1 BACKGROUND

Although the prevalence of childhood chronic conditions has doubled over the last 20 years,^{1, 2} many children and adolescents with chronic conditions are living longer due to better management and increased use of medical technologies for chronic conditions.³ A chronic medical condition is a condition that affects daily life, requires ongoing management and treatment, and needs regular medical attendance.⁴ Common chronic conditions that present in children and adolescents include asthma, diabetes, epilepsy/seizures, obesity, cystic fibrosis, allergies, sickle cell anemia, irritable bowel diseases (e.g. ulcerative colitis, Crohn's disease), migraines/headaches, juvenile arthritis, congenital heart defect, traumatic brain surgery/spinal injury, and organ transplant.⁵ Over time there has been growing interest amongst health professionals in how, and to what extent, childhood chronic conditions affect other family members, especially parents.⁶

Parents of children with chronic conditions often face high stress and burnout,⁷ especially before diagnosis, at diagnosis, and during adjustment to managing the condition.⁸ Parenting stress is a psychological reaction that may be viewed as a negative response when parenting demands are inconsistent with parents’ expectations, and/or when parents do not have the resources to meet the demands.⁹ Parenting stress has been shown to minimize the ability of parents to effectively manage their child's chronic condition (e.g., reduced parental vigilance resulting in poor adherence to disease management regimes).¹⁰ Chronic conditions that require ongoing management, have an uncertain prognosis, and require a high level of care (e.g. Type 1 Diabetes), may be particularly impacted by parenting stress. Increased parenting stress has been associated with poor psychological adjustment for the parent and the child,¹¹ together with negative child behavior (i.e. externalizing problems), and a lack of positive child outcomes (i.e. inability to manage affective, social and achievement challenges).¹² Research shows that these parents often struggle with caregiving, lack confidence in managing their child's condition, and face challenges in ensuring their child's optimal well-being.¹³ Parents also experience increased anxiety and depression symptoms, added financial strain, and an increase in family conflict.^{7, 14, 15} Increased anxiety and depression symptoms may negatively impact not only parenting practices, but also family functioning.^{16, 17}

The above research supports the negative effects of parenting stress on many parent and child outcomes. Given that having a child with a chronic condition increases parenting stress,¹⁸ it is important to explore interventions that provide parents with skills and strategies to better manage the stress they experience, due to the challenges and hardships they face. Parent-based cognitive behavior therapy (CBT) interventions have been found to reduce children's primary symptoms,⁶ together with easing parental distress when managing a child with a chronic condition.¹⁹

Over the last 20 years there has been increased interest in the third wave CBT intervention approach.²⁰ The third wave approach provides more flexible and holistic ways to enhance mental well-being by incorporating components such as acceptance, mindfulness and commitment to values-based living.^{21, 22} Research has suggested that the third wave approach be extended to parents by enhancing current behavioral parenting interventions with mindfulness to investigate the effects of the mindfulness-based intervention approach on parenting and parental adjustment.^{23, 24}

The main aims of the third wave approach are to promote a mindful relationship with both thoughts and emotions, promote acceptance of these thoughts and emotions, and build life coping skills according to one's chosen values.^{25, 26} These approaches include, but are not limited to, Acceptance and Commitment Therapy (ACT),²⁷ Behavior Activation (BA),²⁸ Cognitive Behavioral Analysis System of Psychotherapy (CBASP),²⁹ Compassion Focused Therapy/Compassionate Mind Training (CT/CMT),³⁰ Functional Analytic Psychotherapy (FAP),³¹ Mindfulness Based Cognitive Therapy/Mindfulness Based Stress Reduction (MBCT/MBSR),³² and Dialectical Behavior Therapy (DBT).³³

Research has reported a link between lower parenting stress and higher parental mindfulness.^{34, 35} Accordingly, a growing number of studies have delivered mindfulness-based interventions to parents, with the aim of reducing parenting stress and improving psychological outcomes for youth.^{36, 37} Self-compassion has been identified as an equally or more effective target of intervention in improving parent and child outcomes.³⁸ This may be due it it being a narrower concept than general mindfulness as its reference is to negative thoughts and feelings related to experiences solely of personal suffering, rather than all experiences.³⁹ Self-compassion may be an effective target for increasing parenting quality and decreasing parental distress.^{38, 40, 41}

Although research has explored traditional face-to-face interventions for this parent population, more research is needed on alternative ways to support parents, considering the many challenges they face (i.e. limited access to services, time constraints, lack of self-care).⁴² It has been suggested that parents of children with chronic conditions may benefit from more novel models of delivering support, such as internet-based interventions.⁴³ The advantages of internet-based interventions include instant access, regularly updated content, easy parent engagement for support and answers, and the ability to track parents’ progress.^{44, 45} The internet is also a promising delivery mode as interventions can be scaled, are cost-effective,⁴⁶ and have the potential of reducing the barriers of current face to face interventions due to their flexibility and accessibility.⁴⁷

Research has reported that internet-based parenting interventions are effective in increasing positive parenting behaviors and reducing parent stress (i.e. small effect).⁴⁸ A recent Cochrane review on psychological interventions for parents of children and adolescents with chronic illness,⁴⁹ examined 44 randomized controlled trials and identified eight studies that were delivered via the internet. These studies included five CBT studies^{19, 50-53}; two Problem Solving Therapy (PST) studies^{54, 55}; and one Motivational Interviewing (MI) study.⁵⁶ This review provides evidence-based strategies for managing parent challenges and enhancing psychosocial adaptation for both the parent and the child. Although this review is an important addition to the literature, evidence around third-wave interventions is unknown, despite internet-based parenting interventions being. the most used form of delivering technology-based parenting interventions.^{57, 58} Research is needed on internet-based third wave interventions to help parents of children with chronic conditions manage parenting stress using evidence-based strategies. The International Prospective Register of Systematic Reviews (PROSPERO) was searched and to date there is no systematic review or meta-analysis published that investigates the effectiveness of internet-based third wave CBT interventions for this parent population, and their potential in reducing parent stress. This highlights a key gap, which will be addressed through a systematic review and meta-analysis of randomized controlled trials to assess the effectiveness of internet-based third wave interventions in reducing stress in parents of children and adolescents with chronic conditions.

2 PRIMARY AIM

The primary aim of this research is to conduct a systematic review and meta-analysis to explore the effectiveness of internet-based third wave interventions on reducing stress in parents of children and adolescents with chronic conditions.

3 METHODOLOGY

This systematic review will follow the procedures outlined in the Cochrane Handbook for Systematic Reviews of Interventions,⁵⁹ and the PRISMA-P (Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols),⁶⁰ as outlined below.

4 RESULTS

The search terms are currently being piloted and finalized. Following selection and assessment of the publications, data extraction and analyses will begin. Data synthesis and presentation of the findings is anticipated to be completed by early 2024.

5 DISCUSSION

Parents of children and adolescents with chronic conditions report higher levels of parenting stress.¹² Third-wave CBT approaches show great promise in supporting parents to cope with the stress/distress associated with parenting a child with a chronic condition. Despite the convenience of parents’ preference towards internet-based interventions, no systematic literature review and meta-analyses have been performed to evaluate the effectiveness of internet-based interventions in reducing parents’ stress. This protocol will guide a thorough evaluation of the published studies to assess the effectiveness of internet-based third-wave CBT approaches, and to identify characteristics of interventions that provide evidence of their effectiveness in reducing stress in parents of children and adolescents with chronic conditions.

AUTHOR CONTRIBUTIONS

Maria Davey: Conceptualization; Investigation; Writing—original draft; Methodology; Validation; Writing—review and editing; Formal analysis; Data curation. Leanne Fried: Conceptualization; Supervision. Hui Jun Chih: Methodology; Supervision. Rosanna Rooney: Supervision. Alison Roberts: Supervision.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflict of interest.

ETHICS APPROVAL

As this is a systematic review proposal of the existing literature, no ethics approval is required.

TRANSPARENCY STATEMENT

The lead author Maria Davey affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.