Atopic dermatitis (AD), a chronic relapsing inflammatory dermatosis characterized by recurrent eczematous plaques and severe pruritus, imposes substantial biopsychosocial burdens on the global pediatric population (1). With a worldwide prevalence of 15%–20% in pediatric populations (2), China reports 12.94% prevalence among children aged 1–7 years (3). The disease typically emerges in infancy, with 60%–70% of cases developing symptoms before age 1 (4, 5), and 70%–95% exhibiting clinical manifestations by 5 years (6). AD management requires multimodal strategies addressing skin barrier dysfunction, immune dysregulation, and environmental triggers, reflecting its complex pathophysiology. However, high treatment burden frequently leads to poor adherence, exacerbating disease control challenges.

Childhood behavioral challenges specific to AD significantly impact treatment outcomes. However, existing research has been limited by generic behavioral assessments that fail to capture AD-specific challenges, such as sleep disturbances, treatment adherence resistance, and scratching compulsions. These behaviors substantially impair parental management efficacy. The EBC is the first validated instrument designed to assess psychological characteristics associated with AD-specific behavioral problems in children. Therefore, cross-cultural validation is required to establish its generalizability and clinical applicability. The primary objective of this research was to cross-culturally adapt the EBC-ES for Chinese populations and validate its psychometric properties through comprehensive reliability and validity testing. Through rigorous cultural adaptation and psychometric validation, a 24-item Chinese EBC-ES was established. The Chinese version retained the original scale's three-factor structure, confirming cross-cultural consistency. Critically, it demonstrated robust psychometric properties, including test-retest reliability, construct validity, content validity, and discriminant validity. These results support its applicability for evaluating AD-specific behavioral problems in pediatric clinical and research settings.

The Chinese EBC-ES demonstrated excellent internal consistency and strong test-retest reliability, with all measured metrics surpassing established thresholds for clinical and research application. Notably, the scale's overall reliability was comparable to, and in certain aspects numerically exceeded, that of the original instrument. This high degree of reliability was consistently observed across all three subscales (factors), confirming the temporal stability and robust psychometric properties of the scale for measuring AD-specific behaviors over time.

The validity of the Chinese EBC-ES was rigorously established across multiple psychometric domains. The scale demonstrated excellent content validity, confirming its relevance and accuracy for measuring AD-specific behaviors in the target cultural context. Furthermore, it exhibited strong discriminant and construct validity, with all statistical indices meeting or exceeding recommended psychometric standards. The factor structure was robust, with all items loading significantly onto their hypothesized factors, thereby confirming the theoretical underpinnings of the instrument.

Both exploratory and confirmatory factor analyses provided strong support for the three-factor structure of the Chinese EBC-ES. The factor solution demonstrated excellent explanatory power and all items loaded significantly onto their intended factors, confirming the structural robustness of the adapted scale. While the original three-factor model was preserved, cross-cultural psychometric variations were identified, including the exclusion of item 15 from factor 2 due to its inadequate loading, as well as observed differences in factor loading patterns. These observed discrepancies may be attributed to a combination of factors, with the case of item 15 offering a clear example of cross-cultural contextual influences. The removal of this item (“Frequently visits the nurse at school”) was necessitated by profound cross-cultural disparities in school healthcare systems and parental health-seeking behaviors between the Australian and Chinese contexts, rather than by translation inaccuracies. This conclusion is supported by two key contextual factors. First, fundamental structural differences exist between the school-based healthcare systems of the two countries. In contrast to the Australian educational framework, where dedicated school nurses are systematically integrated, the Chinese educational environment predominantly lacks specialized, permanent nursing professionals. Routine health concerns are typically managed by classroom teachers or temporary medical personnel. Consequently, the concept of “visiting the school nurse” is culturally unfamiliar to most Chinese children, rendering this measurement item methodologically inapplicable for the target population. Second, parental health-seeking behaviors in China demonstrate a strong preference for formal medical institutions over school-based resources, which are often perceived as having limited clinical authority. This perspective significantly reduces the likelihood of parents relying on school services for managing chronic conditions such as atopic dermatitis. Instead, management typically occurs through home-based care or visits to specialized hospitals. Beyond this specific instance, broader reasons for the psychometric variations likely include: First, cross-cultural disparities in perceptions of childhood AD-specific behavioral problems, attributable to distinct cultural backgrounds, may constitute the primary cause of variations between the adapted and original scale versions. Second, imperfect conceptual equivalence during translation—including semantic, idiomatic, and experiential discrepancies—may have compromised the scale's structural validity. Third, variations in sample characteristics may also lead to divergent psychometric properties. In this study, we enrolled a large clinical sample from a premier tertiary care center, with a sample size significantly exceeding that of the original validation study. This robust sampling strategy not only enhances statistical power but also enables a more rigorous psychometric evaluation.

To our knowledge, this is the first study in China and second globally to assess AD-specific behaviors problems in pediatric populations using the EBC-ES. The Chinese adaptation yielded a total score that was marginally lower than, but not statistically different from, the original Australian version's score. This observed discrepancy may reflect culturally mediated reporting biases, wherein Chinese parents—influenced by collectivist values, Confucian emphasis on familial harmony, and traditional child-rearing philosophies—may exhibit systematically lower reporting frequencies of child behavioral problems compared to Western counterparts. The comparative prevalence of AD-specific behavioral problems between Chinese and Australian pediatric populations remains inconclusive, as current evidence lacks directly comparable multicenter studies with standardized diagnostic instruments and matched demographic characteristics. Most notably, our study confirmed that symptom-related behaviors constituted the most impactful domain of behavioral manifestations, with scores significantly surpassing other clinical areas.

Our results corroborate the existing literature, confirming that skin barrier dysfunction and itch-induced sleep disturbances represent the most prevalent behavioral manifestations in pediatric AD (15). This finding is further strengthened by the work of Moraes MM et al. (56) and is supported by previous clinical evidence (56–58). Our study identifies significant clinical and sociodemographic determinants of AD-specific behavioral symptoms within a Chinese pediatric population.

Our findings regarding criterion validity revealed a moderate correlation between the EBC-ES and the ECBI-IS. Crucially, this magnitude of correlation was expected and strengthens the validity argument for the EBC-ES. Rather than being a limitation, this finding provides strong evidence of discriminant validity, by demonstrating that the EBC-ES measures a construct that is related to, yet distinct from, general behavioral problems. While generic behavioral scales like the ECBI-IS fail to fully capture core AD-specific manifestations (e.g., scratching, sleep disruption, and sensory avoidanc), the EBC-ES is specifically designed to assess these unique behavioral challenges. This moderate correlation, therefore, underscores the unique value of our AD-specific tool in capturing a domain that was previously unmeasured. The stronger correlations observed between the factors within the EBC-ES itself further support its internal cohesion as a unified measure of AD-specific behaviors. The development of the EBC-ES was motivated by the critical gap in available tools for assessing AD-specific behaviors in children. Future studies would benefit from comparing the EBC-ES with other condition-specific measures, should they become available, to further triangulate its validity.

Our analysis identified several key sociodemographic risk factors for AD-specific behavioral problems in Chinese children, including male sex, maternal-reported parenting roles, and lower household income. Notably, these determinants extend beyond the domains captured by the original scale, highlighting a culturally-specific context that necessitates future validation. Consistent with Kisieliene et al.'s report on gender-specific AD patterns (59), we observed notably higher behavioral problem scores among male patients compared to females. Specifically, the observed gender disparity in clinical outcomes may be mediated by differences in treatment adherence, as female patients demonstrated better compliance with dermatologic regimens. This finding aligns with the report by Haruka et al., who reported superior treatment adherence among women in chronic dermatological conditions and highlighted “appearance-related concerns” and “societal role expectations” as potential mediating factors (60). Such improved adherence—including regular moisturizing and avoidance of irritants—is known to alleviate AD-related symptoms (e.g., pruritus and xerosis), thereby reducing subsequent behavioral sequelae (61). Conversely, male patients demonstrated lower adherence, potentially influenced by factors such as limited AD-specific health literacy and gender-differentiated socialization. Thus, these psychosocial factors may interact with biological sex differences, possibly exacerbating AD severity in males (62). Importantly, while these cultural and psychosocial pathways are theoretically plausible, they remain speculative and require empirical validation through future research specifically designed to test these mechanisms. Moreover, maternal-reported scores on the EBC-ES were consistently higher than paternal reports. This discrepancy may be explained by mothers' primary caregiver role, which affords greater exposure and potentially enhances symptom recognition (63, 64). Alternatively, context-dependent behavioral variations may be operative, as children often exhibit increased compliance during father-child interactions, thereby reducing paternal reports of disruptive behaviors (65–67). Furthermore, our analysis revealed a clear inverse relationship between socioeconomic status (SES) and AD-specific behavioral problem scores. Children from lower-income households exhibited markedly higher scores, empirically confirming the SES-behavioral morbidity link previously established in the literature (68). This association is likely mediated by a bidirectional dynamic: poverty-related adversities (e.g., financial strain, psychosocial stress) can directly impair disease management efficacy (69) while concurrently undermining parental coping capacity and a child's neurodevelopmental resilience (70). These interconnected pathways collectively sustain a self-perpetuating cycle that exacerbates behavioral morbidity (71).

Finally, accumulating evidence underscores the pivotal role of integrating behavioral and psychological interventions into standard AD care. Structured therapies, such as habit-reversal therapy (HRT) and cognitive-behavioral therapy (CBT), represent a promising approach by simultaneously targeting core pathophysiological mechanisms like the itch-scratch cycle and mitigating associated psychosocial factors (72, 73). To objectively evaluate the benefits of such interventions, future longitudinal studies building on our institution's validated methodologies for patient-reported outcomes (74) will be crucial. These studies should track dynamic changes in EBC-ES scores throughout the disease trajectory and in response to treatment.

To our knowledge, this represents the first translation and validation of the EBC-ES in China, though several limitations should be acknowledged. First, the single-center, tertiary hospital setting in Northeast China represents a key study limitation, likely resulting in an overrepresentation of moderate-to-severe AD cases and limiting the generalizability of the findings to community-based populations and individuals with milder disease. This selection bias is inherent to the recruitment strategy. Future multi-center studies spanning diverse healthcare levels (e.g., primary care clinics, community health centers) are essential to enhance external validity and better reflect the broader AD population spectrum. Second, the exclusive reliance on guardian-reported outcomes, without corroboration through clinician assessment, risks introducing reporting bias due to potential discrepancies between caregiver perceptions and objective clinical evaluations. Incorporating standardized dermatologist-rated severity assessments (e.g., EASI, SCORAD) in future validation work is crucial to improve measurement accuracy and strengthen the scale's psychometric robustness. Third, as a cross-sectional validation study, our analysis did not assess the responsiveness of the EBC-ES to clinical change over time. This limits its potential application in intervention studies. Future longitudinal studies in interventional settings are now needed to evaluate the sensitivity of the EBC-ES scores to change over time, for instance, following standard-of-care treatment or novel therapies. This will be crucial for establishing its role as a primary outcome measure in clinical trials. Furthermore, our analysis did not account for potentially important confounding factors, such as family psychosocial support resources or treatment adherence levels. These factors may significantly influence both AD severity trajectories and caregiver-reported behavioral manifestations.

This study establishes the Chinese Eczema Behavior Checklist Extent Scale (EBC-ES) as a psychometrically robust tool for identifying AD-specific behavioral problems in pediatric populations. To disrupt the cycle of disease exacerbation linked to socioeconomic stressors, we advocate for integrated public health strategies that: (1) implement community-based psychosocial support programs targeting high-risk families, and (2) scale structured educational initiatives teaching adaptive coping mechanisms across healthcare tiers. The validated scale serv es as a precision public health screening instrument, enabling efficient targeting of limited resources to children with greatest need—ultimately reducing long-term psychosocial burden and advancing health equity in AD management.