Dyadic Asthma Management Questionnaire (DAMQ)

Abstract

The Dyadic Asthma Management Questionnaire (DAMQ) is an evidence-based psychometric assessment tool developed by Katja Heyduck-Weides, Jürgen Bengel, Erik Farin, and Manuela Glattacker (2023) to assess the complex, reciprocal dynamics of asthma management between adolescents and their primary caregivers. Anchored in family systems theory, self-determination frameworks, and developmental psychology, the DAMQ evaluates two cardinal operational dimensions: responsibility sharing (the behavioral distribution of disease management tasks across the dyad) and collaboration (the supportive relational processes and autonomy-supportive parental behaviors facilitating chronic illness care). Methodologically designed in accordance with the COSMIN (COnsensus-based Standards for the selection of health Measurement INstruments) risk of bias taxonomy, the DAMQ features parallel 26-item instruments administered to adolescents (aged 10–18 years) and their primary caregivers.

Structural validity evaluated via exploratory and confirmatory factor analysis (CFA) demonstrated robust psychometric functioning across a 26-item, three-factor structure for each major domain. Responsibility sharing factors comprise: (1) Asthma attack management and prevention, (2) Medical and school-related procedures, and (3) Self-care behaviors. The collaboration domain is captured across: (1) Teaching and emotional support, (2) Monitoring and instrumental support, and (3) Promoting autonomy. Confirmatory factor analyses demonstrated adequate-to-good global model fit indices (χ² = 361.3, df = 270, p = 0.226; TLI = 0.91; CFI = 0.92; RMSEA = 0.06; SRMR = 0.07). Reliability metrics substantiated elevated internal consistency across all subscales, with Cronbach’s α, McDonald’s ω, and Greatest Lower Bound (glb) statistics uniformly exceeding 0.70. Concurrent and convergent construct validity demonstrated meaningful associations with juvenile asthma self-management behaviors, adolescent generic health-related quality of life, and parental disease-related burden. The DAMQ fills a vital measurement gap in pediatric psychology, transition medicine, and family-centered disease management research.

Keywords

Dyadic Asthma Management Questionnaire, DAMQ, pediatric asthma, adolescent-caregiver collaboration, responsibility sharing, family management of chronic illness, pediatric healthcare transition, structural validity, COSMIN methodology, dyadic measurement

Authors

The Dyadic Asthma Management Questionnaire was conceptualized, constructed, and psychometrically validated by a multi-institutional research team in Germany specializing in rehabilitation science, pediatric health psychology, and health services research:

• Katja Heyduck-Weides, PhD — Faculty of Medicine, Medical Center – University of Freiburg, Section of Health Care Research and Rehabilitation Research, Freiburg, Germany.
  ORCID: 0000-0001-8487-4642 | Email: [email protected]
• Jürgen Bengel, PhD — University of Freiburg, Department of Rehabilitation Psychology and Psychotherapy, Institute of Psychology, Freiburg, Germany.
• Erik Farin, PhD — Faculty of Medicine, Medical Center – University of Freiburg, Section of Health Care Research and Rehabilitation Research, Freiburg, Germany.
  ORCID: 0000-0001-6867-0316
• Manuela Glattacker, PhD — Faculty of Medicine, Medical Center – University of Freiburg, Section of Health Care Research and Rehabilitation Research, Freiburg, Germany.
  ORCID: 0000-0003-4300-2201

Correspondence Address: Katja Heyduck-Weides, University of Freiburg, Faculty of Medicine, Medical Center – University of Freiburg, Section of Health Care Research and Rehabilitation Research, Hugstetter Str. 49, 79106 Freiburg, Germany.

Purpose

Pediatric bronchial asthma represents one of the most prevalent chronic conditions of childhood and adolescence worldwide, imposing substantial clinical, psychological, and functional burdens. Effective disease self-regulation requires a complex daily regimen consisting of continuous environmental trigger avoidance, adherence to inhaled controller therapies, symptom monitoring via peak expiratory flow meters, immediate administration of quick-relief bronchodilators during acute bronchospasms, and coordination with healthcare providers and school personnel. During the critical developmental transition from middle childhood through adolescence, the governance of these complex behaviors undergoes a systemic reorganization: disease management shifts from complete parental oversight toward juvenile autonomy and autonomous self-management.

Historically, psychological measurement tools in pediatric chronic disease have suffered from substantial structural limitations. Many instruments captured disease management exclusively from the singular perspective of either the parent or the adolescent, ignoring the intersubjective discordance that frequently characterizes familial chronic illness management. Furthermore, existing scales often conflated the discrete task-oriented allocation of behavioral labor (who actually executes the action) with relational support processes (how parents teach, guide, monitor, or scaffold their child’s growing autonomy). Without isolating these dimensions, clinicians and researchers could not decipher whether suboptimal treatment adherence stemmed from premature transfer of responsibility, intrusive parental overprotection, or mutual miscommunication.

The primary clinical and research purpose of the Dyadic Asthma Management Questionnaire (DAMQ) is to provide a standardized, parallel-scaled psychometric instrument capable of capturing both adolescent and caregiver perspectives across two independent functional domains: responsibility sharing and collaboration. By implementing symmetrical adolescent and parent versions, the DAMQ enables clinicians to identify perceptual concordance or incongruence within dyads. Misaligned perceptions—such as an adolescent presuming that a caregiver is tracking prescription refills while the caregiver assumes the youth has taken total ownership—frequently correlate with medication omission, uncoordinated emergency responses, and elevated acute care utilization. In clinical outpatient and inpatient rehabilitation contexts, the DAMQ operates as a diagnostic screening instrument to tailor psychoeducational interventions, assess dyadic transition-readiness, prevent premature withdrawal of caregiver scaffolding, and monitor the longitudinal efficacy of behavioral family interventions.

Psychological Construct

The DAMQ operationalizes juvenile asthma management as an interactive, interdependent social-ecological system rather than an individualistic self-care behavior. The questionnaire parses dyadic management into two overarching psychological and behavioral domains, each partitioned into three latent subscales totaling 26 items per informant:

1. Responsibility Sharing Dimension

Responsibility sharing conceptualizes the behavioral distribution of daily medical, preventative, and administrative tasks required to keep asthma controlled. It gauges where the dyad sits along the continuum of total caregiver execution, shared dyadic execution, or total adolescent autonomy:

• Asthma Attack Management and Prevention: This subscale assesses the distribution of behavioral accountability during acute respiratory exacerbations and pre-emptive clinical scenarios. It encompasses recognizing early prodromal symptoms of bronchoconstriction, initiating action plan protocols, deciding when to administer short-acting beta-2 agonists, determining when to seek professional medical or emergency services, and preemptively avoiding known personal triggers (e.g., cold air, allergens, exercise-induced asthma prophylaxis).
• Medical and School-Related Procedures: This subscale assesses logistical, organizational, and institutional tasks surrounding the illness. Items capture scheduling medical follow-up appointments with pulmonologists or pediatricians, tracking prescription renewals, refilling controller and rescue medications at pharmacies, informing teachers or physical education coaches regarding activity modifications, and ensuring that emergency medications are available in educational settings.
• Self-Care Behaviors: This subscale reflects routine, independent daily maintenance activities, such as executing regular morning and evening controller inhalations, cleaning spacers or dry powder inhalers, logging peak flow values or symptom dairies, and monitoring environmental air quality or allergen burdens within the home.

2. Collaboration Dimension

While responsibility sharing measures who does what, collaboration captures the qualitative, interpersonal, and communication climate governing the dyadic relationship. It evaluates parental interactive styles and support behaviors as perceived by both members of the dyad:

• Teaching and Emotional Support: This subscale captures parental behaviors that cultivate illness understanding, distress tolerance, and psychological resilience. It includes validating the youth’s feelings of frustration or limitation, discussing the biological rationale behind pharmacotherapies, soothing anxiety during acute attacks, and maintaining a communicative environment where the adolescent feels secure expressing fears regarding their health.
• Monitoring and Instrumental Support: This subscale operationalizes non-intrusive parental vigilance and concrete practical assistance. It covers tracking whether medications were taken without resorting to hyper-surveillance, assisting with physical symptom checks, helping to organize medical supplies, and stepping in as a reliable safety net when the adolescent encounters practical logistical barriers.
• Promoting Autonomy: This subscale reflects autonomy-supportive parental behaviors that facilitate the adolescent’s developmental individuation. It assesses whether the caregiver encourages independent medical communication during clinical consultations, praises self-initiated disease-management actions, respects the youth’s evolving mastery, and collaboratively negotiates management transitions rather than imposing unilateral autocratic control.

Theoretical Framework

The conceptual architecture of the Dyadic Asthma Management Questionnaire rests at the intersection of several established theoretical paradigms within health psychology, developmental psychopathology, and family medicine:

Family Systems Theory and the Family Management Framework

Grounded in general systems theory, Family Systems Theory posits that a family functions as an integrated, interdependent emotional and behavioral unit. A chronic health condition such as asthma does not reside merely within an individual child; rather, it introduces systemic demands that shape familial routines, communication patterns, and power hierarchies. According to Knafl and Deatrick’s Family Management Style Framework, families manage childhood chronic illness along patterns ranging from accommodating and collaborative to conflicted or overwhelmed. The DAMQ directly operationalizes this systemic interdependence by constructing parallel adolescent and caregiver instruments, treating the dyadic unit of analysis as paramount.

Self-Determination Theory (SDT)

The collaboration dimension of the DAMQ is heavily informed by Self-Determination Theory, formulated by Edward Deci and Richard Ryan. SDT asserts that sustained psychological well-being and autonomous behavioral regulation require the satisfaction of three innate psychological needs: autonomy, competence, and relatedness. In pediatric illness management, parental control can easily degenerate into controlling, intrusive surveillance, undermining the adolescent’s sense of competence and inciting autonomy-assertion through medical non-adherence. Conversely, parental collaboration characterized by autonomy support, emotional validation, and scaffolding satisfies these core needs, enabling the adolescent to internalize external medical demands into self-concordant health behaviors.

Social Cognitive Theory and Self-Efficacy

Albert Bandura’s Social Cognitive Theory underscores the construct of self-efficacy—the personal conviction in one’s capability to execute behaviors necessary to produce specific performance attainments. In the DAMQ framework, responsibility sharing is viewed as a developmental progression of guided mastery. Through observational learning, guided practice, emotional reassurance, and corrective feedback provided by the caregiver (captured in the Collaboration scales), the adolescent progressively builds task-specific self-efficacy across attack management, logistics, and self-care, culminating in safe and independent disease management.

The Pediatric Healthcare Transition Model (SMART)

The DAMQ aligns conceptually with the Social-ecological Model of Adolescent and Young Adult Readiness for Transition (SMART). The SMART model emphasizes that medical transition readiness is determined not merely by chronological age or cognitive maturation, but by socio-ecological variables including parent-child communication, shared knowledge, mutual expectations, and gradual role delegation. The DAMQ acts as an empirical measurement vehicle for tracking these socio-ecological transition components in clinical practice.

Validity

The psychometric evaluation of the Dyadic Asthma Management Questionnaire was executed using rigorous methodological designs compliant with the international COSMIN standards:

Content Validity

The initial pool of 46 items was derived through a comprehensive literature synthesis coupled with semi-structured qualitative interviews conducted with adolescents diagnosed with asthma and their primary caregivers in Germany. Following item drafting, content validity was formally vetted by an expert panel of multidisciplinary clinicians and clinical psychologists across participating pediatric inpatient rehabilitation centers. Consultants evaluated the clinical relevance, developmental appropriateness, linguistic comprehensibility, and cultural clarity of each item. This expert review led to the rephrasing of ambiguous phrasing, elimination of redundant items, and optimization of paper-based typographic layout and instructional text.

Construct and Convergent Validity

Hypothesis testing for construct validity verified expected theoretical relationships between DAMQ subscales and validated external psychometric instruments:

• Adolescent Self-Management: The DAMQ was compared against the Short Self-Management Questionnaire for Adolescents with Asthma (KM-J-AB; Petermann et al., 2009), which quantifies actual behavioral adherence and management actions executed over the preceding 7-day recall window. Consistent with theoretical expectations, significant positive correlations emerged between the DAMQ Collaboration scales (particularly Teaching and emotional support and Monitoring and instrumental support) and high KM-J-AB self-management scores. Conversely, higher adolescent-reported responsibility sharing in the absence of collaborative support did not uniformly predict higher 7-day adherence, highlighting the crucial finding that behavioral autonomy without emotional scaffolding can lead to inconsistent management.
• Adolescent Quality of Life: Construct validity was further substantiated via significant positive correlations with the DISABKIDS Chronic Generic Measure (DCGM-12; DISABKIDS Group Europe, 2006). Adolescents who reported higher parental collaboration and balanced responsibility sharing demonstrated significantly higher health-related quality of life, fewer perceived physical limitations, and superior emotional well-being.
• Parental Quality of Life and Burden: The caregiver version of the DAMQ exhibited robust convergent validity when correlated with the Ulm Quality of Life Inventory for Parents of Chronically Ill Children (ULQIE; Goldbeck & Storck, 2002). Caregivers reporting collaborative, autonomy-promoting interactions experienced reduced personal strain, decreased family burden, and elevated satisfaction with familial coping mechanisms.

Reliability

The reliability of the DAMQ was comprehensively assessed across both respondent versions using classic and modern psychometric indicators of internal consistency:

• Cronbach’s Alpha (α): Across all six latent subscales (three in Responsibility Sharing and three in Collaboration), Cronbach’s α coefficients consistently exceeded the standard psychometric adequacy threshold of 0.70 in both the adolescent cohort and the caregiver cohort, demonstrating strong internal consistency.
• McDonald’s Omega (ω): Recognizing that Cronbach’s alpha often violates tau-equivalence assumptions in multi-dimensional scales, McDonald’s ω was computed. All subscale omega values surpassed 0.70, confirming high composite construct reliability.
• Greatest Lower Bound (glb): The greatest lower bound to reliability was additionally calculated, yielding values comfortably above 0.70 across all dimensions. These multiple indices confirm that the DAMQ demonstrates minimal measurement error variance and is suited for both aggregate group-level research and individual-level clinical assessment.

Factor Analysis

The structural validity and dimensional architecture of the DAMQ were evaluated through rigorous exploratory and confirmatory factor analytic workflows:

Exploratory Factor Analysis (EFA)

Initial item reduction on the preliminary 46-item inventory was conducted using exploratory factor analyses across separate adolescent and caregiver development samples:

• Responsibility Sharing: Eigenvalue inspection and Cattell’s scree test converged on an identical three-factor solution in both adolescent and caregiver datasets. Items cleanly loaded onto three interpretable factors: Asthma attack management and prevention, Medical and school-related procedures, and Self-care behaviors.
• Collaboration: Scree plot analyses and parallel analyses similarly supported a three-factor structure across both parallel versions, successfully capturing three distinct modalities of parental collaborative behavior: Teaching and emotional support, Monitoring and instrumental support, and Promoting autonomy. Items exhibiting cross-loadings or low communalities (< 0.30) were systematically eliminated, reducing the scale to 26 optimized items.

Confirmatory Factor Analysis (CFA)

The refined 26-item, three-factor structure for each major domain was subsequently cross-validated using confirmatory factor analysis. Global model fit indices demonstrated that the hypothesized structural model adequately reproduced the empirical sample variance-covariance matrix:

• Chi-Square Goodness-of-Fit: χ² = 361.3, degrees of freedom (df) = 270, p = 0.226 (indicating no statistically significant discrepancy between observed and model-implied covariances).
• Tucker-Lewis Index (TLI): 0.91 (exceeding the standard ≥ 0.90 acceptable fit criterion).
• Comparative Fit Index (CFI): 0.92 (exceeding the ≥ 0.90 acceptable fit threshold).
• Root Mean Square Error of Approximation (RMSEA): 0.06 (with 90% confidence intervals meeting the ≤ 0.08 benchmark for good approximation).
• Standardized Root Mean Square Residual (SRMR): 0.07 (surpassing the ≤ 0.08 criterion for acceptable residuals).

Measurement Invariance

Multi-group confirmatory factor analyses tested for measurement invariance across age cohorts. The factor structure demonstrated good-to-excellent configural and metric fit for adolescents aged 14 years and older. However, a slightly poorer fit was observed for youths younger than 14 years, reflecting the transitional nature of disease autonomy in early adolescence where parental scaffolding exhibits greater situational volatility.

Instrument / Measurement Tool

The operational specifications of the Dyadic Asthma Management Questionnaire are structured as follows:

• Test Type: Standardized self-report and proxy-report dyadic psychometric questionnaire.
• Target Population: Adolescents diagnosed with bronchial asthma (aged 10–18 years; validated across childhood 6–12 yrs, adolescence 13–17 yrs, and young adulthood transition) and their primary family caregivers (mothers, fathers, or legal guardians).
• Administration Format: Symmetrical, parallel-form paper-based pencil-and-paper instrument (adaptable to secure digital assessment platforms).
• Total Item Count: 26 items in the Adolescent Version; 26 items in the parallel Caregiver Version.
• Subscales per Version:
  • Responsibility Sharing Domain (3 subscales):
    1. Asthma attack management and prevention
    2. Medical and school-related procedures
    3. Self-care behaviors
  • Collaboration Domain (3 subscales):
    1. Teaching and emotional support
    2. Monitoring and instrumental support
    3. Promoting autonomy
• Authentic Response Formats:
  • Responsibility Sharing Items: Evaluated on an anchored 5-point scale:
    • 1 = Caregiver takes responsibility for this all of the time
    • 2 = Caregiver takes responsibility for this most of the time
    • 3 = Caregiver and adolescent share equal responsibility
    • 4 = Adolescent takes responsibility for this most of the time
    • 5 = Adolescent takes responsibility for this all of the time
    • 0 = Not needed (indicates that a specific task does not apply to an individual adolescent’s management regimen)
  • Collaboration Items: Evaluated on a 5-point frequency scale:
    • 1 = Never
    • 2 = Rarely
    • 3 = Sometimes
    • 4 = Usually
    • 5 = Always
• Scoring and Dyadic Discrepancy Computation: Subscale scores are derived by calculating the mean of completed items within each subscale (excluding 0 = not needed responses from the denominator). Dyadic discrepancy scores can be derived by subtracting adolescent raw subscale scores from caregiver scores, yielding directional indicators of perceptual divergence, overestimation, or underestimation of management autonomy.

Permissions & Fee and Test Year

• Publication Year: 2023.
• Commercial Status: Non-commercial instrument.
• Fee: There are no user licensing fees associated with academic or non-profit clinical research applications.
• Permissions & Access: The complete questionnaire forms, scoring keys, and German language master forms are copyright-protected by the original authors. Clinicians and researchers wishing to utilize, translate, or adapt the DAMQ must contact the corresponding author:
  
  Katja Heyduck-Weides, PhD
  
  Section of Health Care Research and Rehabilitation Research, Faculty of Medicine, Medical Center – University of Freiburg
  
  Email: [email protected]

References

• DISABKIDS Group Europe. (2006). The DISABKIDS questionnaires: Quality of life questionnaires for children with chronic conditions of their parents. Pabst Science Publishers.
• Goldbeck, L., & Storck, M. (2002). Das Ulmer Lebensqualitäts-Inventar für Eltern chronisch kranker Kinder (ULQIE) [The Ulm Quality of Life Inventory for Parents of Chronically Ill Children]. Zeitschrift für Klinische Psychologie und Psychotherapie, 31(1), 31–39. https://doi.org/10.1026/1616-3443.31.1.31
• Heyduck-Weides, K., Bengel, J., Farin, E., & Glattacker, M. (2023). The Dyadic Asthma Management Questionnaire for adolescents and their caregivers: Development and psychometric evaluation. European Journal of Health Psychology, 30(4), 145–156. https://doi.org/10.1027/2512-8442/a000131
• Mokkink, L. B., de Vet, H. C. W., Prinsen, C. A. C., Patrick, D. L., Alonso, J., Bouter, L. M., & Terwee, C. B. (2018). COSMIN risk of bias checklist for systematic reviews of patient-reported outcome measures. Quality of Life Research, 27(5), 1171–1179. https://doi.org/10.1007/s11136-017-1765-4
• Petermann, F., Lindemann, C., & Warschburger, P. (2009). Der Kurzfragebogen zum Asthmamanagement für Jugendliche (KM-J-AB) [The Short Self-Management Questionnaire for Adolescents with Asthma]. Klinische Pädiatrie, 221(5), 296–301. https://doi.org/10.1055/s-0029-1224137

Items of the Scale