|Year : 2015 | Volume
| Issue : 3 | Page : 221-225
Acceptance and commitment therapy on parents of children and adolescents with autism spectrum disorders
Shuvabrata Poddar1, VK Sinha2, Mukherjee Urbi3
1 Department of Clinical Psychology, Central Institute of Psychiatry, Kanke, Ranchi, Jharkhand, India
2 Department of Psychiatry, Central Institute of Psychiatry, Kanke, Ranchi, Jharkhand, India
3 Department of Applied Psychology, University of Calcutta, Kolkata, West Bengal, India
|Date of Web Publication||8-Jun-2015|
Department of Clinical Psychology, Central Institute of Psychiatry, Kanke, Ranchi, Jharkhand
Source of Support: None, Conflict of Interest: None
Aim: Autism spectrum disorders (ASDs) are neurodevelopmental disorders that hinder the normal developmental process and pose enormous challenges to the parents in terms of their role expectations and adjustment with the irreversible conditions of their child. However, little attention has been paid to their psychological needs and wellbeing. Acceptance and commitment therapy (ACT) focuses on accepting things that are beyond control and commit to changing those things, which are possible to change, by increasing the psychological flexibility of the person, thereby aiding to better realistic adjustments. The present study aims at studying the effectiveness of ACT on parents of children and adolescents with ASDs. Materials and Methods: It followed a repeated measures design, comprising five parents having children and adolescents with ASDs receiving treatment from inpatient and outpatient services of Child Guidance Clinic, Central Institute of Psychiatry, to test the effect of 10 session protocol spanned over 2-month. Assessment measures were done along state anxiety, depression, psychological flexibility and quality of life using State-Trait Anxiety Inventory, Beck Depression Inventory, Acceptance and Action Questionnaire, the World Health Organization Quality of Life Assessment-BREF respectively. Baseline measures were taken prior to the treatment and follow-up measures were taken after nine treatment sessions. Results: Pre- to post-treatment improvements were found on state anxiety, depression, psychological flexibility and quality of life. Conclusion: Findings implied that ACT may have promise in helping parents better to adjust to the difficulties in rearing children diagnosed with ASDs.
Keywords: Acceptance and commitment therapy, autism spectrum disorders, parents
|How to cite this article:|
Poddar S, Sinha V K, Urbi M. Acceptance and commitment therapy on parents of children and adolescents with autism spectrum disorders. Int J Educ Psychol Res 2015;1:221-5
|How to cite this URL:|
Poddar S, Sinha V K, Urbi M. Acceptance and commitment therapy on parents of children and adolescents with autism spectrum disorders. Int J Educ Psychol Res [serial online] 2015 [cited 2017 Sep 24];1:221-5. Available from: http://www.ijeprjournal.org/text.asp?2015/1/3/221/158331
| Introduction|| |
In the recent nosology of Diagnostic and Statistical Manual of Mental Disorders, fifth edition,  the autism spectrum disorders (ASDs) are categorized under neurodevelopmental disorders (NDs) that refer to a group of conditions that typically manifest early in development and are characterized by developmental deficits that produce impairments in personal, social, academic or occupational functioning. The range of developmental deficits varies from specific limitations to global impairments and NDs frequently co-occur. ASD is characterized by persistent deficits in social communication and reciprocal social interactions across multiple contexts and restricted, repetitive patterns of behavior, interests, and activities. When parents first encounter such debilitating condition of their child/children and come to know about the irreversible status of the problem, their immediate reaction would become overwhelmed by indecisiveness and confusion as such problems of their children would mallet their expectation of being a parent, which is potential enough to create parenting stress - an aversive psychological reaction to the demands of being a parent.  They tend to feel responsible and blamed for their children's conditions, guilty and ashamed, and feel even hatred, anger, and blame toward their partners for their perceived responsibility.  They experience high levels of chronic stress, , especially owing to the child's need for unique nurturance which is often inconvenient to them, specifically considering the socioeconomic scenario and mental health awareness of our country; and also owing to the social limitations and constraints imposed from the poorly controlled behavioral manifestations of their children. These parents tend to have high rates of depressive and anxiety disorders  that negatively intermingles with psychosocial adjustment. Mothers in particular report difficulties with the impact on their lives of the child's condition.  Both parents tend to be exhausted and pessimistic about the future. , All these clearly indicate the importance of implementing intervention for stressed parents having children with ASD. As many of these children's problems are unlikely to change, at least quickly, acceptance of the "nonnormative" conditions imposed by the pathology rather than challenging it becomes inevitable for the parents having children with ASD. Acceptance and commitment therapy (ACT) , seems well-suited to address the issue as there are evidences that even widely used interventions through behavioral parent training (BPT) overlook parents' internal experiences, their ability to learn and implement behavioral parenting techniques  and appropriately utilize those in changing contexts.  Moreover, the handful of attempts to address the needs of parents having children with ASD ,, are methodologically weak. However, preliminary studies have supported the effectiveness of mindfulness-based interventions, including mindfulness-based stress reduction and an integrative program combining BPT with mindfulness and narrative restructuring therapy. , ACT utilizes an eclectic mix of metaphor, paradox, and mindfulness skills, along with a wide range of experiential exercises and values-guided behavioral intervention that aim to undermine the power of experiential avoidance and cognitive fusion. This is based on two key themes: Learning how to accept those things that are beyond control, and commit to changing those things that can be changed to make client's life better. As there has been dearth of studies regarding intervention of parental distress and no published work we found on ACT in India so far, this present study would abet to investigate relevant, but comparatively unexplored arena in the management of caregivers' burden. Specifically, this study is an attempt to see whether increasing psychological flexibility in parents through ACT can lead to greater acceptance of their children's illness and lower the amount of distress in them.
| Materials and Methods|| |
The study was done in Central Institute of Psychiatry, Child Guidance Clinic. The sample comprised five parents (five mothers, having continuous contact with their children) of children and adolescents suffering from ASD each having a co-morbid intellectual disability. They were chosen from outpatient and inpatient services of the Institute through purposive sampling method. The mean age of children was 10.64 ± 4.27 years. Mean age of the parents was 39.54 ± 6.84 years and their mean years of education were 11.50 ± 3.25 years.
The study followed a hospital-based repeated measure study design. The variables under investigation were state anxiety, depression, psychological flexibility and quality of life.
Sociodemographic and clinical data sheet (developed for the study): This data sheet was used to obtain information about age, gender, education, duration of illness of their children, symptoms and treatment history.
State-Trait Anxiety Inventory (STAI):  It is a 40 item self-report assessment that differentiates between state anxiety and trait anxiety. This study focused on state anxiety, a temporary condition experienced in specific situations, which contains a 20-item scale, each item graded 1-4. Internal consistency coefficients for the scale have ranged from 0.86 to 0.95; test-retest reliability coefficients ranged from 0.65 to 0.75 over a 2-month interval. 
Beck Depression Inventory (BDI):  It consists of 21 clinically derived categories of depression. The statements in each category are graded from 0 to 3, a higher score indicating greater severity. The reliability and validity were reported to be 0.93 and validity of 0.67  respectively. Acceptance and Action Questionnaire:  The 22-item AAQ measures psychological flexibility, the target process of ACT. Questions are rated on a 7-point Likert scale. Lower scores reflect greater psychological flexibility. The internal consistency and test-retest reliability are 0.70 and 0.64 respectively, and has demonstrated relationships with other psychopathology.  The World Health Organization Quality of Life Assessment-BREF (WHOQOL-BREF):  The WHOQOL-BREF contains 26 items constituting four domains, namely, physical health, psychological health, social relationship and the environment.
Participants meeting inclusion criteria for the study were assessed along state anxiety, depression, psychological flexibility and quality of life by using STAI, BDI, AAQ and the WHOQOL-BREF respectively. Prior to the treatment, baseline measures were taken. The therapeutic program consisted 10 sessions spread over 2-month. Initial sessions (1-6) focused on understanding and acceptance of the disorder and teaching different techniques of ACT using metaphors, paradoxes, and experiential exercises. In the next four sessions (7-10) participants were asked to list their values, goals, and future behaviors. Therapy termination comprised postassessment and review of the previous sessions along with feedback.
Statistical operations were done using Statistical Package for IBM SPSS Statistics for Windows, Version 16.0. (Armonk, NY: IBM Company).
Statistical analysis of the change in scores of the different measures used for assessment across time, Wilcoxon signed rank coefficient was calculated. In addition, descriptive statistics of mean and standard deviations were also computed.
| Results|| |
The findings of the data collected from five parents comprising the present study sample can be summarized as follows:
· State anxiety
[Table 1] shows that there has been a significant change in state anxiety scores from pre- to post-assessment (Z = 2.023* and P = 0.04), implying significant decrease in state anxiety from pre- to post-assessment.
|Table 1: The comparison of the change of scores in State Anxiety (STAI) across time (n=5) |
Click here to view
[Table 2] shows that scores of subjective level of distress (measured through BDI) have changed significantly across time (Z = 2.032* and P = 0.04) - the level of subjective distress has lowered significantly from pre- to post-assessment.
|Table 2: The comparison of the change of scores in depression BDI across time (n=5) |
Click here to view
· Psychological flexibility
[Table 3] shows that there has been a significant change in the psychological flexibility across time (Z = 2.032* and P = 0.04). Scores show a significant increase in psychological flexibility from pre- to post-assessment.
|Table 3: The comparison of the change of scores in psychological flexibility (AAQ) across time (n=5) |
Click here to view
· Quality of life
[Table 4] shows that the scores in the psychological dimension have changed significantly across time (Z = 2.023* and P = 0.04), implying a significant improvement in quality of life in the psychological domain.
|Table 4: The comparison of the change of scores in various domains of quality of life (WHOQOL-BREF) across time (n=5) |
Click here to view
| Discussion|| |
The purpose of this study was to evaluate the effectiveness of ACT based intervention for parents of children and adolescents with ASD. Based on combined findings from the ACT literature and behavioral parent intervention, in general, it was hypothesized that the intervention would impact parents in a number of ways. Overall findings indicate that there have been significant changes, in general, clinical distress, anxiety, depression and psychological flexibility from pre- to post-treatment. These findings suggest that, in general, avoidance and fusion decrease immediately in posttreatment. This is in direct contrast to the pattern of results found by Blackledge and Hayes.  In their study of ACT for parents of children diagnosed with autism, there were no significant changes in the AAQ-9 item scores between pretest and posttest, but there were significant changes from posttest to follow-up. The authors explained their findings in terms of an incubation effect, that is, that acceptance skills require time to be developed and practiced.  Other ACT studies have revealed similar effects, including an ACT intervention for smoking cessation  and ACT plus 12-step facilitation for opiate addicts.  Still, we cannot conclude that differential emphasis on acceptance/experiential avoidance is the only factor contributing to change in AAQ scores. In the pilot study by Murrell et al.,  acceptance/experiential avoidance were as prominent in the treatment protocol as they were in the Blackledge and Hayes  study, yet none of the parents evidenced reliable change in AAQ-II scores, with some scores actually increasing from pretest to posttest. Murrell et al.  hypothesized that increased familiarity with the concepts of acceptance and experiential avoidance might be a confounding factor. That is, prior to treatment, parents have little to no understanding of acceptance and experiential avoidance, which would affect the way they comprehend the items on the AAQ. After treatment, parents' level of comprehension changes, thus fundamentally changing the way they interpret the measure.
It was also hypothesized that mean anxiety and depression scores would decrease between pretest and posttest. In addition, there was a decreasing trend in mean scores over time. These findings are consistent with the other two ACT for parent studies. In the pilot study by Murrell et al.,  2 out of 3 parents showed reliable change on the Depression Anxiety and Stress Scale-21. Both of these parents had baseline scores in at least the mild to moderate range. In general, they were higher socioeconomic status than the current sample, and so were not subject to stressors related to that. Similarly, in the study by Blackledge and Hayes,  significant changes were observed in BDI- II scores between pre- and post-treatment as well as at follow-up. These parents also participated in treatment of their own accord. However, effect size was not large, which Blackledge and Hayes  attributed to the fact that their sample was not particularly distressed prior to treatment. Interestingly, baseline scores on the BDI and STAI predicted treatment response in present study such that those parents with higher baseline scores were more likely to demonstrate clinically significant change on at least one outcome measure. This finding is consistent with findings from Blackledge and Hayes,  who also found that their intervention had a larger effect on the more distressed participants.
The findings of the present study suggest that there has been a significant change in the psychological domain of quality of life across time. There has not been any reported study about ACT and quality of life but studies show that the mindfulness-based therapies have helped in enhancing the overall quality of life  and avoidance and fusion seem to correlate negatively with quality of life.  Thus, it would be reasonable to derive that the increase in the psychological flexibility is an indication for reduction in the avoidance across time, which has subsequently enhanced the quality of life especially in the psychological domain.
| Conclusions|| |
It can, therefore, be assumed that the ACT intervention may impact removal of cognitive and affective barriers (by targeting fusion and avoidance) and, therefore, increase parent perceptions about their own effectiveness. However, this would depend on the existence of effective skills in the first place and, therefore, suggest that future studies supplement ACT with behavioral skills training. There is notable absence of measures of parenting practices in the field, and future researchers should consider the development and validation of alternate parenting practices measure prior to or in conjunction with any evaluation of the effectiveness of ACT parent training.
The findings, therefore, imply that ACT may have promise in helping parents better to adjust to the difficulties in raising children diagnosed with ASD. These indicate the need for replication, more research, and more intensive psychological intervention using ACT with them.
| References|| |
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5 th
ed. Arlington, VA: American Psychiatric Publishing; 2013.
Deater-Deckard K. Parenting stress and child adjustment: Some old hypotheses and new questions. Clin Psychol Sci Pract 1998;5:314-32.
Konstantareas MM. A psychoeducational model for working with families of autistic children. J Marital Fam Ther 1990;16:59-70.
DeMyer MK. Parents and children in autism. Toronto: Wiley; 1979.
Holroyd J, Brown N, Wikler L, Simmons JQ 3 rd
. Stress in families of institutionalized and noninstitutionalized autistic children. J Community Psychol 1975;3:26-31.
Breslau N, Davis GC. Chronic stress and major depression. Arch Gen Psychiatry 1986;43:309-14.
Callu D. Parental report of cognitive difficulties, quality of life and rehabilitaiton in children with epilepsy or treated for brain tumour. Dev Neurorehabil 2008;11:268-75.
DeMyer MK, Goldberg P. Family needs of the autistic adolescent. In: Mesibov E, editor. Autism in Adolescents and Adults. New York: Plenum Press; 1983. p. 225-50.
Hayes SC, Bissett RT, Korn Z, Zettle RD, Rosenfarb IS, Cooper LD. The impact of acceptance versus control rationales on pain tolerance. Psychol Rec 1999;49:33-47.
Coyne LW, Wilson KG. The role of cognitive fusion in impaired parenting: An RFT analysis. Rev Int Psichol The Psichol 2004;4:469-86.
Murrell AR, Schmalz J, Mitchell PR, LaBorde CT. Parent action: Acceptance and Commitment Training for Parents. Paper Presented at: Association for Behavior Analysis Annual Convention, Phoenix, AZ; 2009.
Wahler R, Rowinski K, Williams K. Mindful parenting: An inductive search process. In: Greco LA, Hayes SC, editors. Acceptance and Mindfulness Treatments for Children and Adolescents: A Practitioner′s Guide. Oakland, CA: New Harbinger Press; 2008.
Micheli E. A training group for parents of autistic children. Int J Ment Health 1999;28:100-5.
Samit CJ. A group for parents of autistic children. Handbook of Short-Term Therapy Groups. Northvale, NJ: Jason Aronson; 1996. p. 23-37.
Davidson B, Dosser DA. A support system for families with developmentally disabled infants. Fam Relat 1982;31:295-9.
Minor HG, Carlson LE, Mackenzie MJ, Zernicke K, Jones L. Evaluation of a Mindfulness-Based Stress Reduction (MBSR) program for caregivers of children with chronic conditions. Soc Work Health Care 2006;43:91-109.
Spielberger CD. State-Trait Anxiety Inventory: A Comprehensive Bibliography. Palo Alto, CA: Consulting Psychologists Press; 1983.
Spielberger CD, Gorsuch RL, Lushene R, Vagg PR, Jacobs GA. Manual for the State-Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologists Press; 1983.
Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry 1961;4:561-71.
Beck AT, Steer RA. Beck Depression Inventory: Manual. San Antonio, TX: The Psychiatric Corporation; 1987.
Hayes SC, Bissett R, Roget N, Padilla M, Kohlenberg BS, Fisher G. The impact of acceptance and commitment training on stigmatizing attitudes and professional burnout of substance abuse counselors. Behav Ther 2004;35:821-36.
The WHOQOL Group. Development of the WHOQOL: Rationale and current status. Int J Ment Health 1998;23:24-56.
Blackledge JT, Hayes SC. Using acceptance and commitment training in the support of parents of children diagnosed with autism. Child Fam Behav Ther 2006;28:1-18.
Gifford EV, Kohlenberg BS, Hayes SC, Antonuccio DO, Piasecki MM, Rasmussen-Hall MG, et al
. Acceptance-based treatment for smoking cessation. Behav Ther 2004;35:689-705.
Hayes SC, Wilson KG, Gifford E, Bissett R, Batten S, Piaseck M. A preliminary trial of twelve-step facilitation and acceptance and commitment therapy with poly substance-abusing methadone-maintained opiate addicts. Behav Ther 2004;35:667-88.
Greeson JM. Mindfulness Research Update: 2008. Complement Health Pract Rev 2009;14:10-18.
Schmalz JE, Murrell AR. Measuring experiential avoidance in adults: The Avoidance and Fusion Questionnaire. Int J Behav Consult Ther 2010;6:198-213.
[Table 1], [Table 2], [Table 3], [Table 4]