effective communication. A total of 230 parents of children diagnosed with AR completed the questionnaire survey. All self-report questionnaires were administered electronically via the Wenjuanxing platform and completed on mobile devices by the participants. Any uncertainties were clarified in real time, and the investigators checked the completeness and quality of the responses. In cases of missing data or unclear responses, participants were contacted immediately to verify and supplement the information. 2.2. Measurements A sociodemographic questionnaire was developed to collect background information on both the children and their parents. The main items included the child’s sex, age, comorbidities, family history of allergic rhinitis, disease duration, parents’ age and educational level, annual household income, and the child’s type of immunotherapy. Parent Symptom Questionnaire (PSQ) was developed by Conners in 1969 as a parent-report scale for assessing children’s behavioral problems. The Chinese version of the PSQ has demonstrated good reliability and validity, with a Cronbach’s α of 0.932 and a split-half reliability coefficient of 0.900[18]. The scale consists of 48 items rated on a 4-point Likert scale, ranging from 0 (“none”) to 3 (“very much”). It yields six factor scores: conduct problems, learning problems, psychosomatic problems, impulsive-hyperactive behavior, anxiety, and hyperactivity index. A hyperactivity index score≥1.5 indicates a tendency toward hyperactive behavior. The PSQ is widely used in clinical practice to assess behavioral and emotional problems in children. Self-Rating Anxiety Scale (SAS) was developed by Zung to assess the severity of anxiety symptoms[19]. The SAS consists of 20 items rated on a 4-point scale according to symptom frequency: “none or a little of the time,” “some of the time,” “a good part of the time,” and “most or all of the time.” According to the Chinese norm, a standard score below 50 indicates a normal range, while higher scores reflect greater levels of anxiety. The SAS has been widely applied in both clinical and research settings and shows good psychometric properties in Chinese populations. The Parenting Stress Index-Short Form (PSI-SF-15), developed by Luo et al., is a Chinese short version of the Parenting Stress Index designed to assess parenting stress among parents of children[20].The scale consists of three subscales: parental distress, parent-child dysfunctional interaction, and difficult child. Each item is rated on a 5-point Likert scale ranging from 1 (“strongly disagree”) to 5 (“strongly agree”). The total score ranges from 15 to 75, with higher scores indicating greater levels of parenting stress. The Chinese version of the PSI-SF-15 has demonstrated good reliability, with an overall Cronbach’s α of 0.89. In the present study, the Cronbach’s α coefficients were 0.906 for the total scale and 0.740, 0.839, and 0.877 for the three subscales, respectively. 2.3. Ethical considerations Participation in this study was voluntary, and all participants were informed of their right to withdraw at any time. Written informed consent was obtained from each participant prior to the survey. To protect participants’ privacy, the questionnaires were completed anonymously and stored separately. The study was approved by the Ethics Committee of Renmin Hospital of Wuhan University (WDRY2024-K273) and was conducted in accordance with the principles of the Declaration of Helsinki. 2.4. Data analysis Data were entered using Epidata 3.1 and analyzed with SPSS 27.0 and AMOS 26.0. Continuous variables were expressed as mean±standard deviation (SD), and categorical variables were presented as frequencies and percentages. Pearson correlation analysis was conducted to examine the relationships among children’s behavioral problems, parental anxiety, and parenting stress. Based on Hypotheses 1,2 and 3, a structural equation model (SEM) was constructed using AMOS 26.0, and parameter estimation was performed with the maximum likelihood method. Model modifications were made according to the modification indices. Model fit was evaluated using conventional criteria: χ²/df < 3, RMSEA 0.90 indicated acceptable model fit.The bias-corrected percentile bootstrap method (5,000 resamples) was used to test the mediating effect. All statistical tests were two-tailed, and a p-value < 0.05 was considered statistically significant. 3. Results 3.1. Sociodemographic characteristics A total of 250 questionnaires were distributed, and 230 valid questionnaires were retrieved, with an effective response rate of 92%. In total, 230 parents of children with allergic rhinitis (AR) were included in the analysis. The mean age of the children was 9.93±3.00 years, with an average disease duration of 9.97±10.69 months and subcutaneous immunotherapy duration of 8.56±9.92 months. The mean age of mothers was 38.28±4.42 years, and that of fathers was 40.43±4.87 years. Detailed sociodemographic information is presented in Table 1. 3.2. Univariate analysis of parenting stress and related factors The mean total score of the PSI-SF-15 among AR parents was 31.95±9.41. The mean scores for the three subscales were as follows: parental distress 10.43±3.07, parent-child dysfunctional interaction 9.28 ±3.40, and difficult child 12.30±4.53.Univariate analysis showed that parenting stress levels differed significantly by the child’s gender and family annual income (P < 0.05). The detailed results are shown in Table 1. Table 1. Sociodemographic characteristics of parents of children with AR and univariate analysis of factors associated with parenting stress (n = 230) Variable Category n (%) PSI-SF-15 total score (`c±s ) F/t P -value Child’s sex Male 145(63.0) 33.12±9.41 6.204 0.013 Famale 85(37.0) 29.95±9.11 Only child Yes 115(50.0) 32.44±9.88 0.638 0.425 No 115(50.0) 31.45±8.92 Family history of AR Yes 119(51.7) 32.02±9.49 0.012 0.913 No 111(48.3) 31.88±9.37 Comorbidities Tonsillar hypertrophy Yes 32(13.9) 30.44±9.28 0.958 0.329 No 198(13.9) 32.19±9.43 Conjunctivitis Yes 9(3.9) 28.14±8.97 0.314 0.576 No 221(96.1) 32.02±9.44 Sinusitis Yes 6(2.6) 25.33±6.83 3.075 0.081 No 224(97.4) 32.13±6.83 Otitis media with effusion Yes 2(0.9) 37.00±2.83 0.581 0.447 No 228(99.1) 31.90±9.43 Asthma Yes 19(8.3) 31.79±9.89 0.006 0.939 No 211(91.7) 31.96±9.38 Atopic dermatitis Yes 37(16.1) 33.76±9.92 1.636 0.202 No 193(83.9) 31.60±9.29 Mother’s education level Junior high school or below 16(7.0) 37.25±10.75 2.248 0.065 High school 24(10.4) 33.79±9.16 College 67(29.1) 32.45±8.75 Bachelor’s degree 91(39.6) 30.84±8.91 Master’s degree or above 32(13.9) 30.03±10.81 Father’s education level Junior high school or below 13(5.7) 36.62±10.99 1.910 0.110 High school 21(9.1) 34.38±10.81 College 54(23.5) 32.43±8.23 Bachelor’s degree 96(41.7) 31.59±8.99 Master’s degree or above 46(20.0) 29.70±10.04 Annual household income(RMB) ≤100,000 34(14.8) 37.03±10.99 5.060 0.002 100,001-200,000 92(40.0) 31.87±8.30 200,001-300,000 58(25.2) 31.36±8.74 ≥300,000 46(20.0) 29.09±9.86 3.3. Relationships among variables The correlations among children’s behavioral problems, parental anxiety, and parenting stress are presented in Table 2. Children’s behavioral problems were positively correlated with parental anxiety (r = 0.377, p < 0.01) and parenting stress (r = 0.631, p < 0.01). Parental anxiety was also positively correlated with parenting stress (r = 0.445, p < 0.01). Table 2. Correlations among children’s behavioral problems, parental anxiety, and parenting stress (N = 230) Variables `X± SD Behavior problems Parental anxiety Parenting stress Behavior problems 0.33±0.28 1.000 Parental anxiety 35.29±6.87 0.377** 1.000 Parenting stress 31.95±9.41 0.631** 0.445** 1.000 **P＜0.01；*P＜0.05 3.4. Regression coefficients and mediation effects of the model Based on the proposed hypotheses, the initial structural equation model (SEM) is presented in Figure 2. The model demonstrated acceptable fit: χ²/df = 77.052/33 = 2.335, p < 0.01, RMSEA = 0.076, CFI = 0.968, and TLI = 0.957. The results indicated that children’s behavioral problems had a direct effect on parenting stress and an indirect effect mediated by parental anxiety, supporting Hypothesis 1. Parental anxiety also had a direct effect on parenting stress, supporting Hypothesis 2. Standardized path coefficients are presented in Table 3, and the final SEM is shown in Figure 2. Table 3 Regression coefficients and mediating effects of all paths in the final model Relationship Estimate S.E. P-Value Behavior problems→Parental Anxiety 0.344 1.006 ＜0.001 Behavior problems→Parenting stress 0.596 0.351 ＜0.001 Parental Anxiety→Parenting stress 0.267 0.018 ＜0.001 3.5. Effects of model variables on parenting stress The effects of each variable on parenting stress, including total, direct, and indirect effects, are presented in Table 4. Table 4 Effect value of each variable on parenting stress in the final model Variables Behavior problems Parental anxiety Parenting stress Direct effect 0.60 0.27 Indirect effect 0.09 / Total effect 0.69 0.27 4. Discussion This study explored the pathways influencing parenting stress from both child and parent-related factors. We examined the mediating role of parental anxiety in the relationship between children’s behavioral problems and parenting stress. Mediation analysis indicated that children’s behavioral problems could independently predict parenting stress and also exert an indirect effect through parental anxiety. These findings provide insight into the child and parent-related factors associated with parenting stress in children with AR and offer guidance for developing individualized interventions. In this study, the total score of parenting stress among parents of children with AR was 31.95±9.41, indicating a moderate level relative to the scale’s scoring range. Due to the frequent occurrence of allergic rhinitis and the particularity of its treatment [21], parents of children with AR must make repeated hospital visits and strictly adhere to prevention and treatment protocols. Compared with parents of healthy children, they experience not only the routine parenting stress but also additional disease-related stress[10]. Although most AR symptoms are controllable and not life-threatening, frequent sneezing, rhinorrhea, itching, and sleep disturbances can negatively affect the quality of life of both the child and the entire family[21].If parents of children with AR are required to invest high levels of time, energy, and resources over prolonged periods, the combined effects of parenting stress, family stress, and personal psychological burden may lead to parental burnout, ultimately affecting parent-child relationships, parenting behaviors, and the child’s physical and psychological development[22].Therefore, it is crucial to conduct general surveys on disease knowledge and parenting stress in families of children with AR. Such assessments can guide targeted interventions, including health education, disease management guidance, and psychological support, thereby enhancing family management capacity and alleviating parenting stress in a timely manner. In this study, parents of male children reported higher parenting stress than those of female children. Barroso et al. found that male children are more likely to exhibit externalizing behaviors such as impulsivity and oppositionality, which increase the difficulty of daily caregiving and lead to higher perceived parenting burden[23],supporting the findings of the present study. The mean age of the children in this study was 9.93±3.00 years. Previous research has also shown that during childhood and adolescence, allergic rhinitis symptoms are more pronounced in males, potentially increasing caregiving demands and indirectly elevating parental stress. In addition, the analysis of sociodemographic data indicated that family annual income was associated with parenting stress among parents of children with AR, consistent with previous findings[24].On one hand, low-income families already face substantial financial strain, and the costs associated with AR treatment further increase this burden[25].On the other hand, children with AR require meticulous care, while low-income parents often engage in long working hours or jobs with low control, creating conflicts with caregiving demands and leading to the accumulation of parenting stress over time[26,27].For this population, clinical practice may consider implementing online screening and interventions when necessary to reduce the medical burden on parents. The results of this study indicated that parental anxiety is a direct influencing factor of parenting stress. In China, parents are typically the primary caregivers of children and adolescents, with children’s medical care and daily caregiving largely dependent on them[28].However, parents of childbearing age face multiple pressures from work, family, and social roles, making them a high-risk group for anxiety. Previous studies have shown that approximately 67% of mothers in nearly 3,000 Canadian families experience anxiety[29],while a survey conducted during the COVID-19 lockdown in Shanghai, China, reported a parental anxiety prevalence of approximately 72.6%[30].Such high levels of emotional stress may further affect parents’ psychological state and behavioral performance in the caregiving of children with chronic conditions.For families of children with AR, although the disease is generally considered a mild, non-life-threatening chronic condition, it is highly recurrent, has a prolonged symptom management period, and is often accompanied by sleep disturbances and attention difficulties, requiring long-term management and repeated medical visits[21].The repeated caregiving demands and fluctuating symptoms can easily trigger negative emotions in parents, particularly among those with high levels of anxiety[26].According to Abidin’s Parenting Stress Model, parental anxiety is one of the direct sources of parenting stress. Anxious parents often exhibit lower parenting self-efficacy, show excessive concern or overreaction to their child’s symptoms, thereby experiencing less positive emotions during the parenting process and reducing the quality of the parent-child relationship, forming a vicious cycle of "anxiety-stress-negative parenting behaviors"[31].In addition, according to Lazarus and Folkman’s stress-coping theory, individuals with anxiety are more likely to appraise stressful events as threatening and engage in catastrophic thinking. This cognitive bias can amplify their subjective perception of the severity of their child’s symptoms and caregiving demands, leading to a significant increase in parenting stress[32,33].Previous studies have also indicated a bidirectional relationship between parental anxiety and parenting stress, whereby anxious emotions not only directly elevate parents’ perceived stress but also indirectly exacerbate parent–child conflict by reducing parenting self-efficacy and consistency[34,35].Therefore, during the caregiving and follow-up of children with AR, attention should be paid to parents’ psychological status, and anxiety screening and psychological interventions should be incorporated into routine management. Interventions such as cognitive-behavioral anxiety management, relaxation training, and parenting skills training may help alleviate parenting stress and improve overall family coping and disease management outcomes. Future research could further employ longitudinal or interventional study designs to verify the causal mechanisms of parental anxiety on parenting stress. Behavioral problems in children with AR have a direct impact on parenting stress, consistent with previous research[3].Behavioral problems refer to inappropriate internalizing or externalizing behaviors that occur during childhood and adolescence. AR symptoms are relatively persistent, and current studies indicate that treatment adherence in AR is less than 50%[36],Consequently, some children are chronically exposed to physiological discomfort, leading to sleep disturbances, inattention, hyperactivity, impulsivity, and irritability[2].These behaviors not only affect learning and social interactions[37],but may also contribute to the development of psychological issues such as anxiety, depression, and attention-deficit/hyperactivity disorder[38].Behavioral problems thus represent an important source of both disease burden and parenting stress. Developmental psychopathology distinguishes between stressful parenting and parenting stress, considering them as related yet distinct concepts[39].Stressful parenting primarily arises from external factors in the caregiving environment, such as work, income, and social relationships[40].Behavioral problems in children with AR can affect their performance at school, their parents may face work interruptions, treatment burdens, and concerns about their child’s health and academic performance, in addition to communicating with teachers and other parents, which can substantially increase parental psychological distress[41].Studies have shown that, under normal circumstances, parental stress tends to decrease over time[42,43].However, when parenting stress related to caring for a child with a chronic illness accumulates with stress from the external caregiving environment, parents’ positive emotions and capacity for adaptive coping gradually diminish, ultimately resulting in perceived stress that exceeds their coping ability and leading to lower-quality parenting behaviors[44].A lot of evidence supports the relationship between parental negative emotions, such as anxiety and depression, and both parenting stress and positive/negative parenting behaviors,this relationship often considered bidirectional[45,46].The present study confirms the mediating role of parental anxiety in the relationship between children’s behavioral problems and parenting stress. 5. Limitations This study has several limitations. First, data were collected using convenience sampling from a single hospital in Wuhan, which may limit the generalizability of the findings. Second, this was a cross-sectional study; although relationships among variables were examined using structural equation modeling, causal inferences cannot be drawn. Third, the study was framed based on Abidin’s Parenting Stress Model, focusing on the pathways among behavioral problems, parental anxiety, and parenting stress. Therefore, child sex and family income were not included in the model. The current study aimed to directly test our hypotheses.Subsequently, we will conduct longitudinal, multicenter, randomized controlled designs to further verify causal relationships and examine the roles of demographic characteristics and protective factors such as social support in the development of parenting stress. 6. Conclusion In this study, parenting stress among parents of children with AR was at a moderate level. Behavioral problems influenced parenting stress both directly and indirectly through parental anxiety, and both behavioral problems and parental anxiety independently predicted parenting stress. These findings provide evidence for the development of preventive and intervention strategies for children with AR and their families from a psychosocial perspective. At the clinical and community levels, parental mental health screening and emotional regulation should be incorporated into allergic disease management. Interventions such as cognitive-behavioral therapy, emotion regulation training, and family communication guidance may help reduce parental anxiety, improve parent-child interaction quality, and effectively alleviate parenting stress. Furthermore, future research is recommended to explore potential protective factors such as social support, self-efficacy, and family resilience, to establish more comprehensive and sustainable intervention frameworks that promote the long-term physical and mental health of children with AR and their families. Abbreviations AR Allergic rhinitis ADHD Attention Deficit Hyperactivity Disorder SEM Structural Equation Model PSQ Parent Symptom Questionnaire SAS Self-Rating Anxiety Scale PSI-SF-15 Parenting Stress Index-Short Form Declarations Ethics approval and consent to participate The study was conducted in accordance with the guidelines of the Declaration of Helsinki and approved by the Ethics Committee of Renmin Hospital of Wuhan University (WDRY2024-K273) .Informed consent was obtained from all participants. Consent for publication Not applicable. Availability of data and materials: All relevant data are included in the article. Additional supporting data are available from the corresponding authors upon request. All requests for raw and analyzed data and materials will be reviewed by the corresponding authors to verify whether the request is subject to any intellectual property or confidentiality obligations. Competing interests The authors have no conflicts of interest to disclose. Funding This work was supported by grants from the Project Supported by the Open Fund of Hubei Key Laboratory (grant number: 2023KFH007). Authors’ contributions LFL: Writing – original draft，Writing – review & editing，Conceptualization, Data curation, Formal Analysis,Methodology,Funding acquisition. WXJ: Writing – original draft,Conceptualization, Methodology, software, validation, Writing – review & editing. WL: Writing – review & editing,Methodology,Investigation,Supervision . XY-YY: Writing – review & editing, Formal Analysis,Investigation, Supervision. Acknowledgments The authors thank all the participants and researchers for their contributions to this study References Subspecialty Group of Rhinology, Editorial Board of Chinese Journal of Otorhinolaryngology Head and Neck Surgery, Subspecialty Group Of Rhinology, Society Of Otorhinolaryngology Head and Neck Surgery, Chinese Medical Association. Chinese guideline for diagnosis and treatment of allergic rhinitis (2022, revision). Subspecialty Group of Rhinology, Editorial Board of Chinese Journal of Otorhinolaryngology Head and Neck Surgery. 2022;57(2):106-29. doi:10.3760/cma.j.cn115330-20211228-00828. Yamaguchi C, Ebara T, Futamura M, Ohya Y, Asano M. Do allergic clinical manifestations increase the risk of behavioral problems in children? A cross-sectional study. PEDIAT ALLERG IMM-UK. 2021;32(8):1646-53. doi:10.1111/pai.13542. Meltzer EO, Blaiss MS, Naclerio RM, Stoloff SW, Derebery MJ, Nelson HS et al. Burden of allergic rhinitis: allergies in America, Latin America, and Asia-Pacific adult surveys. ALLERGY ASTHMA PROC. 2012;33 Suppl 1:S113-41. 'doi:'10.2500/aap.2012.33.3603. Zhang YM, Zhang J, Liu SL, Zhang X, Yang SN, Gao J et al. Prevalence and associated risk factors of allergic rhinitis in preschool children in Beijing. LARYNGOSCOPE. 2013;123(1):28-35. doi:10.1002/lary.23573. Wang Meng, Zhen Min, Wang Xiangdong, Zhang Luo. Research Progress on the Epidemiology of Allergic Rhinitis in China. CHIN ARCH OTOLARYNGOL HEAD NECK SURG. 2019;26(8):415-20. doi:10.16066/j.1672-7002.2019.08.004. Rusu PP, Candel OS, Bogdan I, Ilciuc C, Ursu A, Podina IR. Parental Stress and Well-Being: A Meta-analysis. CLIN CHILD FAM PSYCH. 2025;28(2):255-74. doi:10.1007/s10567-025-00515-9. Fang Y, Luo J, Boele M, Windhorst D, van Grieken A, Raat H. Parent, child, and situational factors associated with parenting stress: a systematic review. EUR CHILD ADOLES PSY. 2024;33(6):1687-705. doi:10.1007/s00787-022-02027-1. Fang Y, Boelens M, Windhorst DA, Raat H, van Grieken A. Factors associated with parenting self-efficacy: A systematic review. J ADV NURS. 2021;77(6):2641-61. doi:10.1111/jan.14767. Jones TL, Prinz RJ. Potential roles of parental self-efficacy in parent and child adjustment: a review. CLIN PSYCHOL REV. 2005;25(3):341-63. doi:10.1016/j.cpr.2004.12.004. Cousino MK, Hazen RA. Parenting stress among caregivers of children with chronic illness: a systematic review. J PEDIATR PSYCHOL. 2013;38(8):809-28. doi:10.1093/jpepsy/jst049. Chang HY, Seo JH, Kim HY, Kwon JW, Kim BJ, Kim HB et al. Allergic diseases in preschoolers are associated with psychological and behavioural problems. ALLERGY ASTHMA IMMUN. 2013;5(5):315-21. doi:10.4168/aair.2013.5.5.315. Lee YS, Kim SH, You JH, Baek HT, Na C, Kim BN et al. Attention deficit hyperactivity disorder like behavioral problems and parenting stress in pediatric allergic rhinitis. PSYCHIAT INVEST. 2014;11(3):266-71. doi:10.4306/pi.2014.11.3.266. Hwang TY, Kim SK, Kim SH, Kim M. A cross sectional survey on health-related quality of life among parents of children with allergic symptoms using the EQ-5D-5L. J ASTHMA. 2019;56(11):1239-45. doi:10.1080/02770903.2019.1571086. Kou W, Li X, Yao H, Wei P. Meta-analysis of the comorbidity rate of allergic rhinitis and asthma in Chinese children. INT J PEDIATR OTORHI. 2018;107:131-4. doi:10.1016/j.ijporl.2018.02.001. Leonardi A, Castegnaro A, Valerio AL, Lazzarini D. Epidemiology of allergic conjunctivitis: clinical appearance and treatment patterns in a population-based study. CURR OPIN ALLERGY CL. 2015;15(5):482-8. doi:10.1097/ACI.0000000000000204. Cooklin AR, Giallo R, Rose N. Parental fatigue and parenting practices during early childhood: an Australian community survey. CHILD CARE HLTH DEV. 2012;38(5):654-64. doi:10.1111/j.1365-2214.2011.01333.x. Abidin RR. The Determinants of Parenting Behavior. Journal of Clinical Child Psychology. 1992;21(4):407-12. doi:10.1207/s15374424jccp2104_12. Fan Juan, Du Ya song, Wang Li wei. The norm and reliability of the Conners Parent Symptom Questionnaire in Chinese urban children. Shanghai Archives of Psychiatry. 2005;17(6):321-3. doi:10.3969/j.issn.1002-0829.2005.06.001. Zung WW. A rating instrument for anxiety disorders. PSYCHOSOMATICS. 1971;12(6):371-9. doi:10.1016/S0033-3182(71)71479-0. Luo J, Wang MC, Gao Y, Zeng H, Yang W, Chen W et al. Refining the Parenting Stress Index-Short Form (PSI-SF) in Chinese Parents. ASSESSMENT. 2021;28(2):551-66. doi:10.1177/1073191119847757. Schuler IC, Montejo JM. Allergic Rhinitis in Children and Adolescents. IMMUNOL ALLERGY CLIN. 2021;41(4):613-25. doi:10.1016/j.iac.2021.07.010. Aktu Y. The role of parenting stress on parenting self-efficacy and parental burnout among Turkish parents: a moderated mediation model. BMC PSYCHOL. 2024;12(1):475. doi:10.1186/s40359-024-01980-7. Barroso NE, Mendez L, Graziano PA, Bagner DM. Parenting Stress through the Lens of Different Clinical Groups: a Systematic Review & Meta-Analysis. J ABNORM CHILD PSYCH. 2018;46(3):449-61. doi:10.1007/s10802-017-0313-6. Toledano-Toledano F, Dominguez-Guedea MT. Psychosocial factors related with caregiver burden among families of children with chronic conditions. BIOPSYCHOSOC MED. 2019;13:6. doi:10.1186/s13030-019-0147-2. Liu Qing, Cai Yingqi. A study on parenting stress and its influencing factors among urban young parents. Youth Exploration. 2022(1):71-81. doi:10.13583/j.cnki.issn1004-3780.2022.01.007. Cheng M, Dai Q, Liu Z, Wang Y, Zhou C. New progress in pediatric allergic rhinitis. FRONT IMMUNOL. 2024;15:1452410. doi:10.3389/fimmu.2024.1452410. Kochanova K, Pittman LD, McNeela L. Parenting Stress and Child Externalizing and Internalizing Problems Among Low-Income Families: Exploring Transactional Associations. CHILD PSYCHIAT HUM D. 2022;53(1):76-88. doi:10.1007/s10578-020-01115-0. Zhang Y, Zhou Z, Si Y. The role of parental health care utilization in children's unnecessary utilization in China: evidence from Shaanxi province. INT J EQUITY HEALTH. 2017;16(1):47. doi:10.1186/s12939-017-0544-8. Cameron EE, Joyce KM, Delaquis CP, Reynolds K, Protudjer J, Roos LE. Maternal psychological distress & mental health service use during the COVID-19 pandemic. J AFFECT DISORDERS. 2020;276:765-74. doi:10.1016/j.jad.2020.07.081. Yu W, Guo Z, Tian J, Li P, Wang P, Chen H et al. Parental Anxiety, Practices, and Parent-Child Relationships among Families with Young Children in China: A Cross-Sectional Study. CHILDREN-BASEL. 2023;10(8). doi:10.3390/children10081388. Abidin RR. Parenting Stress Index: Professional Manual. 3rd ed ed: Odessa, FL : Psychological Assessment Resources; 1995. Lazarus RS FS. Stress, appraisal, and coping: New York: Springer publishing company; 1984. Rask CU, Duholm CS, Poulsen CM, Rimvall MK, Wright KD. Annual Research Review: Health anxiety in children and adolescents-developmental aspects and cross-generational influences. J CHILD PSYCHOL PSYC. 2024;65(4):413-30. doi:10.1111/jcpp.13912. Pitillas C, Zerolo BE, Jodar R, Ribeiro A. Measuring Parental Response Styles to Child Stress in Severe Pediatric Illness: A Validation Study. NURS REP. 2024;14(4):3539-49. doi:10.3390/nursrep14040258. Rolle L, Prino LE, Sechi C, Vismara L, Neri E, Polizzi C et al. Parenting Stress, Mental Health, Dyadic Adjustment: A Structural Equation Model. FRONT PSYCHOL. 2017;8:839. doi:10.3389/fpsyg.2017.00839. Yang S, Yang J, Xu J, Hu Y, Li C, Zhang L et al. Allergic rhinitis and behaviour problems in urban children aged 6 to 12 years and the mediating role of sleep disturbance. ANN MED. 2025;57(1):2460771. doi:10.1080/07853890.2025.2460771. Kieling C, Buchweitz C, Caye A, Silvani J, Ameis SH, Brunoni AR et al. Worldwide Prevalence and Disability From Mental Disorders Across Childhood and Adolescence: Evidence From the Global Burden of Disease Study. JAMA PSYCHIAT. 2024;81(4):347-56. doi:10.1001/jamapsychiatry.2023.5051. Chen K, Zheng X, Li Z, Xiang H, Chen B, Zhang H. Risk factors analysis of attention deficit/hyperactivity disorder and allergic rhinitis in children: a cross-sectional study. ITAL J PEDIATR. 2019;45(1):99. doi:10.1186/s13052-019-0703-1. Crnic KA. Parenting stress and child behavior problems: Developmental psychopathology perspectives. DEV PSYCHOPATHOL. 2024;36(5):2369-75. doi:10.1017/S0954579424001135. Garmezy, N, Rutter M. Stress, coping, and development in children: Hopkins Fulfillment Service; 1988. Fields A, Harmon C, Lee Z, Louie JY, Tottenham N. Parent's anxiety links household stress and young children's behavioral dysregulation. DEV PSYCHOBIOL. 2021;63(1):16-30. doi:10.1002/dev.22013. Stone LL, Mares SH, Otten R, Engels RC, Janssens JM. The Co-Development of Parenting Stress and Childhood Internalizing and Externalizing Problems. J PSYCHOPATHOL BEHAV. 2016;38:76-86. 'doi:'10.1007/s10862-015-9500-3. Williford AP, Calkins SD, Keane SP. Predicting change in parenting stress across early childhood: child and maternal factors. J ABNORM CHILD PSYCH. 2007;35(2):251-63. 'doi:'10.1007/s10802-006-9082-3. Sturge-Apple ML, Skibo MA, Rogosch FA, Ignjatovic Z, Heinzelman W. The impact of allostatic load on maternal sympathovagal functioning in stressful child contexts: implications for problematic parenting. DEV PSYCHOPATHOL. 2011;23(3):831-44. 'doi:'10.1017/S0954579411000332. Neece CL, Green SA, Baker BL. Parenting stress and child behavior problems: a transactional relationship across time. AJIDD-AM J INTELLECT. 2012;117(1):48-66. doi:10.1352/1944-7558-117.1.48. Thomason E, Volling BL, Flynn HA, McDonough SC, Marcus SM, Lopez JF et al. Parenting stress and depressive symptoms in postpartum mothers: bidirectional or unidirectional effects? INFANT BEHAV DEV. 2014;37(3):406-15. doi:10.1016/j.infbeh.2014.05.009. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 26 Mar, 2026 Reviews received at journal 26 Mar, 2026 Reviewers agreed at journal 25 Mar, 2026 Reviewers agreed at journal 24 Mar, 2026 Reviewers invited by journal 17 Feb, 2026 Editor invited by journal 06 Nov, 2025 Editor assigned by journal 05 Nov, 2025 Submission checks completed at journal 05 Nov, 2025 First submitted to journal 04 Nov, 2025 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-8034172","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":593064573,"identity":"66d0e0d5-386b-47c9-b9e7-67207ebea388","order_by":0,"name":"Fangli Li","email":"","orcid":"","institution":"Renmin Hospital of Wuhan University","correspondingAuthor":false,"prefix":"","firstName":"Fangli","middleName":"","lastName":"Li","suffix":""},{"id":593064574,"identity":"d89f6468-4809-4a48-88b7-c18dd7c0b5d4","order_by":1,"name":"Xiaojia Wu","email":"","orcid":"","institution":"Renmin Hospital of Wuhan University","correspondingAuthor":false,"prefix":"","firstName":"Xiaojia","middleName":"","lastName":"Wu","suffix":""},{"id":593064575,"identity":"ef772c9b-2b72-4f6f-8afd-a6b7e0dd2b1e","order_by":2,"name":"Li Wen","email":"","orcid":"","institution":"Renmin Hospital of Wuhan University","correspondingAuthor":false,"prefix":"","firstName":"Li","middleName":"","lastName":"Wen","suffix":""},{"id":593064576,"identity":"a7c01ab5-9dff-4b51-8e53-649c3b3ce616","order_by":3,"name":"Yunyan Xianyu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0UlEQVRIie3LMQrCMBTG8YRCXQKuD9Q7VApVsId5oVAXdZQOgpkyCW6CeAmP0BLoFJ0LDtbdwdFJNKODNW4O+cMbHnw/Qlyuv4yKHDNYrgkzn2dDvKKudUy3wp74Sf8iU7rPbclgoyPgUnlhNS2BZCMuWoe8kXRPkwjwqPyomqVA9JgLNsNGAh1D5opFxlKpuAAWWBBfQbgz5GFF0iRAmQaBsVRYkaSoUccI52s4xHIcSjb5Rrgo7hlge6X71W0x6q1bupm8h6/zf9i7XC6X60NPRFpEYCt55icAAAAASUVORK5CYII=","orcid":"","institution":"Renmin Hospital of Wuhan University","correspondingAuthor":true,"prefix":"","firstName":"Yunyan","middleName":"","lastName":"Xianyu","suffix":""}],"badges":[],"createdAt":"2025-11-05 04:53:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8034172/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8034172/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103176912,"identity":"c19c27c9-5803-4150-b01d-e041b3404e41","added_by":"auto","created_at":"2026-02-22 16:39:35","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":75414,"visible":true,"origin":"","legend":"\u003cp\u003eProposed conceptual model of parenting stress\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8034172/v1/7f9bedb281dea6bda5c7eb52.png"},{"id":103176911,"identity":"3999f92b-e5c0-4f7c-a9dd-a0b5498edfd3","added_by":"auto","created_at":"2026-02-22 16:39:35","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":75325,"visible":true,"origin":"","legend":"\u003cp\u003eStructural equation model of parenting stress\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8034172/v1/1ad20db28e2d875a7477d263.png"},{"id":104397338,"identity":"d2b77b71-3327-44e7-b449-9f8e3cb87248","added_by":"auto","created_at":"2026-03-11 11:46:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":865865,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8034172/v1/d36cb77e-9f2f-4fc2-ac76-3cadc59a7c52.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Parenting stress level of children with allergic rhinitis ：Role of children's behavior and parental anxiety","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eAllergic rhinitis (AR) is a chronic, non-infectious inflammatory disease of the nasal mucosa mediated by immunoglobulin E (IgE)\u0026nbsp;[1]. Triggered by exposure to allergens in atopic individuals, AR induces significant physical discomfort and substantially impairs daily life[2]. Driven by climate change, environmental pollution, and urbanization, the global incidence of AR is rising. The worldwide prevalence of AR in children is approximately 40%[3], while in China, it ranges from 18.10% to 49.68%[4,5]. Allergic Rhinitis not only imposes a physical burden on children, affecting their learning, social interaction, and quality of life[1], but also brings significant psychological stress and parenting burden to parents[6]. Surveys indicate that 36%-50% of parents express concerns regarding their children\u0026apos;s health, behavioral development, and cognitive development[7]. Studies have shown that higher levels of parenting stress may lead parents to adopt low-quality parenting behaviors, which may, in turn,contribute to long-term behavioral and emotional problems in children[8-10]. Consequently, reducing the psychological and parenting stress of caregivers and enhancing their capacity to fulfill parenting roles effectively have emerged as pressing public health priorities.\u003c/p\u003e\n\u003cp\u003eAllergic Rhinitis (AR) is one of the most common allergic diseases among children and adolescents, mainly characterized by symptoms such as nasal congestion, sneezing, runny nose and nasal itching. Owing to their chronicity and recurrence, AR symptoms have a profound negative impact on the quality of life of young individuals, which manifests not only physically but also in psychological and behavioral domains. Furthermore, studies have demonstrated that chronic AR can adversely affect sleep quality, resulting in issues including attention deficits, emotional dysregulation, and academic challenges[1]. Yamaguchi et al. (2017) reported that children with AR aged 2-6 years scored significantly higher on measures of emotional and behavioral problems than their healthy children[2].This finding suggests a strong association between chronic nasal symptoms of AR and behavioral issues in children, such as emotional lability, irritability, and heightened anxiety. Moreover, these behavioral problems tend to intensify during symptomatic exacerbations. AR is also linked to specific neuropsychological disorders. Studies indicate a higher prevalence of conditions like attention deficit hyperactivity disorder (ADHD) and learning disabilities in this population[11]. The underlying mechanism may involve the chronic inflammatory response associated with AR affecting central nervous system (CNS) function, thereby increasing the risk of concentration difficulties and maladaptive behaviors[11]. The cumulative effect of these psychological and behavioral challenges can further impair a child\u0026apos;s academic performance and social functioning, ultimately compromising their mental health. This, in turn, increases the parenting burden and can negatively impact the parent-child relationship[12]. Based on the above reasons, we hypothesize that behavioral problems in children with AR directly contribute to parenting stress(Hypothesis 1).\u003c/p\u003e\n\u003cp\u003eStudies have demonstrated that parents of children with AR often experience anxiety and helplessness attributable to the disease\u0026apos;s chronicity and the child\u0026apos;s frequent need for medical care. Consequently, these parents bear greater psychological and parenting burdens compared to parents of healthy children[13].\u0026nbsp;The high prevalence of comorbidities, such as asthma (approximately35%) in China[14],and allergic conjunctivitis (30-71%)[15]\u0026nbsp;. Research by Tae-Yoon Hwang et al. confirmed that the number and frequency of a child\u0026apos;s allergic symptoms are significant predictors of impaired parental quality of life, with a higher symptom load correlating with increased reports of parental anxiety and distress[13].This anxiety can, in turn, compromise a parent\u0026apos;s capacity for positive emotional engagement and effective parenting practices, thereby fostering perceptions of parenting as more challenging[16]. Based on this evidence, we hypothesize that parental anxiety directly contributes to parenting stress (Hypothesis 2).\u003c/p\u003e\n\u003cp\u003eFurthermore, behavioral problems in children with AR, such as emotional instability and irritability, can exacerbate parenting difficulties, thereby increasing stress levels[7]. The impact of AR extends beyond physical health to affect psychological well-being and social adaptation. Studies indicate that children with AR exhibit more emotional, behavioral, and academic challenges compared to their healthy children[3], Consequently, parents often invest considerable time and energy in monitoring their child\u0026apos;s behavior and academic progress, a demand compounded by the child\u0026apos;s condition.Given that parenting stress is closely linked to the child\u0026apos;s physical and mental health, their behavioral issues, and the parents\u0026apos; own psychological state[7]. Therefor, we hypothesize that children\u0026apos;s behavioral problems indirectly influence parenting stress through the mediation of parental anxiety (Hypothesis 3).\u003c/p\u003e\n\u003cp\u003eParenting stress refers to the negative emotional experience when parents perceive an imbalance between the demands of their role and their available resources to meet those demands[17].This study is grounded in Abidin\u0026apos;s Parenting Stress Model, which posits that such stress originates from the dynamic interplay among parent domain, child domain, and contextual factors [17]. Within this framework, the parent\u0026apos;s own psychological state(such as anxiety, depression, and self-efficacy) is considered a core determinant of their stress experience. Specifically, when parents experience psychological distress or emotional imbalance, their tolerance for child behavior and their perceived parenting efficacy are often diminished, thereby intensifying the subjective feeling of stress. Guided by this model, this study focuses on the influence paths of child domain behavior problems and parent domain anxiety on parental stress. Moreover, based on the above hypotheses 1, 2, and 3, this study \u0026nbsp;aims to construct a structural equation model (SEM) to examine the effects of behavior problems and parental anxiety on parenting stress. The proposed conceptual model is shown in Figure 1.\u003c/p\u003e"},{"header":"2. Material and Methods","content":"\u003cp\u003e\u003cstrong\u003e2.1. Setting and Participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis is a cross-sectional study to explore the influencing mechanisms and potential intervention strategies for parenting stress among parents of children with Allergic Rhinitis (AR).A convenience sampling method was employed to recruit participants from both the outpatient and inpatient departments of Renmin Hospital of Wuhan University between January 2023 and January 2024.Inclusion criteria were as follows:(1) children diagnosed with AR according to the Guidelines for Diagnosis and Treatment of Allergic Rhinitis developed by the Editorial Board of the Chinese Journal of Otorhinolaryngology Head and Neck Surgery and the Otolaryngology Branch of the Chinese Medical Association, with typical symptoms and signs of AR (e.g., clear rhinorrhea, sneezing, nasal congestion, nasal itching, pale and edematous nasal mucosa, and watery nasal discharge);(2) positive serum-specific IgE to Dermatophagoides pteronyssinus and/or Dermatophagoides farinae on allergen testing;\u003cbr\u003e\u0026nbsp;(3) age \u0026le; 18 years; and(4) either parent (father or mother) provided informed consent and voluntarily participated in the study.Exclusion criteria included:(1) children with severe comorbidities such as congenital heart disease, hepatic or renal dysfunction, or malignancy;(2) presence of severe infectious diseases (e.g., respiratory or hematologic infections);(3) children or parents with psychiatric disorders that might affect cooperation; and(4) hearing or speech impairments in children or parents that could hinder effective communication.\u003c/p\u003e\n\u003cp\u003eA total of 230 parents of children diagnosed with AR completed the questionnaire survey. All self-report questionnaires were administered electronically via the Wenjuanxing platform and completed on mobile devices by the participants. Any uncertainties were clarified in real time, and the investigators checked the completeness and quality of the responses. In cases of missing data or unclear responses, participants were contacted immediately to verify and supplement the information.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2. Measurements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA sociodemographic questionnaire was developed to collect background information on both the children and their parents. The main items included the child\u0026rsquo;s sex, age, comorbidities, family history of allergic rhinitis, disease duration, parents\u0026rsquo; age and educational level, annual household income, and the child\u0026rsquo;s type of immunotherapy. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParent Symptom Questionnaire (PSQ) was developed by Conners in 1969 as a parent-report scale for assessing children\u0026rsquo;s behavioral problems. The Chinese version of the PSQ has demonstrated good reliability and validity, with a Cronbach\u0026rsquo;s \u0026alpha; of 0.932 and a split-half reliability coefficient of 0.900[18]. The scale consists of 48 items rated on a 4-point Likert scale, ranging from 0 (\u0026ldquo;none\u0026rdquo;) to 3 (\u0026ldquo;very much\u0026rdquo;). It yields six factor scores: conduct problems, learning problems, psychosomatic problems, impulsive-hyperactive behavior, anxiety, and hyperactivity index. A hyperactivity index score\u0026ge;1.5 indicates a tendency toward hyperactive behavior. The PSQ is widely used in clinical practice to assess behavioral and emotional problems in children.\u003c/p\u003e\n\u003cp\u003eSelf-Rating Anxiety Scale (SAS) was developed by Zung to assess the severity of anxiety symptoms[19]. The SAS consists of 20 items rated on a 4-point scale according to symptom frequency: \u0026ldquo;none or a little of the time,\u0026rdquo; \u0026ldquo;some of the time,\u0026rdquo; \u0026ldquo;a good part of the time,\u0026rdquo; and \u0026ldquo;most or all of the time.\u0026rdquo; According to the Chinese norm, a standard score below 50 indicates a normal range, while higher scores reflect greater levels of anxiety. The SAS has been widely applied in both clinical and research settings and shows good psychometric properties in Chinese populations.\u003c/p\u003e\n\u003cp\u003eThe Parenting Stress Index-Short Form (PSI-SF-15), developed by Luo et al., is a Chinese short version of the Parenting Stress Index designed to assess parenting stress among parents of children[20].The scale consists of three subscales: parental distress, parent-child dysfunctional interaction, and difficult child. Each item is rated on a 5-point Likert scale ranging from 1 (\u0026ldquo;strongly disagree\u0026rdquo;) to 5 (\u0026ldquo;strongly agree\u0026rdquo;). The total score ranges from 15 to 75, with higher scores indicating greater levels of parenting stress. The Chinese version of the PSI-SF-15 has demonstrated good reliability, with an overall Cronbach\u0026rsquo;s \u0026alpha; of 0.89. In the present study, the Cronbach\u0026rsquo;s \u0026alpha; coefficients were 0.906 for the total scale and 0.740, 0.839, and 0.877 for the three subscales, respectively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.3.\u003c/strong\u003e \u003cstrong\u003eEthical considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipation in this study was voluntary, and all participants were informed of their right to withdraw at any time. Written informed consent was obtained from each participant prior to the survey. To protect participants\u0026rsquo; privacy, the questionnaires were completed anonymously and stored separately. The study was approved by the Ethics Committee of Renmin Hospital of Wuhan University (WDRY2024-K273) and was conducted in accordance with the principles of the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.4. Data analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were entered using Epidata 3.1 and analyzed with SPSS 27.0 and AMOS 26.0. Continuous variables were expressed as mean\u0026plusmn;standard deviation (SD), and categorical variables were presented as frequencies and percentages. Pearson correlation analysis was conducted to examine the relationships among children\u0026rsquo;s behavioral problems, parental anxiety, and parenting stress. Based on Hypotheses 1,2 and 3, a structural equation model (SEM) was constructed using AMOS 26.0, and parameter estimation was performed with the maximum likelihood method. Model modifications were made according to the modification indices. Model fit was evaluated using conventional criteria: \u0026chi;\u0026sup2;/df \u0026lt; 3, RMSEA \u0026lt; 0.08, and CFI and TLI \u0026gt; 0.90 indicated acceptable model fit.The bias-corrected percentile bootstrap method (5,000 resamples) was used to test the mediating effect. All statistical tests were two-tailed, and a p-value \u0026lt; 0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003e\u003cstrong\u003e3.1. Sociodemographic characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 250 questionnaires were distributed, and 230 valid questionnaires were retrieved, with an effective response rate of 92%. In total, 230 parents of children with allergic rhinitis (AR) were included in the analysis. The mean age of the children was 9.93\u0026plusmn;3.00 years, with an average disease duration of 9.97\u0026plusmn;10.69 months and subcutaneous immunotherapy duration of 8.56\u0026plusmn;9.92 months. The mean age of mothers was 38.28\u0026plusmn;4.42 years, and that of fathers was 40.43\u0026plusmn;4.87 years. Detailed sociodemographic information is presented in Table 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2. Univariate analysis of parenting stress and related factors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe mean total score of the PSI-SF-15 among AR parents was 31.95\u0026plusmn;9.41. The mean scores for the three subscales were as follows: parental distress 10.43\u0026plusmn;3.07, parent-child dysfunctional interaction 9.28 \u0026plusmn;3.40, and difficult child 12.30\u0026plusmn;4.53.Univariate analysis showed that parenting stress levels differed significantly by the child\u0026rsquo;s gender and family annual income (P \u0026lt; 0.05). The detailed results are shown in Table 1.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"631\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" style=\"width: 631px;\"\u003e\n \u003cp\u003eTable 1. Sociodemographic characteristics of parents of children with AR and univariate analysis of factors associated with parenting stress (n = 230)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 153px;\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003eCategory\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003ePSI-SF-15 total score\u0026nbsp;(`c\u0026plusmn;s )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u003cem\u003eF/t\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 153px;\"\u003e\n \u003cp\u003eChild\u0026rsquo;s sex\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e145(63.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003e33.12\u0026plusmn;9.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e6.204\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.013\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 153px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003eFamale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e85(37.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003e29.95\u0026plusmn;9.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 153px;\"\u003e\n \u003cp\u003eOnly child\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e115(50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003e32.44\u0026plusmn;9.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e0.638\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e0.425\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 153px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e115(50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003e31.45\u0026plusmn;8.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 153px;\"\u003e\n \u003cp\u003eFamily history of AR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e119(51.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003e32.02\u0026plusmn;9.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e0.012\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e0.913\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 153px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e111(48.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003e31.88\u0026plusmn;9.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 153px;\"\u003e\n \u003cp\u003eComorbidities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 153px;\"\u003e\n \u003cp\u003eTonsillar hypertrophy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e32(13.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003e30.44\u0026plusmn;9.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e0.958\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e0.329\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 153px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e198(13.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003e32.19\u0026plusmn;9.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 153px;\"\u003e\n \u003cp\u003eConjunctivitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e9(3.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003e28.14\u0026plusmn;8.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e0.314\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e0.576\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 153px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e221(96.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003e32.02\u0026plusmn;9.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 153px;\"\u003e\n \u003cp\u003eSinusitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e6(2.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003e25.33\u0026plusmn;6.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e3.075\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e0.081\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 153px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e224(97.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003e32.13\u0026plusmn;6.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 153px;\"\u003e\n \u003cp\u003eOtitis media with effusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e2(0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003e37.00\u0026plusmn;2.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e0.581\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e0.447\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 153px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e228(99.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003e31.90\u0026plusmn;9.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 153px;\"\u003e\n \u003cp\u003eAsthma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e19(8.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003e31.79\u0026plusmn;9.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e0.939\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 153px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e211(91.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003e31.96\u0026plusmn;9.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 153px;\"\u003e\n \u003cp\u003eAtopic dermatitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e37(16.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003e33.76\u0026plusmn;9.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e1.636\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e0.202\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 153px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e193(83.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003e31.60\u0026plusmn;9.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 153px;\"\u003e\n \u003cp\u003eMother\u0026rsquo;s education level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 153px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003eJunior high school or below\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e16(7.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003e37.25\u0026plusmn;10.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e2.248\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e0.065\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 153px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003eHigh school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e24(10.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003e33.79\u0026plusmn;9.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 153px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003eCollege\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e67(29.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003e32.45\u0026plusmn;8.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 153px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003eBachelor\u0026rsquo;s degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e91(39.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003e30.84\u0026plusmn;8.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 153px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003eMaster\u0026rsquo;s degree or above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e32(13.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003e30.03\u0026plusmn;10.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 153px;\"\u003e\n \u003cp\u003eFather\u0026rsquo;s education level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 153px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003eJunior high school or below\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e13(5.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003e36.62\u0026plusmn;10.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e1.910\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e0.110\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 153px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003eHigh school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e21(9.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003e34.38\u0026plusmn;10.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 153px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003eCollege\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e54(23.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003e32.43\u0026plusmn;8.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 153px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003eBachelor\u0026rsquo;s degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e96(41.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003e31.59\u0026plusmn;8.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 153px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003eMaster\u0026rsquo;s degree or above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e46(20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003e29.70\u0026plusmn;10.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 153px;\"\u003e\n \u003cp\u003eAnnual household income(RMB)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 153px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003e\u0026le;100,000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e34(14.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003e37.03\u0026plusmn;10.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e5.060\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.002\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 153px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003e100,001-200,000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e92(40.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003e31.87\u0026plusmn;8.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 153px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003e200,001-300,000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e58(25.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003e31.36\u0026plusmn;8.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 153px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003e\u0026ge;300,000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e46(20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003e29.09\u0026plusmn;9.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 71px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e3.3. Relationships among variables\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe correlations among children\u0026rsquo;s behavioral problems, parental anxiety, and parenting stress are presented in Table 2. Children\u0026rsquo;s behavioral problems were positively correlated with parental anxiety (r = 0.377, p \u0026lt; 0.01) and parenting stress (r = 0.631, p \u0026lt; 0.01). Parental anxiety was also positively correlated with parenting stress (r = 0.445, p \u0026lt; 0.01).\u003c/p\u003e\n\u003cp\u003eTable 2. Correlations among children\u0026rsquo;s behavioral problems, parental anxiety, and parenting stress (N = 230)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"622\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e`X\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 143px;\"\u003e\n \u003cp\u003eBehavior problems\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003eParental anxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003eParenting stress\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003eBehavior problems\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e0.33\u0026plusmn;0.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 143px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003eParental anxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e35.29\u0026plusmn;6.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 143px;\"\u003e\n \u003cp\u003e0.377**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003eParenting stress\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e31.95\u0026plusmn;9.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 143px;\"\u003e\n \u003cp\u003e0.631**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e0.445**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e**P＜0.01；*P＜0.05\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.4. Regression coefficients and mediation effects of the model\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBased on the proposed hypotheses, the initial structural equation model (SEM) is presented in Figure 2. The model demonstrated acceptable fit: \u0026chi;\u0026sup2;/df = 77.052/33 = 2.335, p \u0026lt; 0.01, RMSEA = 0.076, CFI = 0.968, and TLI = 0.957.\u003c/p\u003e\n\u003cp\u003eThe results indicated that children\u0026rsquo;s behavioral problems had a direct effect on parenting stress and an indirect effect mediated by parental anxiety, supporting Hypothesis 1. Parental anxiety also had a direct effect on parenting stress, supporting Hypothesis 2. Standardized path coefficients are presented in Table 3, and the final SEM is shown in Figure 2.\u003c/p\u003e\n\u003cp\u003eTable 3 Regression coefficients and mediating effects of all paths in the final model\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"573\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 271px;\"\u003e\n \u003cp\u003eRelationship\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003eEstimate\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eS.E.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eP-Value\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 271px;\"\u003e\n \u003cp\u003eBehavior problems\u0026rarr;Parental Anxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e0.344\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e1.006\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 271px;\"\u003e\n \u003cp\u003eBehavior problems\u0026rarr;Parenting stress\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e0.596\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0.351\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 271px;\"\u003e\n \u003cp\u003eParental Anxiety\u0026rarr;Parenting stress\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e0.267\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0.018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e3.5. Effects of model variables on parenting stress\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe effects of each variable on parenting stress, including total, direct, and indirect effects, are presented in Table 4.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Table 4 Effect value of each variable on parenting stress in the final model\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"590\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 146px;\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 146px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 146px;\"\u003e\n \u003cp\u003eBehavior problems\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 154px;\"\u003e\n \u003cp\u003eParental anxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 146px;\"\u003e\n \u003cp\u003eParenting stress\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 146px;\"\u003e\n \u003cp\u003eDirect effect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 146px;\"\u003e\n \u003cp\u003e0.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 154px;\"\u003e\n \u003cp\u003e0.27\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 146px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 146px;\"\u003e\n \u003cp\u003eIndirect effect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 146px;\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 154px;\"\u003e\n \u003cp\u003e/\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 146px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 146px;\"\u003e\n \u003cp\u003eTotal effect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 146px;\"\u003e\n \u003cp\u003e0.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 154px;\"\u003e\n \u003cp\u003e0.27\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis study explored the pathways influencing parenting stress from both child and parent-related factors. We examined the mediating role of parental anxiety in the relationship between children\u0026rsquo;s behavioral problems and parenting stress. Mediation analysis indicated that children\u0026rsquo;s behavioral problems could independently predict parenting stress and also exert an indirect effect through parental anxiety. These findings provide insight into the child and parent-related factors associated with parenting stress in children with AR and offer guidance for developing individualized interventions.\u003c/p\u003e\n\u003cp\u003eIn this study, the total score of parenting stress among parents of children with AR was 31.95\u0026plusmn;9.41, indicating a moderate level relative to the scale\u0026rsquo;s scoring range.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDue to the frequent occurrence of allergic rhinitis and the particularity of its treatment\u003c/p\u003e\n\u003cp\u003e[21], parents of children with AR must make repeated hospital visits and strictly adhere to prevention and treatment protocols. Compared with parents of healthy children, they experience not only the routine parenting stress but also additional disease-related stress[10]. Although most AR symptoms are controllable and not life-threatening, frequent sneezing, rhinorrhea, itching, and sleep disturbances can negatively affect the quality of life of both the child and the entire family[21].If parents of children with AR are required to invest high levels of time, energy, and resources over prolonged periods, the combined effects of parenting stress, family stress, and personal psychological burden may lead to parental burnout, ultimately affecting parent-child relationships, parenting behaviors, and the child\u0026rsquo;s physical and psychological development[22].Therefore, it is crucial to conduct general surveys on disease knowledge and parenting stress in families of children with AR. Such assessments can guide targeted interventions, including health education, disease management guidance, and psychological support, thereby enhancing family management capacity and alleviating parenting stress in a timely manner.\u003c/p\u003e\n\u003cp\u003eIn this study, parents of male children reported higher parenting stress than those of female children. Barroso et al. found that male children are more likely to exhibit externalizing behaviors such as impulsivity and oppositionality, which increase the difficulty of daily caregiving and lead to higher perceived parenting burden[23],supporting the findings of the present study. The mean age of the children in this study was 9.93\u0026plusmn;3.00 years. Previous research has also shown that during childhood and adolescence, allergic rhinitis symptoms are more pronounced in males, potentially increasing caregiving demands and indirectly elevating parental stress.\u003c/p\u003e\n\u003cp\u003eIn addition, the analysis of sociodemographic data indicated that family annual income was associated with parenting stress among parents of children with AR, consistent with previous findings[24].On one hand, low-income families already face substantial financial strain, and the costs associated with AR treatment further increase this burden[25].On the other hand, children with AR require meticulous care, while low-income parents often engage in long working hours or jobs with low control, creating conflicts with caregiving demands and leading to the accumulation of parenting stress over time[26,27].For this population, clinical practice may consider implementing online screening and interventions when necessary to reduce the medical burden on parents.\u003c/p\u003e\n\u003cp\u003eThe results of this study indicated that parental anxiety is a direct influencing factor of parenting stress. In China, parents are typically the primary caregivers of children and adolescents, with children\u0026rsquo;s medical care and daily caregiving largely dependent on them[28].However, parents of childbearing age face multiple pressures from work, family, and social roles, making them a high-risk group for anxiety. Previous studies have shown that approximately 67% of mothers in nearly 3,000 Canadian families experience anxiety[29],while a survey conducted during the COVID-19 lockdown in Shanghai, China, reported a parental anxiety prevalence of approximately 72.6%[30].Such high levels of emotional stress may further affect parents\u0026rsquo; psychological state and behavioral performance in the caregiving of children with chronic conditions.For families of children with AR, although the disease is generally considered a mild, non-life-threatening chronic condition, it is highly recurrent, has a prolonged symptom management period, and is often accompanied by sleep disturbances and attention difficulties, requiring long-term management and repeated medical visits[21].The repeated caregiving demands and fluctuating symptoms can easily trigger negative emotions in parents, particularly among those with high levels of anxiety[26].According to Abidin\u0026rsquo;s Parenting Stress Model, parental anxiety is one of the direct sources of parenting stress. Anxious parents often exhibit lower parenting self-efficacy, show excessive concern or overreaction to their child\u0026rsquo;s symptoms, thereby experiencing less positive emotions during the parenting process and reducing the quality of the parent-child relationship, forming a vicious cycle of \u0026quot;anxiety-stress-negative parenting behaviors\u0026quot;[31].In addition, according to Lazarus and Folkman\u0026rsquo;s stress-coping theory, individuals with anxiety are more likely to appraise stressful events as threatening and engage in catastrophic thinking. This cognitive bias can amplify their subjective perception of the severity of their child\u0026rsquo;s symptoms and caregiving demands, leading to a significant increase in parenting stress[32,33].Previous studies have also indicated a bidirectional relationship between parental anxiety and parenting stress, whereby anxious emotions not only directly elevate parents\u0026rsquo; perceived stress but also indirectly exacerbate parent\u0026ndash;child conflict by reducing parenting self-efficacy and consistency[34,35].Therefore, during the caregiving and follow-up of children with AR, attention should be paid to parents\u0026rsquo; psychological status, and anxiety screening and psychological interventions should be incorporated into routine management. Interventions such as cognitive-behavioral anxiety management, relaxation training, and parenting skills training may help alleviate parenting stress and improve overall family coping and disease management outcomes. Future research could further employ longitudinal or interventional study designs to verify the causal mechanisms of parental anxiety on parenting stress.\u003c/p\u003e\n\u003cp\u003eBehavioral problems in children with AR have a direct impact on parenting stress, consistent with previous research[3].Behavioral problems refer to inappropriate internalizing or externalizing behaviors that occur during childhood and adolescence. AR symptoms are relatively persistent, and current studies indicate that treatment adherence in AR is less than 50%[36],Consequently, some children are chronically exposed to physiological discomfort, leading to sleep disturbances, inattention, hyperactivity, impulsivity, and irritability[2].These behaviors not only affect learning and social interactions[37],but may also contribute to the development of psychological issues such as anxiety, depression, and attention-deficit/hyperactivity disorder[38].Behavioral problems thus represent an important source of both disease burden and parenting stress.\u003c/p\u003e\n\u003cp\u003eDevelopmental psychopathology distinguishes between stressful parenting and parenting stress, considering them as related yet distinct concepts[39].Stressful parenting primarily arises from external factors in the caregiving environment, such as work, income, and social relationships[40].Behavioral problems in children with AR can affect their performance at school, their parents may face work interruptions, treatment burdens, and concerns about their child\u0026rsquo;s health and academic performance, in addition to communicating with teachers and other parents, which can substantially increase parental psychological distress[41].Studies have shown that, under normal circumstances, parental stress tends to decrease over time[42,43].However, when parenting stress related to caring for a child with a chronic illness accumulates with stress from the external caregiving environment, parents\u0026rsquo; positive emotions and capacity for adaptive coping gradually diminish, ultimately resulting in perceived stress that exceeds their coping ability and leading to lower-quality parenting behaviors[44].A lot of evidence supports the relationship between parental negative emotions, such as anxiety and depression, and both parenting stress and positive/negative parenting behaviors,this relationship often considered bidirectional[45,46].The present study confirms the mediating role of parental anxiety in the relationship between children\u0026rsquo;s behavioral problems and parenting stress.\u003c/p\u003e"},{"header":"5. Limitations","content":"\u003cp\u003eThis study has several limitations. First, data were collected using convenience sampling from a single hospital in Wuhan, which may limit the generalizability of the findings. Second, this was a cross-sectional study; although relationships among variables were examined using structural equation modeling, causal inferences cannot be drawn. Third, the study was framed based on Abidin\u0026rsquo;s Parenting Stress Model, focusing on the pathways among behavioral problems, parental anxiety, and parenting stress. Therefore, child sex and family income were not included in the model. The current study aimed to directly test our hypotheses.Subsequently, we will conduct longitudinal, multicenter, randomized controlled designs to further verify causal relationships and examine the roles of demographic characteristics and protective factors such as social support in the development of parenting stress.\u003c/p\u003e"},{"header":"6. Conclusion","content":"\u003cp\u003eIn this study, parenting stress among parents of children with AR was at a moderate level. Behavioral problems influenced parenting stress both directly and indirectly through parental anxiety, and both behavioral problems and parental anxiety independently predicted parenting stress. These findings provide evidence for the development of preventive and intervention strategies for children with AR and their families from a psychosocial perspective. At the clinical and community levels, parental mental health screening and emotional regulation should be incorporated into allergic disease management. Interventions such as cognitive-behavioral therapy, emotion regulation training, and family communication guidance may help reduce parental anxiety, improve parent-child interaction quality, and effectively alleviate parenting stress. Furthermore, future research is recommended to explore potential protective factors such as social support, self-efficacy, and family resilience, to establish more comprehensive and sustainable intervention frameworks that promote the long-term physical and mental health of children with AR and their families.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAllergic rhinitis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eADHD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAttention Deficit Hyperactivity Disorder\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSEM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStructural Equation Model\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePSQ\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eParent Symptom Questionnaire\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSAS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSelf-Rating Anxiety Scale\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePSI-SF-15\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eParenting Stress Index-Short Form\u003c/p\u003e \u003c/div\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\u003eThe study was conducted in accordance with the guidelines of the Declaration of Helsinki and approved by the Ethics Committee of Renmin Hospital of Wuhan University (WDRY2024-K273) .Informed consent was obtained from all participants.\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\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll relevant data are included in the article. Additional supporting data are available from the corresponding authors upon request. All requests for raw and analyzed data and materials will be reviewed by the corresponding authors to verify whether the request is subject to any intellectual property or confidentiality obligations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no conflicts of interest to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by grants from the Project Supported by the Open Fund of Hubei Key Laboratory (grant number: 2023KFH007).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLFL: Writing \u0026ndash; original draft，Writing \u0026ndash; review \u0026amp; editing，Conceptualization, Data curation, Formal Analysis,Methodology,Funding acquisition.\u003c/p\u003e\n\u003cp\u003eWXJ: Writing \u0026ndash; original draft,Conceptualization, Methodology, software, validation, Writing \u0026ndash; review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003eWL: Writing \u0026ndash; review \u0026amp; editing,Methodology,Investigation,Supervision .\u003c/p\u003e\n\u003cp\u003eXY-YY: Writing \u0026ndash; review \u0026amp; editing, Formal Analysis,Investigation, Supervision.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank all the participants and researchers for their contributions to this study\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSubspecialty Group of Rhinology, Editorial Board of Chinese Journal of Otorhinolaryngology Head and Neck Surgery, Subspecialty Group Of Rhinology, Society Of Otorhinolaryngology Head and Neck Surgery, Chinese Medical Association. Chinese guideline for diagnosis and treatment of allergic rhinitis (2022, revision). Subspecialty Group of Rhinology, Editorial Board of Chinese Journal of Otorhinolaryngology Head and Neck Surgery. 2022;57(2):106-29. doi:10.3760/cma.j.cn115330-20211228-00828.\u003c/li\u003e\n\u003cli\u003eYamaguchi C, Ebara T, Futamura M, Ohya Y, Asano M. Do allergic clinical manifestations increase the risk of behavioral problems in children? A cross-sectional study. PEDIAT ALLERG IMM-UK. 2021;32(8):1646-53. doi:10.1111/pai.13542.\u003c/li\u003e\n\u003cli\u003eMeltzer EO, Blaiss MS, Naclerio RM, Stoloff SW, Derebery MJ, Nelson HS et al. Burden of allergic rhinitis: allergies in America, Latin America, and Asia-Pacific adult surveys. ALLERGY ASTHMA PROC. 2012;33 Suppl 1:S113-41. \u0026apos;doi:\u0026apos;10.2500/aap.2012.33.3603.\u003c/li\u003e\n\u003cli\u003eZhang YM, Zhang J, Liu SL, Zhang X, Yang SN, Gao J et al. Prevalence and associated risk factors of allergic rhinitis in preschool children in Beijing. LARYNGOSCOPE. 2013;123(1):28-35. doi:10.1002/lary.23573.\u003c/li\u003e\n\u003cli\u003eWang Meng, Zhen Min, Wang Xiangdong, Zhang Luo. Research Progress on the Epidemiology of Allergic Rhinitis in China. CHIN ARCH OTOLARYNGOL HEAD NECK SURG. 2019;26(8):415-20. doi:10.16066/j.1672-7002.2019.08.004.\u003c/li\u003e\n\u003cli\u003eRusu PP, Candel OS, Bogdan I, Ilciuc C, Ursu A, Podina IR. Parental Stress and Well-Being: A Meta-analysis. CLIN CHILD FAM PSYCH. 2025;28(2):255-74. doi:10.1007/s10567-025-00515-9.\u003c/li\u003e\n\u003cli\u003eFang Y, Luo J, Boele M, Windhorst D, van Grieken A, Raat H. Parent, child, and situational factors associated with parenting stress: a systematic review. EUR CHILD ADOLES PSY. 2024;33(6):1687-705. doi:10.1007/s00787-022-02027-1.\u003c/li\u003e\n\u003cli\u003eFang Y, Boelens M, Windhorst DA, Raat H, van Grieken A. Factors associated with parenting self-efficacy: A systematic review. J ADV NURS. 2021;77(6):2641-61. doi:10.1111/jan.14767.\u003c/li\u003e\n\u003cli\u003eJones TL, Prinz RJ. Potential roles of parental self-efficacy in parent and child adjustment: a review. CLIN PSYCHOL REV. 2005;25(3):341-63. doi:10.1016/j.cpr.2004.12.004.\u003c/li\u003e\n\u003cli\u003eCousino MK, Hazen RA. Parenting stress among caregivers of children with chronic illness: a systematic review. J PEDIATR PSYCHOL. 2013;38(8):809-28. doi:10.1093/jpepsy/jst049.\u003c/li\u003e\n\u003cli\u003eChang HY, Seo JH, Kim HY, Kwon JW, Kim BJ, Kim HB et al. Allergic diseases in preschoolers are associated with psychological and behavioural problems. ALLERGY ASTHMA IMMUN. 2013;5(5):315-21. doi:10.4168/aair.2013.5.5.315.\u003c/li\u003e\n\u003cli\u003eLee YS, Kim SH, You JH, Baek HT, Na C, Kim BN et al. Attention deficit hyperactivity disorder like behavioral problems and parenting stress in pediatric allergic rhinitis. PSYCHIAT INVEST. 2014;11(3):266-71. doi:10.4306/pi.2014.11.3.266.\u003c/li\u003e\n\u003cli\u003eHwang TY, Kim SK, Kim SH, Kim M. A cross sectional survey on health-related quality of life among parents of children with allergic symptoms using the EQ-5D-5L. J ASTHMA. 2019;56(11):1239-45. doi:10.1080/02770903.2019.1571086.\u003c/li\u003e\n\u003cli\u003eKou W, Li X, Yao H, Wei P. Meta-analysis of the comorbidity rate of allergic rhinitis and asthma in Chinese children. INT J PEDIATR OTORHI. 2018;107:131-4. doi:10.1016/j.ijporl.2018.02.001.\u003c/li\u003e\n\u003cli\u003eLeonardi A, Castegnaro A, Valerio AL, Lazzarini D. Epidemiology of allergic conjunctivitis: clinical appearance and treatment patterns in a population-based study. CURR OPIN ALLERGY CL. 2015;15(5):482-8. doi:10.1097/ACI.0000000000000204.\u003c/li\u003e\n\u003cli\u003eCooklin AR, Giallo R, Rose N. Parental fatigue and parenting practices during early childhood: an Australian community survey. CHILD CARE HLTH DEV. 2012;38(5):654-64. doi:10.1111/j.1365-2214.2011.01333.x.\u003c/li\u003e\n\u003cli\u003eAbidin RR. The Determinants of Parenting Behavior. Journal of Clinical Child Psychology. 1992;21(4):407-12. doi:10.1207/s15374424jccp2104_12.\u003c/li\u003e\n\u003cli\u003eFan Juan, Du Ya song, Wang Li wei. The norm and reliability of the Conners Parent Symptom Questionnaire in Chinese urban children. Shanghai Archives of Psychiatry. 2005;17(6):321-3. doi:10.3969/j.issn.1002-0829.2005.06.001.\u003c/li\u003e\n\u003cli\u003eZung WW. A rating instrument for anxiety disorders. PSYCHOSOMATICS. 1971;12(6):371-9. doi:10.1016/S0033-3182(71)71479-0.\u003c/li\u003e\n\u003cli\u003eLuo J, Wang MC, Gao Y, Zeng H, Yang W, Chen W et al. Refining the Parenting Stress Index-Short Form (PSI-SF) in Chinese Parents. ASSESSMENT. 2021;28(2):551-66. doi:10.1177/1073191119847757.\u003c/li\u003e\n\u003cli\u003eSchuler IC, Montejo JM. Allergic Rhinitis in Children and Adolescents. IMMUNOL ALLERGY CLIN. 2021;41(4):613-25. doi:10.1016/j.iac.2021.07.010.\u003c/li\u003e\n\u003cli\u003eAktu Y. The role of parenting stress on parenting self-efficacy and parental burnout among Turkish parents: a moderated mediation model. BMC PSYCHOL. 2024;12(1):475. doi:10.1186/s40359-024-01980-7.\u003c/li\u003e\n\u003cli\u003eBarroso NE, Mendez L, Graziano PA, Bagner DM. Parenting Stress through the Lens of Different Clinical Groups: a Systematic Review \u0026amp; Meta-Analysis. J ABNORM CHILD PSYCH. 2018;46(3):449-61. doi:10.1007/s10802-017-0313-6.\u003c/li\u003e\n\u003cli\u003eToledano-Toledano F, Dominguez-Guedea MT. Psychosocial factors related with caregiver burden among families of children with chronic conditions. BIOPSYCHOSOC MED. 2019;13:6. doi:10.1186/s13030-019-0147-2.\u003c/li\u003e\n\u003cli\u003eLiu Qing, Cai Yingqi. A study on parenting stress and its influencing factors among urban young parents. Youth Exploration. 2022(1):71-81. doi:10.13583/j.cnki.issn1004-3780.2022.01.007.\u003c/li\u003e\n\u003cli\u003eCheng M, Dai Q, Liu Z, Wang Y, Zhou C. New progress in pediatric allergic rhinitis. FRONT IMMUNOL. 2024;15:1452410. doi:10.3389/fimmu.2024.1452410.\u003c/li\u003e\n\u003cli\u003eKochanova K, Pittman LD, McNeela L. Parenting Stress and Child Externalizing and Internalizing Problems Among Low-Income Families: Exploring Transactional Associations. CHILD PSYCHIAT HUM D. 2022;53(1):76-88. doi:10.1007/s10578-020-01115-0.\u003c/li\u003e\n\u003cli\u003eZhang Y, Zhou Z, Si Y. The role of parental health care utilization in children\u0026apos;s unnecessary utilization in China: evidence from Shaanxi province. INT J EQUITY HEALTH. 2017;16(1):47. doi:10.1186/s12939-017-0544-8.\u003c/li\u003e\n\u003cli\u003eCameron EE, Joyce KM, Delaquis CP, Reynolds K, Protudjer J, Roos LE. Maternal psychological distress \u0026amp; mental health service use during the COVID-19 pandemic. J AFFECT DISORDERS. 2020;276:765-74. doi:10.1016/j.jad.2020.07.081.\u003c/li\u003e\n\u003cli\u003eYu W, Guo Z, Tian J, Li P, Wang P, Chen H et al. Parental Anxiety, Practices, and Parent-Child Relationships among Families with Young Children in China: A Cross-Sectional Study. CHILDREN-BASEL. 2023;10(8). doi:10.3390/children10081388.\u003c/li\u003e\n\u003cli\u003eAbidin RR. Parenting Stress Index: Professional Manual. 3rd ed ed: Odessa, FL : Psychological Assessment Resources; 1995.\u003c/li\u003e\n\u003cli\u003eLazarus RS FS. Stress, appraisal, and coping: New York: Springer publishing company; 1984.\u003c/li\u003e\n\u003cli\u003eRask CU, Duholm CS, Poulsen CM, Rimvall MK, Wright KD. Annual Research Review: Health anxiety in children and adolescents-developmental aspects and cross-generational influences. J CHILD PSYCHOL PSYC. 2024;65(4):413-30. doi:10.1111/jcpp.13912.\u003c/li\u003e\n\u003cli\u003ePitillas C, Zerolo BE, Jodar R, Ribeiro A. Measuring Parental Response Styles to Child Stress in Severe Pediatric Illness: A Validation Study. NURS REP. 2024;14(4):3539-49. doi:10.3390/nursrep14040258.\u003c/li\u003e\n\u003cli\u003eRolle L, Prino LE, Sechi C, Vismara L, Neri E, Polizzi C et al. Parenting Stress, Mental Health, Dyadic Adjustment: A Structural Equation Model. FRONT PSYCHOL. 2017;8:839. doi:10.3389/fpsyg.2017.00839.\u003c/li\u003e\n\u003cli\u003eYang S, Yang J, Xu J, Hu Y, Li C, Zhang L et al. Allergic rhinitis and behaviour problems in urban children aged 6 to 12 years and the mediating role of sleep disturbance. ANN MED. 2025;57(1):2460771. doi:10.1080/07853890.2025.2460771.\u003c/li\u003e\n\u003cli\u003eKieling C, Buchweitz C, Caye A, Silvani J, Ameis SH, Brunoni AR et al. Worldwide Prevalence and Disability From Mental Disorders Across Childhood and Adolescence: Evidence From the Global Burden of Disease Study. JAMA PSYCHIAT. 2024;81(4):347-56. doi:10.1001/jamapsychiatry.2023.5051.\u003c/li\u003e\n\u003cli\u003eChen K, Zheng X, Li Z, Xiang H, Chen B, Zhang H. Risk factors analysis of attention deficit/hyperactivity disorder and allergic rhinitis in children: a cross-sectional study. ITAL J PEDIATR. 2019;45(1):99. doi:10.1186/s13052-019-0703-1.\u003c/li\u003e\n\u003cli\u003eCrnic KA. Parenting stress and child behavior problems: Developmental psychopathology perspectives. DEV PSYCHOPATHOL. 2024;36(5):2369-75. doi:10.1017/S0954579424001135.\u003c/li\u003e\n\u003cli\u003eGarmezy, N, Rutter M. Stress, coping, and development in children: Hopkins Fulfillment Service; 1988.\u003c/li\u003e\n\u003cli\u003eFields A, Harmon C, Lee Z, Louie JY, Tottenham N. Parent\u0026apos;s anxiety links household stress and young children\u0026apos;s behavioral dysregulation. DEV PSYCHOBIOL. 2021;63(1):16-30. doi:10.1002/dev.22013.\u003c/li\u003e\n\u003cli\u003eStone LL, Mares SH, Otten R, Engels RC, Janssens JM. The Co-Development of Parenting Stress and Childhood Internalizing and Externalizing Problems. J PSYCHOPATHOL BEHAV. 2016;38:76-86. \u0026apos;doi:\u0026apos;10.1007/s10862-015-9500-3.\u003c/li\u003e\n\u003cli\u003eWilliford AP, Calkins SD, Keane SP. Predicting change in parenting stress across early childhood: child and maternal factors. J ABNORM CHILD PSYCH. 2007;35(2):251-63. \u0026apos;doi:\u0026apos;10.1007/s10802-006-9082-3.\u003c/li\u003e\n\u003cli\u003eSturge-Apple ML, Skibo MA, Rogosch FA, Ignjatovic Z, Heinzelman W. The impact of allostatic load on maternal sympathovagal functioning in stressful child contexts: implications for problematic parenting. DEV PSYCHOPATHOL. 2011;23(3):831-44. \u0026apos;doi:\u0026apos;10.1017/S0954579411000332.\u003c/li\u003e\n\u003cli\u003eNeece CL, Green SA, Baker BL. Parenting stress and child behavior problems: a transactional relationship across time. AJIDD-AM J INTELLECT. 2012;117(1):48-66. doi:10.1352/1944-7558-117.1.48.\u003c/li\u003e\n\u003cli\u003eThomason E, Volling BL, Flynn HA, McDonough SC, Marcus SM, Lopez JF et al. Parenting stress and depressive symptoms in postpartum mothers: bidirectional or unidirectional effects? INFANT BEHAV DEV. 2014;37(3):406-15. doi:10.1016/j.infbeh.2014.05.009.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"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":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Allergic rhinitis, patenting stess, behavioral problems, parental anxiety","lastPublishedDoi":"10.21203/rs.3.rs-8034172/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8034172/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Allergic rhinitis (AR) is a common allergic disease among children and adolescents. Parenting stess is closely related to the health of child patients and the anxiety levels of their parents. It is still unclear how the behavioral problems of these children and parental anxiety together affect parenting stress.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eA cross-sectional design and convenience sampling method were employed for 230 parents of children with allergic rhinitis. The Conners' Parent Symptom Questionnaire, Self-Rating Anxiety Scale, and the Simplified Parenting Stress Index were used for assessment. Data were analyzed using descriptive statistics and structural equation modeling with SPSS 27.0 and AMOS 26.0.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: The parents of children with AR had a moderate level of parenting stress (31.95±9.41). In the mediating effects model, children’s behavioral problems could influence parenting stress directly (95% CI: 2.556, 3.990) or indirectly through parental anxiety (95% CI: 0.190, 0.759).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: Behavioral problems of children with AR can have both direct and indirect effects on parenting stress through the mediating factors of parental anxiety.Therefore, when designing supportive interventions, clinicians should consider both the children's clinical symptoms and behavioral issues, as well as the psychological state of their caregivers.On one hand, resources can be directly applied to the children. On the other hand, the utilization of psychological assessment and intervention for caregivers, can alleviate parenting stress and strengthen the family's ability to cope.\u003c/p\u003e","manuscriptTitle":"Parenting stress level of children with allergic rhinitis ：Role of children's behavior and parental anxiety","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-22 16:39:25","doi":"10.21203/rs.3.rs-8034172/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"153810110285690000488189612477395868594","date":"2026-03-26T07:26:14+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-26T06:26:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"166142512073419452564784874741012348980","date":"2026-03-25T17:36:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"68771821058180255720236176478342039956","date":"2026-03-24T19:12:16+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-17T20:30:14+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-06T12:04:19+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-05T14:24:36+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-05T14:20:45+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-11-05T04:47:43+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"55a18aab-8ce4-4e54-84d1-df82ffdb2fd0","owner":[],"postedDate":"February 22nd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":63104884,"name":"Health sciences/Diseases"},{"id":63104885,"name":"Health sciences/Health care"},{"id":63104886,"name":"Health sciences/Medical research"},{"id":63104887,"name":"Biological sciences/Psychology"},{"id":63104888,"name":"Social science/Psychology"},{"id":63104889,"name":"Health sciences/Risk factors"}],"tags":[],"updatedAt":"2026-02-22T16:39:25+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-22 16:39:25","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8034172","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8034172","identity":"rs-8034172","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}