INTRODUCTION
Atopic dermatitis (AD) is a chronic, pruritic inflammatory skin disease prevalent across all ages, with increased incidence in paediatric populations [1]. Affecting approximately 20–30% of children, AD is characterized by persistent symptoms such as xerosis (dry skin), intense itching, and recurring eczematous lesions [2]. Disease severity dictates the likelihood of ophthalmological issues and skin infections in patients. Patients may also experience significant morbidities, such as sleep disorders, reduced quality of life, and psychosocial issues [3]. The chronic and recurrent presentation of the disease, in addition to its observable effects, often leads to emotional and psychological suffering for both the affected individuals and their caregivers [4]. Parental emotional burden, especially for mothers, is a significant psychosocial concern in AD. The consistent demands of caregiving frequently lead to elevated levels of stress, anxiety, and emotional fatigue among these mothers [5].
Food allergies represent a prevalent condition within the paediatric population, affecting 6–8% of patients and frequently co-occurring with AD [6]. Approximately one-third of children with moderate-to-severe AD are also affected by food allergies. Allergic responses, frequently involving immunoglobulin E (IgE), may cause rapid and severe reactions, ranging in severity from mild dermatological symptoms to life-threatening anaphylaxis [3, 7]. The inherent unpredictability and intensity of these reactions impose a substantial emotional burden on caregivers [8, 9]. Studies show a marked increase in anxiety, a decrease in quality of life, and an intensification of caregiving responsibilities for those caring for children with food allergies when compared to those caring for children with other chronic conditions [10].
The co-occurrence of both AD and food allergy can exacerbate the process of caregiving, increasing the psychological burden on parents [11]. Nevertheless, there is a limited amount of research focusing on maternal anxiety in the presence of both conditions concurrently. A thorough understanding of the mental health effects on mothers in such situations is essential to optimize the well-being of both the child and the caregiver.
AIM
The aim of this study is to analyse and contrast the anxiety levels of mothers whose children have been diagnosed with atopic dermatitis, food allergy, or both. This study utilizes the Beck Anxiety Inventory to demonstrate the necessity of incorporating maternal psychological support within comprehensive allergy care models.
MATERIAL AND METHODS
This quantitative study is a cross-sectional study using the Beck Anxiety Scale that measures anxiety in parents. Before starting data collection and analysis, ethical approval was obtained from the non-interventional clinical research ethics committee where the study was conducted. All participants were informed in writing and informed consent forms were obtained before participation.
PARTICIPANTS
This cross-sectional study included patients aged 0–24 months and their mothers who were evaluated at the paediatric allergy and immunology clinic in a tertiary care hospital between November 2023 and March 2024. Of these patients, 60 had both AD and food allergies, 60 had only AD without food allergies, and 60 had no chronic diseases or complaints. Some participants were not included in the evaluation due to leaving questions on the Beck Anxiety Scale blank, and a total of 158 patients were included in the evaluation.
SCALES
The Beck Anxiety Scale was applied to the mothers of patients who were admitted to the clinic and met the study conditions. The Beck Anxiety Scale is a relevant psychometric tool that shows high reliability, the capacity to distinguish between anxious and non-anxious individuals, and improved concurrent, content, and construct validity. On the scale, 21 questions were directed to the patients, and they were asked to rate them from 0 to 3. The results were collected, and the patients’ Beck Anxiety Scale scores were obtained. While selecting mothers to answer the scale/questions, it was taken into consideration that the mother did not have a chronic disease and did not use any psychiatric medication.
SKIN PRICK TEST
The skin prick test is the most common test used to diagnose allergies. It is usually performed by piercing the skin with a lancet on the volar surface of the forearm or the back with a drop of allergen extract and is usually the first-choice test in diagnostic studies for allergic diseases due to its reliability, safety, convenience, and low cost. In our study, skin prick tests were performed by a nurse working in the clinic due to the standardization of the results.
SCORAD INDEX
The index developed by the European Task Force on Atopic Dermatitis is the most frequently used scoring system to measure the severity of atopic dermatitis. The SCORAD index evaluates prevalence (A = Body surface area involvement, 0–100%), intensity (B = Erythema, oedema-papule, exudation-dryness, excoriation (Ex), lichenification (L) and xerosis; mild = 1, moderate = 2, severe = 3; maximum score = 18) and subjective symptoms (C = Itching and lack of sleep, severity is graded from 0 to 10 with a visual analogue scale; maximum score is 20). The total score (maximum total score is 103) is calculated using the formula SCORAD = A/5 + 7B/2 + C. The Score indices of all patients were calculated and recorded by a single doctor.
POWER ANALYSIS
A power analysis was performed using G-Power, utilizing an ANOVA test tailored for three groups (Eczema + food allergy, Eczema, and Control). The effect size was determined to be 0.33, with an α level of 0.05 and a power of 0.80. Consequently, the total sample size consisted of 132 children, evenly distributed across the three groups, on average 44 individuals per group. The observed effect size was determined to be 0.29, while the critical F value was calculated to be 3.07. To mitigate the risk of missing data, a recruitment goal of 50 individuals per group was established.
STATISTICAL ANALYSIS
Statistical analyses were performed using IBM SPSS Statistics (Version 25). Descriptive statistics for continuous variables comprised means and standard deviations where data were normally distributed; otherwise, medians and interquartile ranges were presented. Categorical variables were summarized using frequencies and percentages.
The normality of continuous variables was assessed using the Kolmogorov-Smirnov test. Given the non-normal distribution of certain variables, non-parametric statistical analysis was employed. The Mann-Whitney U test was applied for comparisons between two groups, while the Kruskal-Wallis test was used for comparisons involving three groups. Where the Kruskal-Wallis test indicated statistically significant differences, Dunn’s post hoc test was performed to determine which groups differed. Multiple comparisons were adjusted for using the Bonferroni correction. Associations between categorical variables were analysed using the χ2 test. Statistical significance was defined as a p-value less than 0.05.
Missing data were handled via case-wise exclusion, and no imputation methods were applied. Analysis excluded participants who did not complete the Beck Anxiety Scale in its entirety. Although effect sizes were not computed in this study, their significance for future research is acknowledged.
RESULTS
A total of 158 patients were included in the study, 53 (33.5%) in the ‘Eczema + food allergy’, 54 (34.2%) in the ‘Eczema’, and 51 (32.3%) in the ‘Control’ group. Table 1 shows the findings obtained for the comparison of age, BMI, eosinophil count, total IgE value, SCORAD index, and Beck Anxiety Scale scores among the three groups.
Table 1
Comparison of age, BMI, eosinophil count, total IgE value, SCORAD index, and Beck Anxiety Inventory scores among groups
Eosinophil count was found to differ significantly among the three groups (p < 0.001). Dunn’s test, which was performed to identify which group differs from the other, showed that the eosinophil count of the ‘Control’ group was significantly lower than the ‘Eczema’ (p < 0.001) and ‘Eczema + food allergy’ (p < 0.001) groups.
The total IgE value was found to differ significantly among the three groups (p < 0.001). Dunn’s test, which was performed to identify which group differs from the other, showed that the total IgE value in the ‘Control’ group was higher than the ‘Eczema’ group (p = 0.002) and significantly lower than the ‘Eczema + food allergy’ group (p = 0.047). Additionally, Dunn’s test showed that the total IgE value of the ‘Eczema’ group was significantly lower than the ‘Eczema + food allergy’ group (p < 0.001).
Although the SCORAD index value of the ‘Eczema’ group appeared to be lower than the ‘Eczema + food allergy’ group, this difference was not statistically significant (p = 0.069).
The Beck Anxiety Scale score was found to differ significantly among the three groups (p = 0.001). Dunn’s test, which was performed to identify which group differs from the other, showed that the Beck Anxiety Scale score of the ‘Control’ group was significantly lower than the ‘Eczema’ (p = 0.012) and ‘Eczema + food allergy’ (p = 0.001) groups. No significant difference was found among the groups in terms of age and BMI (p > 0.05).
As shown in Table 2, no significant relationship was found between the SCORAD index and Beck Anxiety Scale score in the ‘Eczema + food allergy’ (p = 0.814) and ‘Eczema’ (p = 0.450) groups.
Table 2
Relationship between SCORAD index and Beck Anxiety Scale scores in the ‘Eczema + food allergy’ and ‘Eczema’ groups
| Variable | Beck Anxiety Scale score | ||
|---|---|---|---|
| Group 1 Eczema + food allergy | |||
| SCORAD index | r | –0.033 | |
| p | 0.814 | ||
| Group 2 Eczema | |||
| SCORAD index | r | 0.105 | |
| p | 0.450 | ||
Table 3 shows the description of the Beck Anxiety Scale scores of the Groups. As shown in Table 3, in the ‘Eczema + food allergy’ group, 14 (26.4%) mothers had normal, 21 (39.6%) mothers had mild, 13 (24.5%) mothers had moderate, and 5 (9.4%) mothers had severe anxiety scores according to the Beck Anxiety Scale scores. In the ‘Eczema’ group, 19 (35.2%) mothers had normal, 20 (37.0%) mothers had mild, 13 (24.1%) mothers had moderate, and 2 (3.7%) mothers had severe anxiety scores. In the ‘Control’ group, 28 (54.9%) mothers had normal, 19 (37.3%) mothers had mild, 3 (5.9%) mothers had moderate, and 1 (2.0%) mother had severe anxiety scores.
Table 3
Description of Beck Anxiety Scale scores according to groups
| Group | Beck Anxiety Scale scores | |||||||
|---|---|---|---|---|---|---|---|---|
| Normal | Mild | Moderate | Severe | |||||
| n | % | n | % | n | % | n | % | |
| Eczema + food allergy | 14 | 26.4 | 21 | 39.6 | 13 | 24.5 | 5 | 9.4 |
| Eczema | 19 | 35.2 | 20 | 37.0 | 13 | 24.1 | 2 | 3.7 |
| Control | 28 | 54.9 | 19 | 37.3 | 3 | 5.9 | 1 | 2.0 |
As shown in Table 4, while 37 (69.8%) patients had mild, 14 (26.4%) patients had moderate, and 2 (3.8%) patients severe AD in the ‘Eczema + food allergy’ group, 43 (79.6%) patients had mild, and 11 (20.4%) patients had moderate AD in the ‘Eczema’ group.
DISCUSSION
This study assessed the comparative anxiety levels of mothers whose children had AD, food allergies, or both, against a control group of mothers of healthy children. By focusing on the relationship between chronic paediatric allergic conditions and caregiver mental well-being, the study aims to highlight the often-overlooked psychosocial dimension of paediatric care, supporting maternal mental health is critical, as it has a direct impact on a child’s disease management, quality of life, and adherence to treatment [12, 13]. Using the Beck Anxiety Scale, this study contributes to a more comprehensive understanding of caregiver needs and the importance of incorporating psychological support into treatment planning.
The prevalence of food allergies in children is approximately 8% worldwide, leading to detrimental effects on the lives of affected individuals and their support systems. While a definitive cure remains elusive, therapeutic interventions are employed to alleviate symptoms and minimize contact with the allergen [14, 15]. Prior studies indicate that the unpredictable and potentially severe nature of allergic reactions elevates parental anxiety and stress levels [16–19]. A study conducted in the United States showed that families with children with food allergies had increased food allergy-related mental health concerns and psychosocial burden, including anxiety, panic, and fear [20]. In our study, participants whose children had both food allergies and AD showed higher mean anxiety scores than those with AD alone. Although this difference was not statistically significant, we hypothesize that a larger sample size may yield a significant result.
Characterized by pruritus and sleep disruption, AD constitutes a prevalent inflammatory skin condition [21]. The stress of caring for a child with AD, including sleep deprivation, emotional strain, lifestyle adjustments, and time demands, greatly affects parents’ mental well-being, financial stability, and relationships, leading to elevated stress levels [18, 19, 22]. These challenges have been linked to negative psychological outcomes in parents, such as exhaustion, guilt, hopelessness, and depression [12].
Previous studies show mixed results regarding the relationship between AD severity and maternal mental health. One Turkish study found an increased risk of obsessive-compulsive symptoms in mothers, but no correlation with AD severity [23]. Similarly, another study reported higher anxiety scores in mothers of children with AD compared to controls, yet no link to disease severity [24]. Conversely, some studies found that greater AD severity was associated with increased maternal stress [25], broader family life impact, including sleep and fatigue [26], and elevated anxiety symptoms [27].
Our findings are in line with the mixed evidence reported in the literature, with some studies indicating a clear association between disease severity and parental stress, while others, such as ours, find no such relationship. These inconsistencies could stem from variations in the study methodologies employed, the measurement tools used, and the characteristics of the study populations. Although SCORAD scores were higher in patients with both AD and food allergy, this difference was not statistically significant. The lack of association between disease severity and maternal anxiety may be due to factors such as prior elimination of allergenic foods before clinical assessment, or the variability in how families experience and manage symptoms.
Importantly, maternal anxiety has been shown to exacerbate AD symptoms in children and hinder effective treatment [13]. Therefore, it is essential that the well-being of mothers is considered alongside the clinical needs of the child. A “positive medicine” approach not only treats symptoms but also aims to enhance the overall quality of life for both patients and caregivers [28].
This study benefits from the use of a validated anxiety scale and including participants with single and dual diagnoses, in addition to a healthy control group. However, certain limitations should be acknowledged. The employed cross-sectional design limits the possibility of causal inference, with anxiety levels determined via self-report instruments, as opposed to clinical interviews. Moreover, the analysis did not consider socioeconomic status, family support, and prior mental health history, factors which may affect caregiver anxiety levels.
Our results emphasize the critical need for recognizing and managing maternal anxiety in paediatric allergy care. Multidisciplinary interventions incorporating caregiver psychological support demonstrate potential for enhanced child and parental outcomes. Further research is needed to explore precisely targeted interventions within a broader context that affect caregiver well-being.
CONCLUSIONS
We found that food allergy and AD increased the anxiety of mothers of the affected children. Contributions should be made to reduce the perceived stress and anxiety of mothers of children with food allergies and AD because their psychological state affects the effectiveness of the treatment. Based on these results, we believe that multidisciplinary cooperation with relevant departments is necessary to take preventive and curative measures on this subject.
