In this study we analyzed parenting stress of children affected by Cystic Fibrosis through a biopsychosocial approach. The latter, which is supported both by the World Health Organization (WHO) and many data [13, 14], indicates that healthcare professionals should provide adequate healthcare assistance to children with the disease as well as a psychological support to their parents in order to improve their overall quality of life. The care should include biomedical and psycho-social interventions to achieve a positive impact on patient’s life.

Contrary to our expectations [15,16,17,18], the study revealed a significant presence of parents with normal stress level. We hypothesize that this result may be attributed to the low Clinical Severity of the children enrolled in this study (Tables 4 and 5). In addition, we found a positive correlation between Clinical severity and Total stress, i.e. it was observed an increasing of abnormal stress in parents connected to an increasing of clinical severity in children. This result was not detected in a previous review [4]. We also investigated on additional parameters to identify possible correlations with parenting stress such as education levels, civil status, number of siblings, clinical status, etc. A significant correlation was found between stress levels and number of siblings in a multivariate analysis, i.e. the presence of more children in the same family is associated with high parental stress levels. This may be due to the higher commitment of parents in having to manage more children, when repeated hospitalizations cause more stress [19]. In terms of Birth order, the study has shown that parents of children with chronic illness bear higher stress level compared to other parents, and in particular, a high Birth order in a family with a child with the disease, implies parents with high or suspicious stress, whereas a low Birth order in a family predicts parents with normal stress levels. It has been recently shown that the mother first born interaction differs from the mother second born interaction in healthy children [20].

Our results may suggest that the increased distress observed in parents of children with chronic disease is probably affected by the great expectations that parents have on their first child.

In the event of a sick, the parents need a mental re-adjustment between their expectations of an ideal child and the real child status. The Clinical Severity analysis revealed a correlation between parental stress levels and degree of clinical severity, that is parental stress is higher in parents with a child with a severe disease and less in parents with a child with low Clinical Severity.

With regard to the total scores among stress sub-scales (Parenting Distress – PD, Parent-Child Dysfunctional Interaction P-CDI, Difficult Child (DC), the lowest score of parents with normal stress value was reported in the P-CDI sub-scale. P-CDI sub-scale measures parents’ expectations and interactions with their child. High scores in P-CDI may indicate a parent’s feelings of disappointment either caused by the child or by a lack of proper bonding with their child [21]. The set of questions made it possible to investigate the parent-child relationship and to point out whether the parent perceived the relationship with their child to be different from the one they expected in a no sick child, (i.e. “My child is not able to do as much as I expected”, “When I do things for my child, I feel that my efforts are not much appreciated”, “My son does not seem to learn as fast as most children do!”). It is clear that the illness event in these parents also negatively influences parent-child dynamics [22].

Similarly, none of the sub-categories has shown any remarkable difference between fathers and mothers in terms of high stress (including stress to be assessed and high stress) 25.0 < 29.03%. In this case, a higher level of stress in mothers would have been more likely expected as they are normally more involved in the history of the disease. As they are nearly always hospitalized together with the child, these mothers could be overloaded with more stress [18, 23].

However, despite the small number of parents with clinically elevated or suspicious stress (27.66%), their features were nonetheless analyzed.

Considering parents with high or suspicious stress levels only (Table 3), a higher presence of mothers was observed as opposed to fathers (69.23% > 30.77), the mean age was of about 40 years, married individuals were the majority (84.62%), and there was a substantial presence of individuals without regular paid job (69.23%) and a middle school education level (61.54%). Finally, among the examined parents, high stress was detected in parents having a second child (53.85%) with Cystic Fibrosis, i.e. an ill child with one sibling.