Children with acute leukaemia often have adverse social adaptive behaviors during treatment, and good social support and family function are considered to be important protection factors. However, little is known about the interaction mechanism of social adaptive behaviors, social support and family function in children with acute leukaemia. This study aimed to explore the mediating role of family function in social support and social adaptive behaviors of children with acute leukemia in China.

From August to December 2022, face-to-face data collection was conducted using convenience sampling in the Blood Department of a 3 A Children’s Hospital in Chongqing, China. A total of 202 caregivers of children with acute leukemia participated in the questionnaire. Children’s Adaptive Behavior Scale, family function scale and social support scale were used for evaluation. AMOS 26.0 structural equation modelling method was adopted, and Pearson correlation analysis and deviation-corrected centile Bootstrap method were adopted for analysis.

Among the 202 participants, 22.77% (46/202) of the children with acute leukaemia showed adverse social adaptive behaviors. Social support, family functioning and social adaptive behaviors demonstrated significant correlations(r = 0.318、-0.392,p < 0.05). It is worth noting that family functioning has a full mediating effect on social support and social adaptive behaviors.

The evidence provided by this study indicates that social support can positively predict social adaptive behaviors, family functioning can negatively predict social adaptive behaviors, and family functioning mediates the relationship between social support and social adaptive behaviors.This study attributes to the development of precise interventions for caregivers for socially adapted behaviours in children with acute leukaemia and has important implications for policy development to improve the social adaptation of children with leukaemia.

Acute leukemia (AL) is divided into Acute Lymphoblastic Leukemia(ALL) and acute non-lymphoblastic leukemia (ANLL), which is one of the most common cancers in children and teenagers [1]. According to the literature, acute leukemia is the most common type of leukemia among children in China. There are about 15,000 newly diagnosed leukemia children in China every year, and more than 90% of them are acute leukemia, which is more common among preschool and school-age children [2]. Throughout the entire process of a child’s illness, they are faced with situations such as being in an unfamiliar environment away from school and peers, undergoing invasive treatments, and having their everyday developmental experiences interrupted, which are likely to lead to severe consequences. Research has shown that children with leukemia exhibit numerous adverse social adaptive behaviors in terms of independent function, cognitive function, and social function. In terms of independent function: Studies have found that children with leukemia have apparent regression in self-care abilities and developmental problems, such as being unable to complete an appropriate amount of household chores and having language development disorders [3,4,5].In the aspect of cognitive function, KIZILOCA [6] indicated that 10 − 42.8% of children with cancer, including leukemia, have mild to moderate intellectual disabilities, and the incidence of neurocognitive deficits is three times that of normal children. In severe cases, memory disorders or early-onset dementia may occur.Regarding social function: When Tremolada [7] evaluated the social skills and cognitive development of children with leukemia one year after treatment, they discovered that the children had significant deficiencies in social and coping skills. China attaches great importance to the psychological and behavioral monitoring of children with leukemia. The Action Promotion Plan for Healthy Children (2021–2025) emphasizes the need to strengthen the monitoring and evaluation of children’s psychological and behavioural development and improve the diagnostic capabilities and medical support capabilities for major diseases in children such as hematological diseases.Therefore, social adaptive behaviors, as an important indicator and one of the influencing factors of psychological behavior in this group, research on social adaptive behaviors of children with acute leukemia has attracted more and more attention.

There are many factors affecting the social adaptive behaviour of children with acute leukaemia. In terms of individual characteristics, the main factors are age [8], gender [9] and personal coping style [10]. With regard to disease factors, studies have shown that disease treatment [11], complications [12], intermediate- and high-risk cytogenetic typing [13], and increased hospitalization days affect children’s psychological adjustment and maladaptive behaviour. In terms of family environment, it was found that parental literacy [14], family economy [14], and family function [15]could influence children’s adaptive behaviors. Parents with lower literacy generally neglect the development of children’s early sense of independence and social adaptability. The family’s emotional support was beneficial in reducing psychological stress and promoting social adaptation in children with leukaemia. Social factors include information support from medical personnel [16], geography [16], and social support [17]. However, the core factors are not apparent. Growing up the environment is an important prerequisite for regulating children’s social adaptive behaviors [18], while family functioning and social support are two key influences on children’s growing up environment [19]. Therefore, this study intends to extend the idea to the developmental environment, with a core focus on the relationship between family functioning and social support and socially adapted behaviors of children with acute leukaemia.

Social support is the help and support that people receive from family, friends, and leaders in social interaction activities, including actual material objective support, emotional subjective support, and utilization of support [20]. Early studies have shown that social support, as a key determinant in promoting the well-being of children with cancer, is increasingly recognized by the public as an effective way to reduce depression, fear, and negative mental health psychology in children [21]. There are many mechanisms of social support, among which the buffer model is a theoretical framework that places the relationship between social support and physical and mental health in the stress-coping framework, arguing that social support not only directly affects an individual’s physical and mental health, but also plays a role in an individual’s ability to cope with the stress, which then has an impact on physical and mental health [22, 23]. In recent years, the social support buffer-based model has been widely used and applied to the groups of diabetes and adolescent children. For example, Parviniannasab [24] found that in the group of type 2 diabetes patients, social support can influence their health outcomes; Chinese scholars Zhang Jinglin et al. [25] investigated and analyzed the adolescent left-behind children and found that social support can affect the quality of life by influencing the psychological resilience of adolescent left-behind children. The above shows that in children in stressful events, the whole perception of social support can affect children’s physical and mental health by improving coping ability; it can be understood that social support is an important resource to improve the social adaptive behaviors of children with acute leukemia, this also provides a framework for the current study of a basic theoretical model.

Family functioning refers to the ability of the family as a whole to meet the needs of its members and plays an important role in individual development and social progress [26,27,28]. Freud believed that early human experiences were crucial to the development of an individual. Among the early experiences, family upbringing style undoubtedly has a profound impact on the individual, and poor family functioning may lead to children showing more external or internal psychological problems [29]. McMaster’s theory of the family functioning model claims that the structure and organization of the family are important factors that strongly influence and determine the behaviour of the family members [30]. Based on this theory, researcher Bu T [31] conducted a cross-sectional study using the McMaster Family Assessment Device (FAD, a scale with reverse scoring) for a group of nurses and found that family functioning was positively correlated with negative emotions (β = 0.443, p < 0.05). In a previous study, our group analyzed cross-sectional data from seven Chinese hospitals and constructed a risk prediction model by using the XGBoost algorithm. The results of the importance ranking showed that family functioning ranked first in terms of its impact on social maladjustment in children with cancer [32]. However, there is still a lack of specific data to support the relationship between family functioning and socially adapted behaviors in the group of children with acute leukaemia.

Previous studies have suggested the mediating role of family functioning in the relationship between social support and adaptive behaviour [33]. Based on the connotation of family functioning, it is known that improving coping skills can include sounding their family functioning [34] and developing acute leukaemia is considered a significantly stressful event faced by children. Therefore, this study will extend the buffer model in the mechanism of social support from the family perspective by introducing the variable of family functioning to construct a theoretical model of the social adaptive behaviour of children with acute leukaemia(Fig. 1) and put forward the following three hypotheses: H1 social support positively predicts social adaptive behaviour; H2 family functioning negatively predicts social adaptive behaviour; H3 family functioning can influence acute leukaemia through the mediating role of social support. Social adaptive behaviors in children with leukaemia.

Theoretical model

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This study was conducted in the Department of Haemato-Oncology of a tertiary care children’s hospital in Chongqing From August to December 2022, and 202 children with acute leukaemia were recruited using convenience sampling. The inclusion criteria were as follows: (1) the children were diagnosed with acute leukaemia (2) they were aged 3–12 years old (3) their caregivers volunteered to participate and were able to respond correctly to the questions and were able to fill in the study questionnaire either independently or with the help of the investigator. In order to ensure the completeness and quality of the scale, the investigators received professional training before the official survey, and the scale was checked during the face-to-face interviews to collect data and the behaviour of the children and caregivers. Before the test, the researcher will inform the children and carers that the results of this test will only be used for scientific research, and that the results will not be available to anyone other than the researcher, and that the test will be started after obtaining the consent of the research subjects and carers.The study was approved by the Ethical Review Committee of Children’s Hospital of Chongqing Medical University [(2022) Nianlun Audit (Research) No. (353)].

In the stage of formulating the general information questionnaire, the research team, based on the discussion of the subject group, as well as based on the literature reviewed in the previous period [8,9,10,11,12,13,14,15], finally determined the general information questionnaire, which covers the general information of the children with acute leukaemia and the general information of the family in two parts. (1) General information about the child: gender, age, disease diagnosis, disease stage, number of hospitalizations, hospitalizations, and daily internet usage. (2) General family information: caregiver’s parenting style, family type, and family emotional support. The age and gender of the child are the essential demographic characteristics; the stage of the disease, diagnosis of the disease, and the number of hospitalizations reflect the severity of the disease and the course of treatment; and the type of family and the emotional support of the family reflect the environment in which the child grows up in the family and the family resources that he or she may have access to.

It was compiled by Chinese scholars Yao Shuqiao [35, 36] et al. in 1990. This study used this scale to assess the social adaptive behaviour of children with acute leukaemia. The Children’s Adaptive Behaviour Scale consists of 8 subscales with 59 items, which are categorized into three factors (independent functioning factor, cognitive functioning factor, and social/self-control factor) and finally converted into the Adaptive Behaviour Quotient (ADQ) to judge the level of children’s social adaptive behaviors: an ADQ of < 25 is classified as a severe deficit, 25–40 as a serious deficit, 40–55 as a moderate deficit, and 55–70 as a mild deficit, the ADQ score of < 70 is classified as socially maladaptive behaviour. The higher the ADQ score, the better the child’s social adaptive behaviour.The scale has been validated in a population of chronically ill children in China [37, 38]. Despite the lack of independent validation for children with leukaemia, children with tumours are similar to children with chronic diseases in terms of their psycho-behavioural characteristics [39], so this study used the scale to assess the social adjustment behaviour of children with acute leukaemia.

Compiled by Epstein in 1983 [40], and the Chinese version was revised in Chinese by Li Rongfeng et al. [38] in 2013, with a Cronbach’s alpha coefficient of 0.892.The scale has been validated in a group of children with acute leukaemia with good results [41], so this study used the scale to assess family functioning in children with acute leukaemia. The scale consists of 7 dimensions and consists of 60 entries, including problem-solving (6 entries), communication (9 entries), roles (11 entries), affective responses (6 entries), emotional involvement (7 entries), behavioural control (9 entries), and total functioning (12 entries). A 4-point Likert scale was used (1 for strongly agree, 2 for agree, 3 for disagree, and 4 for completely disagree) with some entries reverse scored. Mean scores were calculated for all entries, with lower scores indicating better family functioning [42]. Cronbach’s alpha coefficient in this study ranged from 0.741 to 0.849.

The Social Support Rating Scale (SSRS) consists of three dimensions: objective support (3 items), subjective support (4 items), and utilization utilization of social support (3 items), with a total of 10 items [43]. Objective support refers to support from friends, family, and social networks that meets an individual’s physical, psychological, and social needs; subjective support refers to moral support such as respect, understanding, and acceptance from family members such as parents, siblings, classmates, and friends; and utilization of social support refers to the extent to which an individual utilizes and participates in social support when experiencing setbacks. The total score on the SSRS ranges from 12 to 66 points. The total score of SSRS ranges from 12 to 66, and the higher the score, the higher the level of social support of the participant.The SSRS not only has a wide range of applications in the Chinese population [44], but also has good reliability and validity in worldwide studies on children with acute leukaemia [45], and the Cronbach’s alpha coefficient for the scale level in this study was 0.781.

SPSS 26.0 software was used for statistical analysis. Descriptive statistics were used to describe basic information about subject characteristics (e.g. frequencies and percentages) and study variables (e.g. means and standard deviations). T-tests and ANOVA were used to analyse the differences in social adjustment behaviors of children with acute leukaemia in the general information survey data. Correlation analysis and multiple linear regression analysis were used to assess the relationship between family functioning, social support and social adaptive behaviour. Mediation analyses were used to examine whether expressing family functioning (mediating variable) influenced the relationship between social support (independent variable) and social adaptive behaviour (dependent variable). Prior to analyses, all continuous variables were pooled to eliminate multicollinearity. Finally, structural equation modelling was performed using AMOS 26.0. The bootstrap method (5,000 repeated samples) was used to test the mediated effects model, and all tests were two-sided, with P < 0.05 being a statistically significant difference.

The tolerance of all predictor variables ranged from 0.25 to 0.77 (≤ 0.1 indicates multicollinearity), and the variance inflation factor ranged from 2.14 to 3.19 (≥ 10 indicates multicollinearity), indicating that there was no multicollinearity problem among the predictor variables.

A total of 202 valid questionnaires were recovered, including 120 (59.41%) males and 82 (40.59%) females, with a mean age of (6.64 ± 2.969) years, with the majority of children with acute lymphoblastic leukaemia (81.68%), and with children in the diagnostic phase (41.09%)(Table 1).

Maladaptive social behaviour in 46 of 202 children with acute leukaemia, with an abnormality detection rate of 22.77%. According to the scoring criteria of the Child Adaptive Behaviour Rating Scale (CABS), 46 children with acute leukaemia in the present study had poorly developed social adaptive behaviour (22.77%)(Table 2).

In the social adaptive behaviour score of children with acute leukaemia, the total social adaptive behaviour score was (81.77 ± 17.05), the independent functioning factor score was (26.31 ± 15.77), the cognitive functioning factor score was (28.34 ± 11.25), and the social/self-control factor score was (52.69 ± 10.37)(Table 3).

The results of the correlation analysis between family functioning and social adaptive behaviour of children with acute leukaemia showed that all dimensions and total scores of family functioning of children with acute leukaemia were negatively correlated with social adaptive behaviour; objective support, subjective support, and total social support scores of children with acute leukaemia were positively correlated with the total score of social adaptive behaviour, the more adequate the perceived social support, the lower the score of family functioning scales (the healthier the family functioning), the higher the level of social adaptive behaviour (P < 0.01)(Fig. 2).

Correlation analysis of family functioning, social support, and social adaptive behaviour scales in children with acute leukaemia. (Note. 1 = Social Adaptive Behaviour; 2 = Problem Solving; 3 = Communication; 4 = Family Role; 5 = Emotional Response; 6 = Emotional Involvement; 7 = Behavioural Control; 8 = Total Functioning; 9 = Total Family Functioning Score; 10 = Objective Support; 11 = Subjective Support; 12 = Utilization of Support; 13 = Total Social Support)

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Determination of control variables

Before using structural equation modelling to explore that family functioning has a mediating role between social adaptive behaviour and social support in children with acute leukaemia, the effect of general information on social adaptive behaviour was explored using one-way analysis of variance and multiple linear regression analysis. The results showed that child age, number of hospitalizations, hospitalizations, and stage of illness were independent influences (p < 0.05) on social adaptive behaviour in children with acute leukaemia. They were used as control variables(Tables 4 and 5).

Structural equation modelling was carried out with social adaptive behaviour as the dependent variable, social support as the independent variable and family functioning as the mediating variable. The model was fitted using the excellent likelihood ratio method, and the parameters were: χ2/df = 1.691, CFI = 0.924, GFI = 0.924, AGFI = 0.888, NFI = 0.887, IFI = 0.951, RFI = 0.858, ILI = 0.947, TLI = 0.947, CFI = 0.950, RMSEA = 0.059, suggesting a good model fit. The model showed that social support had a direct negative predictive effect on family functioning (β= -2.179, P < 0.001), and family functioning had a direct negative predictive effect on socially adapted behaviors (β=-2.838, P < 0.001), thus supporting H1 and H2(Table 6; Fig. 3).

The bootstrap method was used to identify and test the significance of the mediating effect by taking 5000 repetitions of the sample. The results of the study showed that the effect value of the total effect of social support on social adaptability was 6.739, and the upper and lower limits of the confidence interval did not contain 0, which means that the total effect value existed; the direct effect of social support and social adaptability was not significant (β = 6.184, P > 0.05), and the indirect effect of social support-family functioning-social adaptability was significant (β = 0.555, P < 0.05). Therefore, family functioning plays a fully mediating role between social adaptive behaviour and social support in children with acute leukaemia [46](Table 7).

Model of mediating effects of family functioning on social adaptive behaviour and social support in children with acute leukemia. (Note. FF1 = Problem solving; FF2 = Communication; FF3 = Family roles; FF4 = Emotional response; FF5 = Emotional involvement; FF6 = Behavioural control; FF7 = Total functioning; SS1 = Objective support; SS2 = Subjective support; SS3 = Utilisation of support; SAD1 = Independent function factor; SAD2 = Cognitive function factor; SAD3 = Social/self-direction factor)

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In this study, we examined the mediating role of family functioning on social support and social adaptive behaviors in children with acute leukaemia. We used a sample of 202 children with acute leukaemia from a tertiary children’s hospital in China. Consistent with our hypotheses, social support was positively associated with socially adapted behaviour in children with acute leukaemia; H2 family functioning was negatively associated with socially adapted behaviour in children with acute leukaemia; and mediation analyses showed that family functioning mediated the relationship between social support and social adaptive behaviors in children with acute leukaemia, acting as a full mediator.

Firstly, our results showed that children with acute leukaemia had a social adaptive behaviour score of (81.77 ± 17.05) and 22.77% had impaired social adaptive behaviour with a mean entry score of (1.39 ± 0.29). The lowest mean score of independent functioning entries was (0.97 ± 0.58), which is similar to the results of Okado’s [47] study. The results of the study suggest that the overall social adaptive behaviour of children with acute leukaemia is at a low level, suggesting that children with acute leukaemia face socially maladaptive behaviour during hospitalization hospitalization. The study suggests a significant decline in independent functioning, which may be related to the young age and immaturity of some of the children in this study, as well as overprotection by their parents. Thus, we can see that the social adaptive behaviour of Chinese children with acute leukaemia needs to be paid more attention to. In the future, we can learn from Murphy M’s study and set up a multidisciplinary cancer support expert service team [48], which can be equipped with psychological counsellors to visit hospitals and provide one-on-one counselling to the children in combination with the characteristics of different stages of children’s mental development, and provide psychological counselling to the children who have an immature mind (mainly the preschool-aged children). Psychological counselling for children with immature minds (mainly preschoolers), encouraging children to take the initiative to express their feelings and thoughts to their parents, take the initiative to think of solutions when they encounter difficulties, and learn to care for others, etc. Various activities can be carried out (e.g., games, storytelling, painting, etc.) to cultivate a sense of direction, initiative and creativity. At the same time, through the role model method (parents can set up a good image of not lying and keeping promises in front of their children), Token method (the correct behaviour is rewarded with a small red flower or a small red star) to correct the bad behavioural habits [49]; while for school-age children can be through the home and family co-education method (family education and school education cooperate, and parents and teachers work together to promote the development of good habits of school-age children) and the situational simulation method (e.g. simulate the shopping scene of the supermarket, teach children how to politely communicate with the clerk, how to choose the goods, etc., so that school-age children can learn and learn in a simulated environment). (such as simulating supermarket shopping scenes and teaching children how to communicate politely with shopkeepers and how to choose goods so that school-age children can learn and practice good behavioural habits in the simulated environment) and other methods, which ultimately promote the physical and mental healthy development of preschool and school-age children with leukaemia.

Second, according to H1, social support is a positive predictor of social adjustment behaviour in children with acute leukaemia. It can be understood that the more adequate social support a child perceives during the illness, the better his or her subsequent social adaptive behaviour, i.e., adequate social support can provide sufficient and good emotional experiences and resources within the family of a child with leukaemia, which is conducive to the child’s positive adaptive psychological and behavioural changes, thus improving the child’s social adaptive capacity. This finding is consistent with the results of Yu Xide’s cross-sectional study [50]. In addition, it was found during the investigation of this study that some caregivers were afraid of being ridiculed or discriminated against by others and adopted a self-contained approach, not accepting the help and support of others and refusing to provide social assistance such as health education, knowledge dissemination, and family and friend visits, which ultimately led to distraction in caring for the children, and the inability to coordinate the arrangement of daily events and concentrate on the careful care of children, affecting the social adaptive capacity of children with leukaemia. Care, affecting the all-round development of social adaptation of children with leukaemia. Therefore, in clinical work, medical personnel should assess the health status of children with acute leukemia and their caregivers, as well as the problems in the process of caregiving, and may intervene in a timely manner by combining online and offline psychological counselling activities with caring people and friends in the community on a regular basis, and using cognitive-behavioural therapy (CBT) at [51], which guides the caregivers to reevaluate the society’s attitude towards the disease, and to challenge and change the unreasonable negative beliefs, such as “to be taken care of by others”, or “to be a good person”. By guiding caregivers to reassess social attitudes towards the disease, challenge and change their irrational negative beliefs, such as “being discriminated against is inevitable”, “seeking help is a sign of weakness”, etc., so as to establish a positive concept of social interaction; it is also possible to carry out emotional resonance groups based on WeChat, a local Chinese communication software. We can also organize emotional empathy groups based on China’s native communication software, WeChat, to organize sharing sessions for carers with similar experiences, to promote mutual understanding and support, to reduce loneliness, and to enhance the courage and strength to face challenges, so as to practically help the children to solve the problem of social support, so as to promote their social adaptation and rehabilitation.

According to H2, family functioning negatively predicts social adaptive behaviour, consistent with previous findings [52]. The higher the family functioning score of children with acute leukaemia, the more it proves that the family functioning is not functioning well, which is reflected in the aspects of distant or even tense family relationships, low family intimacy, poor communication among family members, and low frequency and quality of interactions, etc. This tense and depressing family atmosphere puts the children’s emotions also be in a state of high-level stress for an extended period, which is not conducive to the transmission of family emotions and the inculcation of the correct concepts and improves the affected children’s Positive psychological experience, affecting the long-term social adaptive behaviour. Therefore, healthcare professionals are reminded to hold regular parent education training courses, which include the disadvantages of spoiled parenting, how to balance attention to the needs of multiple children, and encouraging interaction and support between other siblings in the family and the child. Based on the age and condition of the children, we design fun games and special psychological counselling modules that incorporate elements of psychological healing. With the help of standardized psychological assessment tools, such as The emotion matching task [53], we quantitatively assess the quality of interactions between family members and their closeness before and after the intervention so as to strengthen the development of good social adaptive behaviors in the affected children.

Finally, this study further found that family functioning fully mediated the relationship between social support and social adaptive behaviors in children with acute leukaemia. This finding elucidates the influence mechanism of family functioning, social support, and socially adapted behaviour, i.e., social support can indirectly influence children’s socially adapted behaviour through influencing family functioning, similar to previous studies [25], which is in line with the assumption of the theoretical model of the present study (social support buffer model).The primary reason for this finding can be explained on the basis of the buffer model [22], where social support needs to be transformed through the internal family system in order to be effective. The therapeutic trauma faced by children with acute leukaemia (e.g. chemotherapy pain, isolation treatment) is essentially a common family stressor, and external support (e.g. help from family and friends) needs to first improve the family’s problem-solving skills (FAD scale core dimensions) and emotional attunement before it can indirectly contribute to the child’s adaptive behaviour. This is consistent with the process of ‘family internalisation of external resources’ emphasised by McMaster’s theory of family functioning [30]. Secondly, Bronfenbrenner’s ecosystem theory [54] emphasises the ‘core mediating role of the microsystem (family)’, and children’s behavioural development is family-dependent [55], so children’s social adaptive behaviours are highly dependent on family demonstration and reinforcement, and when the family is dysfunctional (e.g., communication deficits, role confusion), even if social support is available, the child lacks behavioural imitation and a positive feedback When the family is dysfunctional (e.g., communication disorder, role confusion), even with social support, the child lacks a good environment for behavioural imitation and positive feedback. In addition, correlation analysis suggests that the total function and total score in family functioning have the most significant influence on the social adaptive behaviour score (r = -0.392, -0.491, P < 0.05), which not only suggests that the pathways through which social support works on the social adaptive behaviour of children with acute leukemia are multifaceted but also confirms that the completeness of the overall family functioning influences social adaptive behaviour. The reason for this is that when children with acute leukaemia have rich social support, the level of support among family members is high, and the parent-child relationship is close; at this time, the family functioning status is good, so the children can get more care from the promising family atmosphere, which helps the children to face the disease optimistically and adapt better to the changes brought about by the disease, which in turn promotes the children’s socially well-adjusted behaviour [56]. It is suggested that healthcare professionals need to formulate intervention strategies based on the pathway of social support affecting social adaptive capacity, strengthen the attention to the children’s family functioning and timely assessment, and comprehensively improve the children’s social adaptive capacity from all aspects of the dimensions of problem-solving, emotional response, problem-solving, communication, and emotional intervention. For families of children with insufficient perceived social support, we can help them enrich their social support network and social intimacy, create a good external support environment for them, pay more attention to the family support system, implement the overall intervention measures of the family as a unit [57], improve the caregiver’s caregiving ability and the caregiving participation of other members of the family, and encourage caregivers to communicate with their family members in a timely and effective manner and to express their inner feelings, care and love each other bravely. Express their inner feelings, care for each other and love each other, so as to make the family relationship closer and more harmonious, and to strengthen their family function; and make a timely assessment of maladaptive behaviors of children with acute leukaemia, which can be guided by cognitive-behavioural interventions, empowering psychological interventions, and other nursing measures [58].

Recently, the mental health of children with leukaemia has received increasing attention. However, in China, there has been no mechanistic research on the domain of socially adapted behaviors of children with leukaemia, combining the two major socio-family level factors, namely family functioning and social support. A total of 202 questionnaires were received for this study. Structural equation modelling was used to estimate the hypotheses. The results of the study showed that 22.77% (46/202) of children with acute leukaemia showed poor social adjustment behaviour. In addition, the study found the effect of social support and family functioning on social adjustment behaviour. Finally, we tried to develop family functioning as a mediator in the relationship between perceived social support and socially adapted behaviour in children with acute leukaemia, confirming the role of family functioning as a complete mediator between social support and social adaptive behaviors in children with acute leukaemia. It is suggested that healthcare professionals should focus on observing the social adaptive behaviors of children with acute leukaemia, formulate interventions focusing on sound family functioning, call for the participation of the system of social professional institutions and the public, establish a perfect social support system in terms of emotion, information, and the allocation of social resources, promote the active integration of children into the society, alleviate the burden of illness and psychology of the affected child and his/her family, and then prevent or alleviate the occurrence of acute leukaemia children This will in turn prevent or reduce the occurrence of social maladaptation in children with acute leukaemia and help them build a suitable social adaptation mechanism.

This study not only investigated the relationship between family functioning, social support and social adaptive behaviors of children with leukaemia, but also explored the ability of family functioning to mediate between social support and social adaptive behaviors of children with leukaemia, contributing to the development of precise interventions for caregivers on social adaptive behaviors of children with acute leukaemia, and allowing nurses to use the results of the study to design individualised care plans. By understanding the importance of family functioning and social support, they can encourage family members to actively participate in the care process and provide emotional and practical support to children to help them better adapt to the challenges posed by the disease. In addition, it is important for policy development to improve the social adaptation of children with leukaemia.

There are some limitations in this study. Firstly, this study was conducted during the Xin Guan epidemic. Conducting a large-scale survey may bring additional burden to the daily operation of the hospital and the work of parental care, so the study was limited to a tertiary hospital in Chongqing City to obtain a small sample size. The area can be expanded in the future for the sample selection in order to improve the generalisability and reliability of the results. Secondly, only family functioning was included as a mediating variable in the analysis of this study, and future studies could introduce other variables, such as cognitive functioning and self-efficacy, to explore their effects on social adaptive behaviors or their correlation with social adaptive behaviors. This is necessary to enrich research on social adjustment behaviour in children with leukaemia. Finally, this study is a cross-sectional study conducted at a single point in time, while it is not possible to determine the temporal order between the variables, cross-sectional studies can only reveal associations between variables, and some experts currently believe that there are different support needs at different stages of the disease and recovery process [59], which depends on the risks and resources of the child and the family, and we can not exclude that these may affect the results of the Potential factors, so our research team has taken this factor into consideration and has been conducting a long-term follow-up survey, and we look forward to sharing other findings with you subsequently.

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Shen Yuqing1, Mo Lin2*, Yu Lu3,Chen ZeFang4,Liu Tao5,Zeng Yan6,Sabika71.Yuqing Shen, Formal analysis, Methodology, Writing–original draft2.Lin Mo, Writing – review & editing3.Yu Lu, Chen ZeFang, Liu Tao, Zeng Yan, Sabika, Data curation, Project administration, Validation4.All authors reviewed the manuscript.

Correspondence to Mo Lin.

This study was conducted in accordance with the Declaration of Helsinki (World Medical Association, 2013). Ethical approval was obtained from Ethics Committee (full name: Institutional Review Board of Children’s Hospital of Chongqing Medical University) (reference number [2022 (year) No. 353]) to the Department of Scientific Research, Children’s Hospital of Chongqing Medical University, China. All methods were carried out according to the relevant guideline and regulations. This study was carried out in compliance with the STROBE Statement. All included patients gave their oral and written informed consent, and the informed consent form was signed by the guardians of the participating children as they had not yet reached the age of independent civil responsibility. The study was entirely voluntary, and patients will give their consent for this material to appear in academic journals and associated publications. In addition, data adhered to the principle of confidentiality, private information such as the child’s name was not disclosed, the primary caregiver signed an informed consent form, and the survey was completed anonymously.

The consent of the guardian has been obtained.

The authors declare no competing interests.

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