Mindfulness Improves the Well-Being of The Caregivers of Children with Developmental Disabilities

Mindfulness Improves the Well-Being of The Caregivers of Children with Developmental Disabilities

 

By John M. de Castro, Ph.D.

 

There are only four kinds of people in the world. Those who have been caregivers. Those who are currently caregivers. Those who will be caregivers, and those who will need a caregiver.” — Rosalyn Carter

 

Intellectual disabilities involve below average intelligence and relatively slow learning. They are quite common, affecting an estimated 10% of individuals worldwide. These disabilities present problems for the individual in learning mathematics, reading and writing. Individuals with intellectual disorders often have challenging behaviors including aggression, disruptive and socially inappropriate behaviors, self‐injury and withdrawal behaviors. The challenging behaviors not only reduce the quality of life of the individual but also puts them at higher risk of abuse, neglect, deprivation, institutionalization, and restraints.  In addition, caregivers may have to deal with verbal and physical abuse. Obviously, there is a need for therapies that can reduce these behaviors. Mindfulness training may be useful. It has been shown to improve the behavior of individuals with intellectual disabilities and the well-being or their caregivers. So, there is a need to summarize what has been learned regarding the influence of mindfulness on the caregivers of children with developmental disabilities.

 

In today’s Research News article “The Effect of Mindfulness-Based and Acceptance Commitment Therapy-Based Interventions to Improve the Mental Well-Being Among Parents of Children with Developmental Disabilities: A Systematic Review and Meta-Analysis.” (See summary below or view the full text of the study at:  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8237545/ ) Chua and Shorey review, summarize, and perform a meta-analysis of the published research on the influence of mindfulness on the caregivers of children with developmental disabilities.

 

They identified 10 published research studies that clearly demonstrate that mindfulness improves the well-being of the caregivers including improvements in anxiety, depression, and perceived stress. Importantly, these improvements would predict that the caregivers would be less likely to burnout and would provide better care for the children.

 

My caregiver mantra is to remember: the only control you have is over the changes you choose to make.” — Nancy L. Kriseman

 

CMCS – Center for Mindfulness and Contemplative Studies

 

This and other Contemplative Studies posts are also available on Twitter @MindfulResearch

 

Study Summary

 

Chua JYX, Shorey S. The Effect of Mindfulness-Based and Acceptance Commitment Therapy-Based Interventions to Improve the Mental Well-Being Among Parents of Children with Developmental Disabilities: A Systematic Review and Meta-Analysis. J Autism Dev Disord. 2022 Jun;52(6):2770-2783. doi: 10.1007/s10803-021-04893-1. Epub 2021 Jun 28. PMID: 34181139; PMCID: PMC8237545.

 

Abstract

Parents of children with developmental disabilities are susceptible to mental health problems. Mindfulness-based and acceptance and commitment therapy (ACT)-based interventions can improve their mental well-being. This review examined the effectiveness of mindfulness-based and ACT-based interventions in improving mental well-being and mindfulness among parents of children with developmental disabilities. Six electronic databases were searched, resulting in the inclusion of ten studies published between 2014 and 2020. Meta-analysis was conducted using the random-effect model. The results suggest that mindfulness-based and ACT-based interventions were effective in decreasing parental stress, anxiety and depression, however, the effectiveness of these interventions in increasing parental mindfulness was inconclusive. Based on these findings, we discussed considerations for implementing interventions and identified areas which warrant further research.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8237545/

 

Reduce Burnout in Caregivers for the Elderly with Meditation and Yoga

Reduce Burnout in Caregivers for the Elderly with Meditation and Yoga

 

By John M. de Castro, Ph.D.

 

“Self-care is very important for preventing caregiver burnout and senior stress, and two of the most effective self-care habits you can start are meditation and yoga.” – Harry Cline

 

There is a tremendous demand for caregiving. It is estimated that over 65 million (29% of the adult population) in the US provides care to someone who is ill, disabled or aged, averaging 20 hours per week spent caring for their loved ones. This caregiving comes at a cost exacting a tremendous toll on caregivers’ health and well-being. Caregiving has been associated with increased levels of depression and anxiety as well as higher use of psychoactive medications, poorer self-reported physical health, compromised immune function, and increased mortality. Mindfulness practice for caregivers has been shown to help them cope with the physical and psychological demands of caregiving.

 

In today’s Research News article “The effects of yoga and mindful meditation on elderly care worker’s burnout: a CONSORT-compliant randomized controlled trial.” (See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8753257/ ) Kukihara and colleagues recruited adult caregivers for the elderly and randomly assigned them to receive either no-treatment, or 6 weekly 60-minute programs of either yoga or mindful meditation. They were measured before and after treatment for burnout and provided saliva samples for assay for the stress marker α-amylase.

 

They found that in comparison to baseline and the no-treatment control group both the yoga and meditation groups had significant reductions in burnout, particularly emotional exhaustion, and the salivary stress marker α-amylase. There were no significant differences in the benefits of the yoga or the mindful meditation programs.

 

So, practice yoga or meditation to reduce burnout and stress in caregivers for the elderly.

 

Caregiving for a senior is a wonderful thing to do, but it comes with its difficulties and stresses. Yoga and meditation are two practices that can help seniors and their caregivers lead happier and healthier lives.” – Beverly Nelson

 

CMCS – Center for Mindfulness and Contemplative Studies

 

This and other Contemplative Studies posts are also available on Twitter @MindfulResearch

 

Study Summary

 

Kukihara, H., Ando, M., & Yamawaki, N. (2022). The effects of yoga and mindful meditation on elderly care worker’s burnout: a CONSORT-compliant randomized controlled trial. Journal of rural medicine : JRM, 17(1), 14–20. https://doi.org/10.2185/jrm.2021-021

 

Abstract

Objectives: This study aims to investigate the effects of mindful meditation and yoga on reducing burnout and stress in care workers who assist elderly individuals. Knowing how to reduce burnout is important because that of care workers is associated with the quality of client care, worker productivity, and job turnover.

Patients and Methods: The participants included 44 care workers who worked for elderly care facilities in rural Fukuoka. They were randomly assigned to one of three intervention groups: control, yoga, or mindfulness. In the yoga intervention group, a certified yoga instructor taught a 60-minute yoga session each week for six weeks. In the mindfulness group, an experienced medical doctor instructed a mindful meditation program for the same length. Participants were asked to complete the Japanese Burnout Scale (JBS), and the research team collected the level of α-amylase in saliva using NIPRO: T-110-N pre- and post-interventions.

Results: MANOVA was performed with each intervention (control, yoga, mindfulness) as the independent variable on the three subscales of the JBS (emotional exhaustion, depersonalization, and personal achievement) and a biomarker of stress level (α-amylase). The results indicated a significant main effect of interventions, and a follow-up ANOVA showed a significant effect of interventions on emotional exhaustion and personal achievement.

Conclusion: The results indicate that practicing mindful meditation or yoga for 60 minutes once a week for six weeks can reduce care workers’ burnout. This study was notable because the biomarker of stress also improved. It is strongly recommended and encouraged that institutions caring for the elderly population provide mindful meditation or yoga intervention to reduce burnout, which benefits not only care workers but also their clients.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8753257/

 

Improve the Well-Being of Children with Special Health Care Needs and Their Parents with Mindfulness

Improve the Well-Being of Children with Special Health Care Needs and Their Parents with Mindfulness

 

By John M. de Castro, Ph.D.

 

“mindfulness-based parenting program can be an effective intervention for reducing the stress experienced by parents of children with special needs.” – Elizabeth J. Shaffer

 

There is a tremendous demand for caregiving in the US. It is estimated that over 65 million (29% of the adult population) provides care to someone who is ill, disabled, or aged, averaging 20 hours per week spent caring for their loved ones. Children with special health care needs include a variety of conditions from psychological such as anxiety disorders or depression to chronic conditions such as asthma or diabetes or chronic pain, to developmental issues such as autism. They place considerable burdens on their caregivers.  Mindfulness practice for caregivers has been shown to help them cope with the physical and psychological demands of caregiving.

 

A therapeutic technique that contains mindfulness training and Cognitive Behavioral Therapy (CBT) is Acceptance and Commitment Therapy (ACT). It focuses on the individual’s thoughts, feelings, and behavior and how they interact to impact their psychological and physical well-being. It then works to change thinking to alter the interaction and produce greater life satisfaction. ACT employs mindfulness practices to increase awareness and develop an attitude of acceptance and compassion in the presence of painful thoughts and feelings. ACT teaches individuals to “just notice”, accept and embrace private experiences and focus on behavioral responses that produce more desirable outcomes.

 

There has been accumulating research on the application of Acceptance and Commitment Therapy (ACT) for the treatment of children with special health care needs and their caregivers and there is a need to review and summarize the findings. In today’s Research News article “Acceptance and Commitment Therapy for Children with Special Health Care Needs and Their Parents: A Systematic Review and Meta-Analysis.” (See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8345967/ ) Parmar and colleagues review, summarize, and perform a meta-analysis of the published research studies on the effectiveness of Acceptance and Commitment Therapy (ACT) for the treatment of children with special health care needs and their caregivers.

 

They identified 10 published research studies. They report that the published research finds that Acceptance and Commitment Therapy (ACT) produces significant reductions in depression and perceived stress, and increases in psychological flexibility in the children. On the other hand, the parents did not show similar improvements except for a small improvement in psychological flexibility.

 

The published research, then, suggests that Acceptance and Commitment Therapy (ACT) is effective for children with special health care needs in reducing mental distress and increasing their flexibility in dealing with it.  ACT also produce small improvements in their caregivers. This suggests that ACT should be recommended to increase mindfulness in children with special health care needs to improve their psychological well-being.

 

CMCS – Center for Mindfulness and Contemplative Studies

 

cultivating a more mindful way of parenting is associated with reduced stress, anxiety, and depression. Parents experienced increased mindful awareness and improved psychological well-being, and they were more accepting of their children. Their children also had fewer behavior problems and enhanced positive interaction with their parents.” – Manika Petcharat

 

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Study Summary

 

Parmar, A., Esser, K., Barreira, L., Miller, D., Morinis, L., Chong, Y. Y., Smith, W., Major, N., Church, P., Cohen, E., & Orkin, J. (2021). Acceptance and Commitment Therapy for Children with Special Health Care Needs and Their Parents: A Systematic Review and Meta-Analysis. International journal of environmental research and public health, 18(15), 8205. https://doi.org/10.3390/ijerph18158205

 

Abstract

Context: Acceptance and Commitment Therapy (ACT) is an emerging treatment for improving psychological well-being. Objective: To summarize research evaluating the effects of ACT on psychological well-being in children with special health care needs (SHCN) and their parents. Data Sources: An electronic literature search was conducted in PubMed, Web of Science, Ovid/EMBASE and PsycINFO (January 2000–April 2021). Study Selection: Included were studies that assessed ACT in children with SHCN (ages 0–17y) and/or parents of children with SHCN and had a comparator group. Data Extraction: Descriptive data were synthesized and presented in a tabular format, and data on relevant outcomes (e.g., depressive symptoms, stress, avoidance and fusion) were used in the meta-analyses to explore the effectiveness of ACT (administered independently with no other psychological therapy) compared to no treatment. Results: Ten studies were identified (child (7) and parent (3)). In children with SHCN, ACT was more effective than no treatment at helping depressive symptoms (standardized mean difference [SMD] = −4.27, 95% CI: −5.20, −3.34; p < 0.001) and avoidance and fusion (SMD = −1.64, 95% CI: −3.24, −0.03; p = 0.05), but not stress. In parents of children with SHCN, ACT may help psychological inflexibility (SMD = −0.77, 95% CI: −1.07, −0.47; p < 0.01). Limitations: There was considerable statistical heterogeneity in three of the six meta-analyses. Conclusions: There is some evidence that ACT may help with depressive symptoms in children with SHCN and psychological inflexibility in their parents. Research on the efficacy of ACT for a variety of children with SHCN and their parents is especially limited, and future research is needed.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8345967/

 

Mindfulness is Associated with Better Dementia Patient and Caregiver Outcomes

Mindfulness is Associated with Better Dementia Patient and Caregiver Outcomes

 

By John M. de Castro, Ph.D.

 

“Research has shown preliminary but promising results for mindfulness-based interventions to benefit people with dementia and caregivers.” – Lotte Berk

 

Dementia is a progressive loss of mental function produced by degenerative diseases of the brain. Dementia patients require caregiving particularly in the later stages of the disease. Caregiving for dementia patients is a daunting intense experience that can go on for four to eight years with increasing responsibilities as the loved one deteriorates. This places tremendous psychological and financial stress on the caregiver. Hence, there is a need to both care for the dementia patients and also for the caregivers. Mindfulness practice for caregivers has been shown to help them cope with the physical and psychological demands of caregiving. In addition, mindfulness training has been found to help protect aging individuals from physical and cognitive declines.

 

In today’s Research News article “The Effect of Baseline Patient and Caregiver Mindfulness on Dementia Outcomes.” (See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8324319/ ) Innis and colleagues recruited patients with dementia and their caregivers and both were measured for cognitive function, functional activities, health related quality of life, verbal learning, memory, executive function, visual ability, mindfulness, resilience, vulnerability, and Apolipoprotein E. In addition, “caregivers completed ratings of care confidence, care preparedness, burden, mood, and appraisals of caregiving”.  Finally, a subset of participants underwent brain scanning with Magnetic Resonance Imaging (MRI).

 

They found that participants without dementia had significantly higher levels of mindfulness than those with even mild dementia. They also found that the higher the level of patient mindfulness the lower the caregiver ratings of patient dementia, the higher the ratings of health-related quality of life, and the lower the rated patient impairment, cognitive complaints, anxiety, and depression. In addition, the higher the patient’s level of mindfulness the higher the levels of cognition, verbal learning, memory, visuospatial ability, and resilience and the lower the levels of vulnerability. Finally, the found that the association of patient mindfulness on cognitive ability was mediated by resilience and vulnerability.

 

These results are based upon correlations and thus causation cannot be determined. Nevertheless, the associations are clear. The degree of mindfulness of dementia patients is associated with better cognitive ability, emotional health, and resilience and lower levels of vulnerability. These latter relationships appear to be the intermediaries between the patient’s mindfulness and their cognitive ability. It has been shown that mindfulness training in normal individuals produces improvements in resilience. This suggests that mindfulness may help protect against cognitive decline by improving the patient’s resilience and lessening their vulnerability to the effects of aging. This further suggests the possibility that mindfulness training might help to ameliorate the cognitive decline associated with dementia. It remains for future research to explore these possibilities.

 

So, mindfulness is associated with better dementia patient and caregiver outcomes.

 

Alzheimer’s disease patients who practice mindfulness may have better outcomes than those who do not.” – Josh Baxt

 

CMCS – Center for Mindfulness and Contemplative Studies

 

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

 

Study Summary

 

Innis, A. D., Tolea, M. I., & Galvin, J. E. (2021). The Effect of Baseline Patient and Caregiver Mindfulness on Dementia Outcomes. Journal of Alzheimer’s disease : JAD, 79(3), 1345–1367. https://doi.org/10.3233/JAD-201292

 

Abstract

Background:

Mindfulness is the practice of awareness and living in the present moment without judgment. Mindfulness-based interventions may improve dementia-related outcomes. Before initiating interventions, it would be beneficial to measure baseline mindfulness to understand targets for therapy and its influence on dementia outcomes.

Objective:

This cross-sectional study examined patient and caregiver mindfulness with patient and caregiver rating scales and patient cognitive performance and determined whether dyadic pairing of mindfulness influences patient outcomes.

Methods:

Individuals (N = 291) underwent comprehensive evaluations, with baseline mindfulness assessed using the 15-item Applied Mindfulness Process Scale (AMPS). Correlation, regression, and mediation models tested relationships between patient and caregiver mindfulness and outcomes.

Results:

Patients had a mean AMPS score of 38.0 ± 11.9 and caregivers had a mean AMPS score of 38.9 ± 11.5. Patient mindfulness correlated with activities of daily living, behavior and mood, health-related quality of life, subjective cognitive complaints, and performance on episodic memory and attention tasks. Caregiver mindfulness correlated with preparedness, care confidence, depression, and better patient cognitive performance. Patients in dyads with higher mindfulness had better cognitive performance, less subjective complaints, and higher health-related quality of life (all p-values<0.001). Mindfulness effects on cognition were mediated by physical activity, social engagement, frailty, and vascular risk factors.

Conclusion:

Higher baseline mindfulness was associated with better patient and caregiver outcomes, particularly when both patients and caregivers had high baseline mindfulness. Understanding the baseline influence of mindfulness on the completion of rating scales and neuropsychological test performance can help develop targeted interventions to improve well-being in patients and their caregivers.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8324319/

 

Improve the Psychological Well-Being of Caregivers with Self-Compassion and Mindfulness

Improve the Psychological Well-Being of Caregivers with Self-Compassion and Mindfulness

 

By John M. de Castro, Ph.D.

 

“Being more aware of our present moment experience also helps with self-care, something that caregivers often overlook. With a mindfulness practice you can notice sooner when you feel tired, or are having an emotional experience, and make sure you stop and look after yourself.” – Naomi Stoll

 

There is a tremendous demand for caregiving in the US. It is estimated that over 65 million (29% of the adult population) provides care to someone who is ill, disabled or aged, averaging 20 hours per week spent caring for their loved ones. This caregiving comes at a cost exacting a tremendous toll on caregivers’ health and well-being. Caregiving has been associated with increased levels of depression and anxiety as well as higher use of psychoactive medications, poorer self-reported physical health, compromised immune function, and increased mortality. Mindfulness practice for caregivers has been shown to help them cope with the physical and psychological demands of caregiving.

 

In today’s Research News article “The Short- and Long-term Causal Relationships Between Self-compassion, Trait Mindfulness, Caregiver Stress, and Depressive Symptoms in Family Caregivers of Patients with Lung Cancer.” (See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8096886/)  Hsieh and colleagues recruited family caregivers of patients diagnosed with non-small cell lung cancer.  To investigate longitudinal changes, they were administered questionnaires initially and 2, 5, and 8 months later. They were measured for mindfulness, depression, perceived stress, and self-compassion.

 

They found that over time depressed caregivers had significant declines in their depression levels. They also found that the higher the levels of mindfulness the lower the levels of depression and perceived stress, and the higher the levels of self-compassion and the higher the levels of depression the lower the levels of self-compassion and the higher the levels of perceived stress. Further they found that over the 4 measurements self-compassion at time 1 was associated with higher mindfulness at time 2 which was associated with lower perceived stress at time 3 which was associated with lower depression at time 4.

 

It has been well established that mindfulness is associated with greater self-compassion and lower stress and depression. The present study found that depression tends to decrease over time associated with self-compassion and mindfulness. In particular self-compassion appears to be important for lowering caregiver depression levels over time and it does so by being associated with higher mindfulness which is associated with lower stress levels which, in turn, are associated with lower depression.

 

The present study is correlational and as such causation cannot be determined. But, in combination with prior manipulative research it can be suggested that training in self-compassion and mindfulness should be very beneficial for caregivers of lung cancer patients lowering their stress and depression.

 

So, improve the psychological well-being of caregivers with self-compassion and mindfulness.

 

The big open secret is that the key to reducing caregiver burnout and compassion fatigue lies in what can be construed to some as the seemingly counterintuitive wisdom of mindfulness.“ – Audrey Meinertzhagen

 

CMCS – Center for Mindfulness and Contemplative Studies

 

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

 

Study Summary

 

Hsieh, C. C., Lin, Z. Z., Ho, C. C., Yu, C. J., Chen, H. J., Chen, Y. W., & Hsiao, F. H. (2021). The Short- and Long-term Causal Relationships Between Self-compassion, Trait Mindfulness, Caregiver Stress, and Depressive Symptoms in Family Caregivers of Patients with Lung Cancer. Mindfulness, 1–10. Advance online publication. https://doi.org/10.1007/s12671-021-01642-4

 

Abstract

Objectives

Using a prospective longitudinal design, this paper examines a serial mediation model of the associations between self-compassion, trait mindfulness, caregiver stress, and depressive symptoms among the family caregivers of patients with lung cancer.

Methods

A four-wave design was used, with initial assessment (T1) and three follow-ups, at the 2nd month (T2), the 5th month (T3), and the 8th month (T4). A total of 123 family caregivers completed the baseline measurements, including caregiver stress, self-compassion, trait mindfulness, and depressive symptoms. Data were analyzed by serial mediation models to determine the causal ordering of these variables.

Results

Nearly one-quarter of the family caregivers suffered from clinically significant depressive symptoms and the severity of their depression remained unchanged throughout the 8-month follow-up period. Both cross-sectional and longitudinal path analyses revealed that the relationship between self-compassion and depressive symptoms was mediated sequentially by trait mindfulness and caregiver stress. The subscale analysis indicated that the association of higher compassionate action with fewer depressive symptoms was through chain-mediating effects of higher mindful awareness and lower caregiver stress.

Conclusions

Family caregivers who have higher levels of self-compassion tend to have more mindfulness; greater mindfulness leads to lower levels of perceived caregiving stress which, in turn, links to fewer symptoms of depression. Both self-compassion and mindfulness could be regarded as protective factors for caregivers to reduce caregiving stress and depression.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8096886/

 

Improve Caregivers Psychological and Physiological Health with Meditation

Improve Caregivers Psychological and Physiological Health with Meditation

 

By John M. de Castro, Ph.D.

 

Feel overwhelmed with the responsibilities of caring for a loved one? One of the most effective ways to avoid burnout is engaging in a mindfulness practice like meditation.” – Audrey Meinertzhagen

 

There is a tremendous demand for caregiving in the US. It is estimated that over 65 million (29% of the adult population) provides care to someone who is ill, disabled or aged, averaging 20 hours per week spent caring for their loved ones. This caregiving comes at a cost exacting a tremendous toll on caregivers’ health and well-being. Caregiving has been associated with increased levels of depression and anxiety as well as higher use of psychoactive medications, poorer self-reported physical health, compromised immune function, and increased mortality. Mindfulness practice for caregivers has been shown to help them cope with the physical and psychological demands of caregiving.

 

In today’s Research News article “Effects of Meditation on Mental Health and Cardiovascular Balance in Caregivers.” (See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7828286/ ) Díaz-Rodríguez and colleagues recruited caregivers for dependent family members for at least 2 years. They were assigned to either no treatment or to receive twice weekly, 2-hour, sessions of focused meditation training on the basis of availability for the training sessions. They were measured before and after training for happiness, anxiety, depression, heart rate, heart rate variability, and blood pressure.

 

They found that in comparison to baseline and the control group, the group that received meditation training were significant higher in happiness and heart rate variability and significantly lower in anxiety, heart rate, and blood pressure. Hence meditation training improved the mental health and cardiovascular balance of caregivers.

 

These are excellent results. A higher level of heart rate variability is an indicator of increased parasympathetic and reduced sympathetic nervous system activity. Hence, the relaxation promoting portion of the autonomic nervous system increases while the portion promoting activation and arousal decreases. This is further evidenced by the significant decrease in heart rate and blood pressure. This suggest that a 4-week training in meditation improves caregivers’ psychological and physiological state. The effectiveness of the caregiving was not measured but based upon the improvements observed it would be expected that the quality of caregiving would also be improved. This suggests that meditation training should be recommended for caregivers.

 

So, improve caregivers psychological and physiological health with meditation.

 

Caregiving is a tough job and the stress can seriously affect your physical and mental health. An effective and simple way to combat that is to meditate.” – Daily Caring

 

CMCS – Center for Mindfulness and Contemplative Studies

 

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

 

Study Summary

 

Díaz-Rodríguez, L., Vargas-Román, K., Sanchez-Garcia, J. C., Rodríguez-Blanque, R., Cañadas-De la Fuente, G. A., & De La Fuente-Solana, E. I. (2021). Effects of Meditation on Mental Health and Cardiovascular Balance in Caregivers. International journal of environmental research and public health, 18(2), 617. https://doi.org/10.3390/ijerph18020617

 

Abstract

Background: Caring for a loved one can be rewarding but is also associated with substantial caregiver burden, developing mental outcomes and affecting happiness. The aim of this study was to determine the effects of a four-week, 16-h presential meditation program on physiological and psychological parameters and vagal nerve activity in high-burden caregivers, as compared to a control group. Methods: A non-randomized repeated-measures controlled clinical trial was conducted. Results: According to the ANCOVA results, the global happiness score (F = 297.42, p < 0.001) and the scores for all subscales were significantly higher in the experimental group than in the control group at 5 weeks. Anxiety levels were also significantly reduced in the experimental group (F = 24.92, p < 0.001), systolic (F = 16.23, p < 0.001) and diastolic blood (F = 34.39, p < 0.001) pressures, and the resting heart rate (F = 17.90, p < 0.05). HRV results revealed significant between-group differences in the HRV Index (F = 8.40, p < 0.05), SDNN (F = 13.59, p < 0.05), and RMSSD (F = 10.72, p < 0.05) in the time domain, and HF (F = 4.82 p < 0.05)) in the frequency domain, which were all improved in the experimental group after the meditation program. Conclusions: Meditation can be a useful therapy to enhance the mental health and autonomic nervous system balance of informal caregivers, improving symptoms of physical and mental overload.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7828286/

 

Improve Children with Intellectual and Developmental Disabilities, their Caregivers, and the Agency with Mindfulness

Improve Children with Intellectual and Developmental Disabilities, their Caregivers, and the Agency with Mindfulness

 

By John M. de Castro, Ph.D.

 

“mindfulness practices could be helpful for these caregivers because they encourage a nonjudgmental interpretation of their child’s situation, and increased acceptance of their reality.” – Emily Nauman

 

There is a tremendous demand for caregiving in the US. It is estimated that over 65 million (29% of the adult population) provides care to someone who is ill, disabled or aged, averaging 20 hours per week spent caring for their loved ones. This caregiving comes at a cost exacting a tremendous toll on caregivers’ health and well-being. Caregiving has been associated with increased levels of depression and anxiety as well as higher use of psychoactive medications, poorer self-reported physical health, compromised immune function, and increased mortality.

 

Caring for children with intellectual and developmental disabilities can be particularly difficult. Developmental disabilities are a group of conditions due to an impairment in physical, learning, language, or behavior areas. These conditions begin during the developmental period, may impact day-to-day functioning, and usually last throughout a person’s lifetime. Recent estimates in the United States show that about one in six, or about 15%, of children aged 3 through 17 years have a one or more developmental disabilities.

 

The challenges of caring for a child with intellectual and developmental disabilities require that the caregiver be able to deal with stress, to regulate their own emotions, and to be sensitive and attentive to the child. These skills are exactly those that are developed in mindfulness training. It improves the psychological and physiological responses to stress. It improves emotion regulation, it improves the ability to maintain attention and focus in the face of high levels of distraction, and can reduce burnout.

 

In today’s Research News article “Comparative Effectiveness of Caregiver Training in Mindfulness-Based Positive Behavior Support (MBPBS) and Positive Behavior Support (PBS) in a Randomized Controlled Trial.” (See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7223775/) Singh and colleagues recruited caregivers from a home for children with intellectual and developmental disabilities. They were randomly assigned to receive either Mindfulness-Based Positive Behavior Support (MBPBS) of Positive Behavior Support (PBS).  The interventions were for 10 weeks and consisted of “an 8-h day on the first day of week 1 of training, followed by daily practice for 4 weeks. . .  a second part included five 8-h days (i.e., 40 h) during week 5, followed by daily practice for 4 weeks. . . and third part was again an 8-h day on the first day of week 10, followed by daily practice for the rest of the week.” During the next 30 weeks data were collected. The caregivers were measured before and after training for compassion satisfaction, compassion fatigue, perceived stress, professional quality of life, and meditation practice. The children’s behavior was rated for aggressive events, staff injury, and peer injury. The agency was evaluated for the use of physical restraints, emergency medication, staffing, and cost effectiveness.

 

They found that both interventions produced significantly increased compassion satisfaction, and decreased perceived and traumatic stress, and burnout for the caregivers. The Mindfulness-Based Positive Behavior Support (MBPBS) group, however, had significantly greater improvements than the Positive Behavior Support (PBS) group. Similar results were found for the children’s behavior with both treatments producing significant decreases with aggression, staff injuries, and peer injuries. Once again, the mindfulness group had significantly superior results. For the agency outcomes Mindfulness-Based Positive Behavior Support (MBPBS) produced significantly reduced use of physical restraints, emergency medication, and one-on-one staffing. In addition, the mindfulness treatment had significantly greater cost effectiveness.

 

These are very encouraging results that demonstrate that Mindfulness-Based Positive Behavior Support (MBPBS) is highly effective in improving the situation for staff, children, and the agency in an institution for children with intellectual and developmental disabilities. It increased

caregivers’ well-being and the children’s behavior, and decreased the strains on the agency. Amazingly, the mindfulness-based treatment was even more cost-effective.

 

So, improve children with intellectual and developmental disabilities, their caregivers, and the agency with mindfulness.

 

“the greater effects associated with mindfulness techniques may be due to “the immediacy of physiologic relaxation responses incurred in mindfulness practice, including strengthened attention to bodily sensations, and less reliance on rumination or other automatic emotions.” – Summer Allen

 

CMCS – Center for Mindfulness and Contemplative Studies

 

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

 

Study Summary

 

Singh, N. N., Lancioni, G. E., Medvedev, O. N., Myers, R. E., Chan, J., McPherson, C. L., Jackman, M. M., & Kim, E. (2020). Comparative Effectiveness of Caregiver Training in Mindfulness-Based Positive Behavior Support (MBPBS) and Positive Behavior Support (PBS) in a Randomized Controlled Trial. Mindfulness, 11(1), 99–111. https://doi.org/10.1007/s12671-018-0895-2

 

Abstract

Caregivers of individuals with intellectual and developmental disabilities are often stressed due to the demands of the job, including the nature and severity of challenging behaviors of the clients, work conditions, degree of management support for the staff, and the demands of implementing some interventions under adverse conditions. Mindfulness-Based Positive Behavior Support (MBPBS) and PBS alone have been shown to be effective in assisting caregivers to better manage the challenging behaviors of clients with intellectual and developmental disabilities. The aim of the present study was to undertake a head-to-head assessment of the effectiveness of MBPBS and PBS alone in a 40-week randomized controlled trial. Of the 123 caregivers who met inclusion criteria, 60 were randomly assigned to MBPBS and 63 to PBS alone, with 59 completing the trial in the MBPBS condition and 57 in the PBS alone condition. Results showed both interventions to be effective, but the caregiver, client, and agency outcomes for MBPBS were uniformly superior to those of PBS alone condition. In addition, the MBPBS training was substantially more cost-effective than the PBS alone training. The present results add to the evidence base for the effectiveness of MBPBS and, if independently replicated, could provide an integrative health care approach in the field of intellectual and developmental disabilities.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7223775/

 

Improve Mothers and Children with Autism with Mindfulness

Improve Mothers and Children with Autism with Mindfulness

 

By John M. de Castro, Ph.D.

 

“Parents of children with autism spectrum disorder (ASD) often experience high stress in the form of psychological problems, marital strain, and/or family interaction difficulties. . . Mindfulness-based interventions have been found to be beneficial for these parents in many ways, such as decreasing their levels of depression, stress, and emotional reactivity . . . Additionally, many parents of children with ASD who engage in a mindfulness-based practice see a decrease in their child’s aggression and challenging behaviors and an improvement in the child’s overall functioning.” – Katy Oberle

 

Autism spectrum disorder (ASD) is a developmental disability that tends to appear during early childhood and affect the individual throughout their lifetime. It affects a person’s ability to communicate, and interact with others, delays learning of language, makes eye contact or holding a conversation difficult, impairs reasoning and planning, narrows and intensifies interests, produces poor motor skills and sensory sensitivities, and is frequently associated with sleep and gastrointestinal problems. ASD is a serious disorder that impairs the individual’s ability to lead independent lives including complete an education, enter into relationships or find and hold employment. Mindfulness training has been shown to be helpful in treating ASD.

 

Providing care for children with autism can be particularly challenging. These children’s behavior is characterized, in varying degrees, by difficulties in social interaction, verbal and nonverbal communication and repetitive behaviors. These make it difficult to relate to the child and receive the kind of positive feelings that often help to support caregiving. The challenges of caring for a child with autism require that the parent be able to deal with stress, to regulate their own emotions, and to be sensitive and attentive to their child. These skills are exactly those that are developed in mindfulness training. It improves the psychological and physiological responses to stress. It improves emotion regulation. And it improves the ability to maintain attention and focus in the face of high levels of distraction.

 

In today’s Research News article “A Component Analysis of the Mindfulness-Based Positive Behavior Support (MBPBS) Program for Mindful Parenting by Mothers of Children with Autism Spectrum Disorder.” (See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7223597/), Singh and colleagues examine the ability of mindful parenting to improve children with autism and their parents. They recruited mothers of children with Autism spectrum disorder (ASD). After a 10-week preintervention control period the mothers were randomly assigned to receive training for 3 days followed by 30 weeks of practice of either Mindfulness-Based Positive Behavior Support (MBPBS), mindfulness and meditation, or Positive Behavior Support (PBS). PBS involved instruction on how to positively manage their children’s behavior. They were measured before and after the intervention and yearly for 3 years following the intervention for perceived stress and amount of meditation practice and the children’s’ aggressive behaviors, disruptive behaviors, and compliance with mothers’ instructions.

 

They found that in comparison to baseline all groups had significant decreases in the mothers, perceived stress and the children’s aggressive behaviors and disruptive behaviors and significant increases in the children’ compliance with mothers’ instructions that was maintained over the 3-year follow-up period. But the group receiving Mindfulness-Based Positive Behavior Support (MBPBS) had significantly greater improvements in these measures than the mindfulness only group which in turn had significantly greater improvements than the Positive Behavior Support (PBS) group.

 

Dealing with a child with autism spectrum disorder is difficult, challenging and stressful. The results of the present study suggest that training in mindfulness and positive behavior support produces long lasting improvements in the children’s behaviors and the mother’s stress levels. The results further suggest that both mindfulness training and positive behavior support training produce significant benefits with mindfulness training superior. But the combination of the trainings produces maximum effects. Hence, the benefits of mindfulness training and positive behavior support training appear to be additive.

 

The levels of effectiveness of the combined Mindfulness-Based Positive Behavior Support (MBPBS) were quite remarkable with the children’s aggressive and disruptive behaviors almost reduced to zero and this compliance with the mothers’ instructions nearly doubled. The fact that these benefits last over 3 years is quite remarkable. As such MBPBS training should be recommended for mothers of children with autism spectrum disorder.

 

So, improve mothers and children with autism with mindfulness.

 

mindful parenting can affect not just you and reduce your own stress, but it can also help your children, as well.” – A. Stout

 

CMCS – Center for Mindfulness and Contemplative Studies

 

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

 

Study Summary

 

Singh, N. N., Lancioni, G. E., Medvedev, O. N., Hwang, Y. S., & Myers, R. E. (2020). A Component Analysis of the Mindfulness-Based Positive Behavior Support (MBPBS) Program for Mindful Parenting by Mothers of Children with Autism Spectrum Disorder. Mindfulness, 1–13. Advance online publication. https://doi.org/10.1007/s12671-020-01376-9

 

Abstract

Objectives

Mindfulness-Based Positive Behavior Support (MBPBS) has been shown to be effective in reducing stress and burnout in parents and professional caregivers of children and adolescents with intellectual and developmental disabilities (IDD) and autism spectrum disorder (ASD). The aim of this study was to assess the comparative effects of the mindfulness (MB) and positive behavior support (PBS) components against the MBPBS program for mindful parenting.

Methods

The study utilized a three-arm randomized controlled trial design, with a 10-week pre-treatment control condition, 30 weeks of intervention, and 3 years of post-intervention follow-up. Mothers of children with ASD were randomly assigned to the MB, PBS, and MBPBS conditions and provided 3 days of training specific to each condition. The effects of these programs were assessed on the mothers (i.e., training attendance, meditation time, perceived psychological stress) and spillover effects were assessed on their children with ASD (i.e., aggression, disruptive behavior, compliance with mothers’ requests).

Results

Mothers in the MBPBS condition reported greater reductions in perceived psychological stress, followed by those in the MB condition, and with no significant changes reported by those in the PBS condition. Reduction in the children’s aggression and disruptive behavior followed a similar pattern, with most to least significant reductions being in MBPBS, MB, and PBS condition, respectively. Significant increases in compliance (i.e., responsiveness to mothers’ requests) were largest in the MBPBS condition, followed by MB, and then PBS. Changes across all variables for both mothers and their children were maintained for 3 years post-intervention. After time and training type were controlled for, meditation time was a significant predictor in reducing aggressive and disruptive behaviors, and in enhancing compliance of the children with mothers’ requests.

Conclusions

Positive outcomes for mothers and their children with ASD were significantly greater in the MBPBS condition, followed by the MB condition, and least in the PBS condition. MBPBS appears to be an effective mindful parenting program on the assessed variables.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7223597/

 

Reduce the Psychological Burdens on Parkinson’s Disease Caregivers with Mindfulness

Reduce the Psychological Burdens on Parkinson’s Disease Caregivers with Mindfulness

 

By John M. de Castro, Ph.D.

 

Mindfulness-based interventions can improve mental health status, including reduction of stress and anxiety levels, in family caregivers of veterans with Parkinson’s disease.” Patricia Inacio

 

Parkinson’s Disease (PD) is an incurable progressive degenerative disease of the central nervous system. The condition is caused by the death of nerve cells in the brain that produce the neurotransmitter dopamine. There are around seven million people worldwide and one million people in the U.S. living with PD and about 60,000 people are diagnosed with PD every year. Its physical symptoms include resting tremor, slow movements, muscle rigidity, problems with posture and balance, loss of automatic movements, and slurring of speech. PD itself is not fatal but is often associated with related complications which can reduce life expectancy, such as falls, choking, and cardiovascular problems. Parkinson’s Disease (PD) also has psychological effects, especially cognitive decline, anxiety, and depression. All of these symptoms result in a marked reduction in the quality of life. There are no cures for Parkinson’s Disease or even treatments to slow its progression. There are only treatments that can produce symptomatic relief.

 

Caring for Parkinson’s Disease patients is very demanding and goes on for years. This exacts a tremendous toll on caregivers’ health and well-being. Caregiving has been associated with increased levels of depression and anxiety as well as higher use of psychoactive medications, poorer self-reported physical health, compromised immune function, and increased mortality. Mindfulness training has been shown to be beneficial for caregivers. So, mindfulness training may be helpful in decreasing the psychological difficulty of caring for a patient with Parkinson’s Disease.

 

In today’s Research News article “Mindfulness and Psychological Flexibility are Inversely Associated with Caregiver Burden in Parkinson’s Disease.” (See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7071391/), Klietz and colleagues recruited Parkinson’s Disease patients and their primary caregivers. The patients and the caregivers were asked to complete a questionnaire measuring depression, and health-related quality of life. The caregivers only completed measures of Parkinson’s disease caregiver burden, psychological flexibility, and mindfulness. The patients also completed a measure of Parkinson’s disease -related impairment.

 

They found that the higher the levels of Parkinson’s Disease symptoms, patient quality-of-life restrictions, caregiver quality-of-life restrictions, and depressive symptoms of the caregiver the higher the Parkinson’s Disease caregiver burden. But the higher the levels of mindfulness and psychological flexibility the lower the levels of Parkinson’s Disease caregiver burden.

 

These results are correlational and so causation cannot be determined. They show that the burden on the caregivers are related to the severity of Parkinson’s Disease symptoms and their impact on the patient’s and caregiver’s quality of life. But the results also suggest that if the caregiver’s have high levels of mindfulness and the ability to be flexible, they experience lower burden.

 

Psychological flexibility refers to the extent to which a person can cope with changing circumstances and think about problems and tasks in novel and creative ways.” This then suggests that the caregiver’s ability to think about their situation in different ways is important for reducing the burden they experience. “Mindfulness is defined as the tendency to purposely bring one’s attention to experiences occurring in the present moment without judgement.” This suggests that the caregiver’s ability to see their situation as it really is but not judge it contributes to lessening their burden. In the future it would be interesting to train caregivers in mindfulness and psychological flexibility and determine if this training produces a decrease in the burden the caregivers experience.

 

So, reduce the psychological burdens on Parkinson’s Disease caregivers with mindfulness.

 

Family caregivers fill a world of need, and in doing so are at risk of falling into the caregiver burnout abyss. . . Mindfulness is a necessary core competency that we all need to develop. Taking space for yourself will keep you grounded and peaceful while allowing you to be of service.” – Audrey Meinertzhagen

 

 

CMCS – Center for Mindfulness and Contemplative Studies

 

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

 

Study Summary

 

Klietz, M., Drexel, S. C., Schnur, T., Lange, F., Groh, A., Paracka, L., Greten, S., Dressler, D., Höglinger, G. U., & Wegner, F. (2020). Mindfulness and Psychological Flexibility are Inversely Associated with Caregiver Burden in Parkinson’s Disease. Brain sciences, 10(2), 111. https://doi.org/10.3390/brainsci10020111

 

Abstract

Parkinson’s disease (PD) is a neurodegenerative movement disorder with progressive impairments in activities of daily living. With disease progression, people with PD (PwP) need more help and care from their spouses or professional caregivers. Identifying factors that help caregivers to cope with their burden is needed to frame future interventions for PwP caregivers. Mindfulness and psychological flexibility might be factors contributing to resilience against the burden of giving care. In this cross-sectional questionnaire-based study, 118 PwP and their respective primary caregivers were included. Caregivers reported moderate burden and only mild depressive symptoms. Mindfulness measured by the Mindfulness Attention and Awareness scale (p 0.003) and psychological flexibility measured by Acceptance and Actions Questionnaire II (p 0.001) correlated negatively with caregiver burden. Data from this study indicate mindfulness and psychological flexibility are factors contributing to resilience against caregiver burden. Future interventions to reduce burden in PwP caregivers might be improved by the inclusion of mindfulness training programs.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7071391/

 

Improve the Well-Being of Mothers of Children with Autism with Mindfulness

Improve the Well-Being of Mothers of Children with Autism with Mindfulness

 

By John M. de Castro, Ph.D.

 

Parents of children with autism spectrum disorder . . . who engage in a mindfulness-based practice see a decrease in their child’s aggression and challenging behaviors and an improvement in the child’s overall functioning.” – Katy Oberle

 

There is a tremendous demand for caregiving in the US. It is estimated that over 65 million (29% of the adult population) provides care to someone who is ill, disabled or aged, averaging 20 hours per week spent caring for their loved ones. This caregiving comes at a cost exacting a tremendous toll on caregivers’ health and well-being. Caregiving has been associated with increased levels of depression and anxiety as well as higher use of psychoactive medications, poorer self-reported physical health, compromised immune function, and increased mortality.

 

Providing care for a child with autism can be particularly challenging. About one out of every 68 children is considered autistic. These children’s behavior is characterized, in varying degrees, by difficulties in social interaction, verbal and nonverbal communication and repetitive behaviors. These make it difficult to relate to the child and receive the kind of positive feelings that often help to support caregiving. The challenges of caring for a child with autism require that the parent be able to deal with stress, to regulate their own emotions, and to be sensitive and attentive to their child. These skills are exactly those that are developed in mindfulness training. It improves the psychological and physiological responses to stress. It improves emotion regulation. And it improves the ability to maintain attention and focus in the face of high levels of distraction.

 

Acceptance and Commitment Therapy (ACT) is a mindfulness-based psychotherapy technique that employs many of the techniques of Cognitive Behavioral Therapy (CBT). ACT focuses on the individual’s thoughts, feelings, and behavior and how they interact to impact their psychological and physical well-being. It then works to change thinking to alter the interaction and produce greater life satisfaction. ACT employs mindfulness practices to increase awareness and develop an attitude of acceptance and compassion in the presence of painful thoughts and feelings. ACT teaches individuals to “just notice”, accept and embrace private experiences and focus on behavioral responses that produce more desirable outcomes. The application of mindfulness skills to the parents of children with autism is relatively new. So, it would seem reasonable to investigate the ability of ACT to improve the psychological well-being of mothers of children with autism.

 

In today’s Research News article “The Effectiveness of Group Based Acceptance and Commitment Therapy (ACT) on Emotion Cognitive Regulation Strategies in Mothers of Children with Autism Spectrum.” (See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6861729/?report=classic), Salimi and colleagues recruited mothers of children with autism and randomly assigned them to receive either a once a week for 2 hours for 8 weeks program of Acceptance and Commitment Therapy (ACT) or a health education control condition. They were measured before and after training for emotion regulation including self-blaming, blaming others and positive reevaluation, blaming, rumination, considering a situation as disastrous, reception, planning/positive refocuses.

 

They found that after treatment the mothers showed a significant increase in reception, planning/positive refocuses and significant decreases in self-blaming, blaming others and positive reevaluation, blaming, and considering a situation as disastrous. Hence, Acceptance and Commitment Therapy (ACT) significantly improved the ability of mothers of children with autism to regulate their emotions. This is very important as these mothers are extremely important for these children but under great stress and emotional turmoil. Being able to improve their psychological well-being is important for both the mother and child.

 

So, improve the well-being of mothers of children with autism with mindfulness.

 

“People who practice mindfulness learn to pay specific attention to what is happening in the moment — and that includes moments that are stressful or chaotic. It is easy to get overtaken by stress or negativity, but mindfulness teaches people to find distance from their negative thoughts by learning to acknowledge them and label them when they happen.” – Julianne Garey

 

CMCS – Center for Mindfulness and Contemplative Studies

 

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts and on Twitter @MindfulResearch

 

Study Summary

 

Salimi, M., Mahdavi, A., Yeghaneh, S. S., Abedin, M., & Hajhosseini, M. (2019). The Effectiveness of Group Based Acceptance and Commitment Therapy (ACT) on Emotion Cognitive Regulation Strategies in Mothers of Children with Autism Spectrum. Maedica, 14(3), 240–246. doi:10.26574/maedica.2019.14.3.240

 

Abstract

Background:Autism spectrum disorder has a big impact on family life. Mothers of children with autism face many challenges. This study was conducted to determine the effectiveness of group-based acceptance and commitment therapy on cognitive emotion regulation strategies in mothers of children with autism.

Method:This is a quasi-experimental study with a pretest-posttest control group design. The research population included mothers of children with autism spectrum disorder referring to exceptional schools, who were living in Tehran. After cluster random sampling, 30 mothers of children with autism spectrum disorder were selected and randomly assigned to two groups: an experimental group and a control group, each consisting of 15 women. Participants responded to the cognitive emotion regulation questionnaire vulbefore and after intervention. The experimental group received group-based acceptance and commitment therapy (eight two-hour sessions), while no intervention was given to the control group.

Results and conclusion:Covariance analysis of data showed that group-based acceptance and commitment therapy had a significant effect on positive/planning strategy refocusing (p=0.003), positive reappraisal (p=0.004), self-blaming (p=0.001), blaming others (p=0.007), considering a situation as disastrous (p=0.001), reception (p=0.008). However, there was not a significant difference in the dimensions of rumination (p=0.025). Therefore, it is recommended that welfare institutions and centers should provide a training plan based on acceptance and commitment therapy to improve the current cognitive emotion regulation strategies for mothers of children with autism spectrum.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6861729/?report=classic