Being a parent or a caregiver of a child with autism can present great challenges, often affecting the parent or caregiver’s psychological and physical well-being, especially their stress and depressive symptoms (Lunskey, 2017). Parents report feelings of despair, sadness, anger, denial, and self-blame upon receiving their child’s autism diagnosis (Da Paz et al., 2018). This can cause the parent or caregiver stress as their child is engaging in behaviors that are challenging to deal with despite the child receiving Applied Behavior Analysis (ABA). Although parents and caregivers receive parent education from their child’s ABA services to learn how to manage their autistic child’s behaviors, other mindfulness interventions have been designed to focus on reducing parental and caregiver stress and anxiety. One of those interventions is Acceptance and Commitment Therapy (ACT) (Hayes, 2011). ACT has been shown to reduce depression symptoms and develop psychological flexibility, which helps accept negative self-thoughts as they happen and change those thoughts to reflect accurate representations of oneself.
Figure 1: The Six Components of ACT
What is Acceptance and Commitment Therapy (ACT)?
Developed by Steven C. Hayes, ACT is a form of evidence-based psychotherapy that works to develop psychological flexibility by using mindfulness and engaging in positive behaviors when experiencing challenging thoughts, sensations, and feelings (Hayes, 2011). ACT can be used to help parents and caregivers with an autistic child reduce their stress and anxiety by emphasizing the acceptance of negative emotions, using cognitive defusion from those negative thoughts, identifying the parent or caregiver’s values and goals, and enhancing the effectiveness in moving toward those values and goals (Blackledge et al., 2006). See Figure 1 for more information on the different components of ACT.
Benefits of Using ACT
Studies have found a reduction in depressive symptoms in participants of ACT. One research study evaluated the effectiveness of ACT intervention on the parents of children and adolescents with autism (Poddar et al., 2015). The results indicated there was a statistically significant decrease in the depressive symptoms the mothers were experiencing before the ACT intervention began.
Increasing psychological flexibility can help with pursuing values and goals by not being influenced or controlled by negative thoughts. For instance, a distressed parent with low psychological flexibility may avoid going out into society and attending social events, thinking that their child may “act out” or have behaviors that can potentially be embarrassing (Hahs et al., 2019). A study was conducted by Hahs et al. in 2018, where 18 parents with autistic children attended a brief 4-hour ACT session that focused on psychological flexibility. The results of the study showed that the ACT session increased the parent’s psychological flexibility and significantly reduced depressive symptoms, thought suppression, and shame while also demonstrating an increased level of acceptance towards their child’s autism diagnosis and mindfulness practice.
One of the core values of ACT is being committed to action of the identified value that the person is wanting to pursue (Hayes, 2011). Value-directed behavior is defined as a person engaging in overt behavior that aligns with the value they have defined during ACT (Gould et al., 2018). A study was conducted to examine the effects of ACT on the value-directed behavior that parents identified. For instance, one of the values the mother wanted to focus on was having quality and joyful time with their family. During the study, three mothers with autistic children went to six ACT sessions. The results of the study demonstrated that ACT could increase overt behavior in mothers with autistic children as the mothers engaged in behaviors that aligned with their values (Gould et al., 2018).
Using ACT in a clinical setting, such as during parent education, can help the parents reduce the stress and anxiety they face from the challenges of having an autistic child. ACT can teach them how they have control over their thoughts and increase their self-awareness when their child is experiencing behaviors.
This study examined the effects of reducing depression and stress and developing value-directed behaviors using ACT with a mother who has an autistic son. The research questions guiding this study were:
- What is the effectiveness of using Acceptance and Commitment Therapy (ACT) in reducing depression and stress for a mother with an autistic son?
- What is the effectiveness of using Acceptance and Commitment Therapy (ACT) in increasing value-directed behaviors for a mother with an autistic son?
Methods
Research Design
This study used a single-subject, multiple-baseline design across behaviors. Baseline and intervention data on the goals were taken on a platform called Central Reach.
Participant
A woman who is 38 years old participated in the study. She is Filipino and a mother of 4 children, including one child who has autism and is 5 years old. The autistic child has behaviors that include non-compliance with demands, tantrums, physical aggression towards other individuals, and throwing objects. The sessions took place in the family’s home.
Measures
The Central Reach data collection system was used in this study. This system included the goals that the mother and researcher agreed to work on during the intervention. Data was taken on the percent independence of the mother correctly responding.
Two questionnaires were administered before and after the intervention. The Acceptance and Action Questionnaire-version 2 (AAQ-2) (Bond et al., 2011) is a 7-question questionnaire that is scored using a Likert scale and designed to measure psychological flexibility. Lower scores indicate higher levels of psychological flexibility. The Depression Anxiety Stress Scale (DASS-21) (Lovibond et al., 1995) measures the severity of depression, anxiety, and stress symptoms. It consists of 21 statements and uses a 4-point Likert scale. Lower scores indicate lower levels of depression, anxiety, and depressive symptoms.
Procedures
To recruit participants, mothers from the agency where the author works were asked if they were interested in participating in the study. Before conducting the intervention, an online training by Dr. Katie Saint called Introduction to Acceptance and Commitment Therapy (ACT) for Behavior was completed by the first author.
This study lasted four weeks, with three sessions a week lasting one hour. The first session consisted of the participant completing the questionnaires and identifying goals and values she wanted to work on. Values that were targeted for the participant were increasing community outings and decreasing her child’s challenging behavior by using antecedent strategies. The goals that were worked on during the intervention include the participant using first/then statements, working on the child’s safety skills, including “stop” and “come here,” and using differential reinforcement of other behavior (DRO) to decrease maladaptive behaviors displayed by her child. One of the sessions per week consisted of learning about strategies that the participant can use when her child is engaging in maladaptive behaviors, and the other two sessions were direct observations of the participant implementing the strategies that she learned.
Results
Figure 2 depicts the participant’s engagement in the value-based behaviors, which include the frequency of the participant using DRO (top graph), the participant using first/then statements (middle graph), and the participant practicing safety skills with her child (bottom graph). There are increasing trends with low variability in the data for all goals. Furthermore, Table 1 below displays the participant’s pre and post-test results from the questionnaires that were administered. The results from the questionnaire show the participant decreased her depression, anxiety, and stress symptoms and increased her psychological flexibility.
Figure 2: Participant’s Progress on Goals
Discussion
The results of the current study show that within four weeks of the participant receiving ACT intervention, depression, stress, and anxiety symptoms decreased while psychological flexibility increased. ACT also increased the participant’s value-directed behaviors. This study builds upon the knowledge that ACT can reduce depression, stress, and anxiety in mothers with autistic children. However, very few studies have examined the effects of using ACT with increasing value-directed behaviors of mothers with autistic children. This current study does present some limitations. First, there were inconsistencies with sessions being held due to canceled sessions. Additionally, the child’s ABA services were reduced. This caused the child to engage in novel, challenging behaviors, including hitting his younger sister. During this time, the participant reported feelings of frustration, anxiety, and stress due to the significant decrease in her son’s ABA session hours and the occurrence of novel challenging behavior.
Clinical implications of the study include using ACT intervention instead of using a traditional parent education model for parent education, although further research should be conducted on evaluating the effectiveness of using ACT in replacement of using a parent education model. Instead of using a traditional parent education where parents learn about the components of ABA, strategies to reduce behavior, and implementing ABA procedures (e.g., using extinction), Board Certified Behavior Analysts should use ACT to identify goals that they want to work on that align with their values. In this way, the parents have autonomy during parent education.
With the stress and anxiety that mothers with autistic children face, ACT is helpful in reducing these symptoms and addressing the mother’s goals they want to work to increase value-directed behaviors and their psychological well-being.
Emily Shearon, MA, is an Associate Clinical Supervisor at Community Autism Services. Melina Melgarejo, PhD, is an Assistant Professor at San Diego State University. For more information, please contact eshearon23@gmail.com.
References
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