Abstract
Background:
Handicap is a critical factor with significant effects on family. Stress is the main result of such effects on parents. As a classical procedure, mothers have the major caregiving role to the child; therefore, they experience more stress than other members. Then, development program for stress management is essential.Objectives:
The current study aimed to develop and assess a de-stress training program on decreasing the stress of mothers with mentally retarded children.Materials and Methods:
The current study was a semi-experimental research with Follow-up. Study subjects included 20 mothers with slow paced children connected to a non-governmental organization (NGO) of show paced children in Tehran, Iran. Mothers were randomly divided into experimental and control groups (10 cases in each group). All mothers responded to the parental stress scale used to measure mothers’ stress. Experimental group received de-stress training program for 13 sessions. Post-test was administered in session fourteenth and after one month the results were followed-up. Data were analyzed by univariate analysis of covariance (P < 0.01).Results:
Data presented a significant difference between the control and experiment groups. Also, results did not show a significant difference between the post-test and follow up. It means that the effect of training was persistent.Conclusions:
De-stress training program significantly decreased the stress of mothers with show paced children, and the training effect was persistent.Keywords
Slow Paced Children Parenting Stress De-Stress Training Program
1. Background
Families with slow paced children (slow paced innovation which has a term equal to the term mental retardation, this term has been established by Dr. Afrooz. This has a common term in Iranian except children psychologists) encounter challenges. The first steps toward acceptance and growing the child and necessities of special caregivers have different effects on families. All parents are positive about bringing up a new child, but none of them expect a disable child. The birth of a child with disability is unexpected for parents and has special consequences. The stages of grief for parents of children with special needs are as follows: shock, denial, guilt, anger, depression, frustration, anxiety and acceptance (1).
The birth of a slow paced (mentally retarded) child is not out of this rule. Slow paced children have special characteristics such as: under average intelligence quotient, limitation of memory, word storage, abstract thinking, visual and auditory deficit and immovability. These signs make adjustment of children with Down syndrome, microcephaly and macrocephaly more difficult (2).
Social stigma is addressed by some researches (3). It is the extreme disapproval of (or discontent with) a person or group on social characteristics that are perceived, and serve to distinguish them from other members of a society. Stigma may then be affixed to such a person, by the greater society, who differs from the cultural norms. Experiences can be affected by stigma and others who have direct relationships with this person can be affected. Relatives may be internalizing the received stigma and then their lives will be affected., Mothers’ perception about internalized stigma increases the stress of child more than their responsibility to bring up a child with disability (4).
Fulfilling the needs of these children requires patience and scarification of their parents. It leads to forgetting themselves, inattention to other children and incompatibility (5). Moreover, difficulty in marriage, relationship with siblings, relatives and neighbors are results of the birth of a child with mental retardation (6).
The birth of child with disability arouses a wide range of sensitive responses in parents. It is a critical subject for some parents that needs mental regulation. For others, it is a regretful event and initial response to such events is the affective collapse (7). The birth of child with mental retardation can have deep effects on the whole family (parents and children) and extended family members (grandfather and grandmother). It is a common experience among all members of the family and will affect all aspects of family functions (8).
Stress is the consequence of having a slow paced child. Stress starts when demands are more than abilities (9).
Parental stress can be perceived as challenges between parental duties and the existing capacities of parents (10). Stress has various effects on life. Stress impairs the social, psychological and physical functions. Parental roles are limited by stress and they may increase the chronic diseases such as blood pressure and heart disease (11). Some researchers estimate the parental role (12, 13). Finally, most of the studies show that stress correlates with decrease of mental health (14), low life satisfaction (15), behavioral problems in children (16) and economic and wellbeing challenges (17).
Coping with stress is mostly attended by psychologists. Some therapists believe that changing cognition and behaviors lead to decrease of stress (18). Psychologists believe that evaluation of an event is a useful coping skill against stress. Evaluation or cognition of an event is different among people behave based on these cognitions (19).
Studies about stress management started in 1930 when Hill presented his ABC-X model about family stress management. This model is designed to cope with stress in families and specifically in families with mentally retarded children (19).
2. Objectives
According to the importance of family in bringing up children with mental retardation, parental stress management is necessary. Then, the current study aimed to design and assess the effects of de-stress training programs on the stress of mothers with slow paced children.
3. Materials and Methods
The current study was an applied research. It was a semi-experimental method with follow-up.
Population of this study included all mothers with slow paced children in Tehran, Iran. The study subjects were randomly selected from one of the slow paced children associations. Twenty mothers were selected based on the study criteria and randomly divided into experimental and control groups.
Inclusion criteria included mental retardation diagnosis, age under 16 years, with normal mothers who at least finished high school. Mothers signed a written letter of consent to participate in the research; all responded to the Berri and Jones parental stress scale in pre-test, post-test and follow-up stages.
After selecting the sample group and performing the pre-test, the experimental group received the de-stress training program for 13 sessions. This program is designed based on the stress inoculation training of Donald Meichenbaum. Also, the Jacobson progressive relaxation training is used. Jacobson suggested that anxiety leads to tension in muscles; when tension is removed, anxiety will be removed (20). Each session started with review of the past session and responding to questions. Mothers had enough time to express themselves.
3.1. Parental Stress Scale (Berri and Jones, 1995)
This scale is used to assess parental stress. This self-report scale has 18 items which have to be completed by parents. Expressions are paying attention to positive and negative aspects of parental duties.
For instance, the first item of the scale is: “ I’m happy for my role as a parent” or the fourteenth item is: “If I could have a new possibility, I wouldn’t decide to have a child”. Parents were requested to answer each expression, based on normal relationship, which they had with their children.
The parents could declare their opinions in one Likret scale including: completely disagree, disagree, no idea, agree and completely disagree. Seven expressions, namely 1, 2, 5, 6, 7, 17 and 18 were scored reversely, and the rest were directly scored. In this scale, the minimum and maximum scores were 18 - 90. Higher scores indicated greater stress. Berry and Jones (1995) reported the test internal validity and test-post-test validity 0.83 and 0.80, respectively. To verify and assess the validity of the translated version of the scale, it was performed on 23 mothers and the obtained test-post-test validity was 0.78, with one week interval. The relative advantage of this scale compared with similar tools is pertaining to its fewer expressions, thus the scale becomes shorter, and accordingly parents can use it more comfortably (21).
Data were analyzed by univariate analysis of covariance (P < 0.01) using SPSS ver. 16.
3.2. Stress Management Training Program
Description of Each Session
| Sessions | Brief Description of Sessions |
|---|---|
| 1, 2 | Introducing, presenting goals, method and performance |
| 3 | The Jacobson progressive relaxation training, analysis of environment, response to questions, homework |
| 4 | Parenting skills training, the Jacobson progressive relaxation training, homework |
| 5 | Self-monitoring, information about mental retardation, anger management, the Jacobson progressive relaxation training, homework |
| 6 | Anger management, facilitating communication, response to questions, the Jacobson progressive relaxation training, homework |
| 7 | Parenting skills training with focus on healthy environment, facilitating communication of sibling, the Jacobson progressive relaxation training, homework |
| 8 | Finding false thoughts, following up the rehabilitation periods, the Jacobson progressive relaxation training, homework |
| 9 | Recognizing negative thoughts and replacing the positive thoughts, having real expectations, considering the feedback and demands of parents and children, the Jacobson progressive relaxation training, homework |
| 10 | Self-caring, focus on present, reasonable demands (self and others), the Jacobson progressive relaxation training, homework |
| 11 | Self-talking technique, considering anger management, assertiveness, considering needs of children, the Jacobson progressive relaxation training, homework |
| 12 | Considering self-attention, problem solving skills, considering mothers reaction to stress, the Jacobson progressive relaxation training, homework |
| 13 | Review of the past session, response to questions, considering feedback during trainings |
| 14 | Post-test |
| 15 | Follow-up |
Post-test was performed in session fourteen and after one month follow-up. Obtained data analyzed by descriptive and inferential statistics.
4. Results
Descriptive characteristics of experimental and control groups are presented in Table 2; in the experimental group: in pre-test M = 46.90, SD = 7.19, in post-test M = 35.10, SD = 7.65; in the control group: in pre-test M = 47.90, SD = 10.05; in post-test: M = 47.60 SD = 9.80.
| Variables | Experimental Group | Control Group | ||
|---|---|---|---|---|
| Pre-Test | Post-Test | Pre-Test | Post-Test | |
| Maternal stress | 46.90 ± 7.19 | 35.10 ± 7.65 | 47.90 ± 10.05 | 47.60 ± 9.80 |
According to the obtained differences between the groups, univariate analysis of covariance was used to demonstrate the significant differences.
Brief Results of Univariate Analysis of Covariance
| Variable | SS | df | MS | F | P Value | ηP2 |
|---|---|---|---|---|---|---|
| Pre-test | 1288.95 | 1 | 122.95 | 214.09 | 0.01 | 0.93 |
| Group | 662.45 | 1 | 662.45 | 110.03 | 0.01 | 0.87 |
| Error | 102.35 | 17 | 6.02 | - | - | - |
According to Table 3, there was a significant difference between the experimental and control groups. There were also significant differences after covariance analysis and omission of initial differences (F = 11.03; P < 0.01).
Based on the obtained results, the mean of maternal stress decreased in post-test. Therefore, it can be concluded that de-stress training program significantly decreased stress in mothers.
Descriptive Characteristics and Dependent T-Test
| Group/Variable | Post-Test | Follow-Up | Dependent T-Test | ||
|---|---|---|---|---|---|
| t | df. | P Value | |||
| Experiment | |||||
| Maternal stress | 35.10 ± 7.65 | 43.50 ± 12.89 | 0.55 | 9 | 0.59 |
| Control | |||||
| Maternal stress | 47.60 ± 9.80 | 52.60 ± 10.08 | -1.21 | 9 | 0.22 |
According to Table 4, there was no significant difference between the post-test and follow-up points of maternal stress. It means that effectiveness of de- stress training program on decreasing stress was persistent (stress was reduced in post-test and this reduction continued). Thus, there was no difference between the mean of post-test and that of the follow-up test)
5. Discussion
Results of the study showed that the de-stress training program had significant effects on decreasing stress, which was persistent.
One reason for effectiveness of this program was active participant of mothers in sessions. In other words, mothers were not just listeners; they had time to describe their feelings and thoughts. Therefore, it did lead to empathy and releasing emotions. Moreover, mothers shared their experiences and it helped them solve problems and manage their stress.
An existing problem for mothers was the differences between normal and slow paced children. Usually, mothers with favoritism toward slow paced child increased the family challenges. In this program, strategies to cope with challenges were trained to mothers. Also, the necessary information about slow paced children was presented in sessions.
In this program, the stress inoculation training designed by Meichenbaum was used. This method is not focused just on an especial technique, individual differences are also considered (20, 22). Attention to critical needs of mothers with slow paced children guided the sessions toward clear and real needs.
Overall, identifying slow paced children, sharing experiences, training strategies to cope with stress and all other factors led to controlling stress and coping with the problems that are followed by stress.
Results of the study showed that the de-stress training program had significant effects on decreasing stress. It was accommodated with the studies in this field: effectiveness of coping skills training programs on decreasing psychological signs of mothers who have a child with Down syndrome (23), effectiveness of stress management with cognitive-behavior therapy on decreasing anxiety and depression of parents with mentally retarded children (24), effectiveness of decreasing anxiety treatments (25), effectiveness of primary intervention on improving social supports (26), effectiveness of coping skills training on maternal stress (27), effectiveness of coping skills training and stress management on decreasing anxiety and depression of mothers with disabled child (28).
Results of the current study did not match with the findings of Kaveh et al. (29). They used resiliency program against stress. The study showed that the program was not effective on decreasing stress. They suggested that their inconsistent findings could due to using general questions in the questionnaire (29).
The content of the de-stress training program used in the current study was according to other methods such as cognitive-behavioral (23, 24, 27), and progressive relaxation therapy (23, 27).
Anger management was a factor that focused on stress management. This factor was important in other programs (23). It seems that using cognitive-behavior therapy, relaxation and anger management are very effective in decreasing stress. This study approves the latter findings.
The current study showed that effectiveness of the program was persistent. Other studies presented the same results (30).
5.1. Limitations
One of the limitations was the difficulty to have access to mothers for a long time. Physical conditions such as heat, small room, noise and long distance for mothers was noticeable.
Ethical Issues Ethical issues were as follows: satisfaction of mothers participating in the study, conducting the program on the control group, confidentiality regarding participants name and personal information.
5.2. Conclusions
It can be concluded that the de-stress training program was significantly effective on decreasing maternal stress. It features the necessities of regular and continuous training to mothers. In other hand, empowerment of families with slow paced children should be regarded beside other rehabilitation strategies.
Acknowledgements
References
-
1.
Heward WL. Exceptional children: An introduction to special education. New Jersey: Pearson; 2012.
-
2.
Afrooz GA. Psychological and Rehabilitation of slow pace Children. Tehran: Tehran University Press; 2014.
-
3.
Goffman E. Stigma: Notes on the management of spoiled identity. Simon and Schuster; 2009.
-
4.
Green SE. "We're tired, not sad": benefits and burdens of mothering a child with a disability. Soc Sci Med. 2007;64(1):150-63. [PubMed ID: 17014946]. https://doi.org/10.1016/j.socscimed.2006.08.025.
-
5.
Motamedin M, Sohrabi F, Fathi AE, Maleki S. The comparison of mental health, marriage satisfaction and assertiveness between parents of mental retarded and normal (girl and boy) of primary school's student in west Azerbaijan. J Knowledge Res. 2009;5(36):123-52.
-
6.
Malhotra AK, Sharma AK. A study to assess the disability impact on parents of children with mental retardation in two special schools of Dehli. Indian J Prev Soc Med. 2013;44(1-2):24-7.
-
7.
Gohel M, Mukherjee S, Choudhary SK. Psychosocial impact on the parents of mentally retarded children in Anand District. Healthline. 2011;2(2):62.
-
8.
Reichman NE, Corman H, Noonan K. Impact of child disability on the family. Matern Child Health J. 2008;12(6):679-83. [PubMed ID: 18060488]. https://doi.org/10.1007/s10995-007-0307-z.
-
9.
Lazarus RS, Folkman S. Stress, appraisal, and coping. Springer publishing company; 1984.
-
10.
Asberg KK, Vogel JJ, Bowers CA. Exploring correlates and predictors of stress in parents of children who are deaf: Implications of perceived social support and mode of communication. J Child Fam Stud. 2008;17(4):486-99.
-
11.
Stora JB. Le stress. Tehran: Roushd; 2008.
-
12.
Browne G, Bramston P. Stress and the quality of life in the parents of young people with intellectual disabilities. J Psychiatr Ment Health Nurs. 1998;5(5):415-21. [PubMed ID: 10067490].
-
13.
Singer GH, Ethridge BL, Aldana SI. Primary and secondary effects of parenting and stress management interventions for parents of children with developmental disabilities: a meta-analysis. Ment Retard Dev Disabil Res Rev. 2007;13(4):357-69. [PubMed ID: 17979202]. https://doi.org/10.1002/mrdd.20175.
-
14.
Amiri M, Afrooz A, Malahmadi E, Javadi S, Nour-allahi F, Rezaei-Bidakhavidi A. A study of mental health and parenting stress among parents of mentally disabled children. J Behav Sci. 2011;4(4):261-8.
-
15.
McConkey R, Truesdale-Kennedy M, Chang MY, Jarrah S, Shukri R. The impact on mothers of bringing up a child with intellectual disabilities: a cross-cultural study. Int J Nurs Stud. 2008;45(1):65-74. [PubMed ID: 17022985]. https://doi.org/10.1016/j.ijnurstu.2006.08.007.
-
16.
Osborne LA, Reed P. The relationship between parenting stress and behavior problems of children with autistic spectrum disorders. Except Child. 2009;76(1):54-73.
-
17.
Parish SL, Rose RA, Grinstein-Weiss M, Richman EL, Andrews ME. Material hardship in US families raising children with disabilities. Except Child. 2008;75(1):71-92.
-
18.
Carpenter BN. Personal coping: Theory, research, and application. ABC-CLIO; 1992.
-
19.
Feher-Prout T. Stress and coping in families with deaf children. J Deaf Stud Deaf Educ. 1996;1(3):155-65. [PubMed ID: 15579820].
-
20.
Janbozorgi M, Nouri N. Stress and anxiety psychotherapy. Tehran: Samt; 2010.
-
21.
Hasanzadeh S. Parenting stress in mothers with deaf children. J Psychol Educ. 2012;42(1):51-62.
-
22.
Biemiller A, Meichenbaum D. The consequences of negative scaffolding for students who learn slowly--a commentary on C. Addison Stone's "The metaphor of scaffolding: its utility for the field of learning disabilities". J Learn Disabil. 1998;31(4):365-9. [PubMed ID: 9666612].
-
23.
Pourmohamadreza-Tajrishi M, Azadfallah P, Hemmati Garakani S, Bakhshi E. The effect of problem-focused coping strategy training on psychological symptoms of mothers of children with down syndrome. Iran J Public Health. 2015;44(2):254-62. [PubMed ID: 25905060].
-
24.
Hosseinkhanzadeh AA, Yeganeh T, Rashidi N, Zareimanesh G, Fayeghi N. Effects of Stress Management Training by Using Cognitive-Behavioral Method on Reducing Anxiety and Depression among Parents of Children with Mental Retardation. Soc Mind. 2013;3(1):62.
-
25.
Rohini D. Management of anxiety and QOL in the parents of children with special needs through positive therapy. Int J Multidiscip Res. 2012;2(6):75-91.
-
26.
Raspa M, Bailey DB, Olmsted MG, Nelson R, Robinson N, Simpson ME, et al. Measuring family outcomes in early intervention: Findings from a large-scale assessment. Except Child. 2010;76(4):496-510.
-
27.
Valizadeh S, Davoodifar A, Bardi R, Aalaei Z. The efficacy of coping skills training on stress and hopelessness of mothers with mentally retarded children and normal children. Res Except Child. 2010;10(3):237-44.
-
28.
Singer GH, Irvin LK, Hawkins N. Stress management training for parents of children with severe handicaps. Ment Retard. 1988;26(5):269-77. [PubMed ID: 2973546].
-
29.
Kaveh M, Alizadeh H, Delavar A, Borjali A. Development of a resilience fostering program against stress and its impact on quality of life components in parents of children with mild intellectual disability. Iran J Except Child. 2011;11(2):119-40.
-
30.
Yousofi-Naminy AS, Gobari-Bonab B, Hassanzadeh S, Sokoohi-Yekta M. Development of behavior management program for mothers of deaf children and studing its effectiveness on reduction of mothers stress. J Clin Psychol. 2014;6(3):95-107.