The Effects of Mindful Parenting Training on Parental
Stress and Over-reactivity, in
Families of a Child with ASD.
Anneloes Slaghekke Student Number: 5648122
Master thesis in Research of Child Development and Education Faculty of Social and Behavioural Sciences, University of Amsterdam
End date: 20 august 2018
Supervisor and first reader: Dr. C. Colonnesi Second reader: Drs. A. Ridderinkhof
Abstract
Objectives: Mindful Parenting Training (MPT) aims to improve parenting by increasing awareness of stress and reducing parental reactivity. This study examined the effectiveness of MPT, in families of a child with ASD, on parental stress and over-reactivity. In addition, differences in gender- and parent participation were examined.
Method: Hundred seventeen parents (64 mothers and 53 fathers) of 64 children (age range 8-23 years) diagnosed with an autistic spectrum disorder, participated in the study. After the pretest, the training was conducted, followed by a posttest and a two-month follow-up. For measuring differences in parent participation, parents were distinguished from each other in two groups; one group where both parents of a family participated in MPT and one group where one parent of a family participated.
Results: Positive changes between pre-test, post-test and two-month follow-up were found for parental stress and over-reactivity. A difference in effect was found between mothers and fathers on parental stress. Mothers seems to benefit more from MPT on parental stress. No difference in effect was found for parent participation on parental stress and over-reactivity. Finally, a strong association was found between parental stress and over-reactivity.
Conclusion: Mindful Parenting Training is a promising training for improving parenting, by reducing parental stress and over-reactivity, in families of a child with ASD.
Abstract (Dutch version)
Doel van het onderzoek: Mindful Parenting Training (MPT) is bedoeld om opvoeden te verbeteren door het bewustzijn van ouderlijke stress te vergroten en reactiviteit te verminderen. Deze studie onderzocht de effectiviteit van MPT op ouderlijke stress en over-reactiviteit, in gezinnen met een kind met ASS. Daarnaast werden verschillen in gender- en ouderparticipatie onderzocht.
Methode: Honderd zeventien ouders (64 moeders en 53 vaders), van 64 kinderen (leeftijd 8-23 jaar) gediagnosticeerd met een autistisch spectrum stoornis, namen deel aan het onderzoek. Na de
voormeting werd de training uitgevoerd, gevolgd door een nameting en een follow-up van twee maanden. Voor het meten van verschillen in ouderparticipatie werden ouders in twee groepen van
elkaar onderscheiden; een groep waar beide ouders deelnamen aan MPT en een groep waarvan een van de ouders deelnam aan de training.
Resultaten: Er werden positieve veranderingen gevonden tussen voormeting, nameting en een follow-up na twee maanden, voor ouderlijke stress en over-reactiviteit. Een verschil in effect op ouderlijke stress werd gevonden tussen moeders en vaders. Moeders lijken meer te profiteren van MPT ten opzichte van ouderlijke stress. Er werd geen verschil in effect gevonden voor ouderparticipatie op ouderlijke stress en over-reactiviteit. Tenslotte werd er een sterke associatie gevonden tussen ouderlijke stress en over-reactiviteit.
Conclusie: Mindful Parenting Training is een veelbelovende training voor het verbeteren van opvoeden, door ouderlijke stress en over-reactiviteit te verminderen, in gezinnen met een kind met ASS.
Introduction
Children and adolescents with Autism Spectrum Disorder (ASD) have a developmental disorder that presents with atypical language and social behavior, along with restrictive and repetitive behaviors and unusual interests (American Psychiatric Association, 2013). These children and adolescents also are at increased risk for the development of behavioral and emotional problems (Hastings, 2002), which can be predictors of parental stress (Jones, Hastings, Totsika, Keane, & Rhule, 2014). Parents of children with ASD report greater psychological distress and parenting stress when compared to parents of typically developing children (Hayes & Watson, 2013; Keenan,
Newman, Gray, & Rinehart, 2016). Parent’s psychological distress can be defined as general measured stress related to parent’s own psychological well being, which does not directly pertain to the
relationship with the child (Keenan et al., 2016) Parenting stress, on the other hand, refers to stress directly related to the parenting role. In this study, we use parental stress as a definition of general measured stress related to parents own psychological well being. Under stress, parents become over-reactive to their children (Belsky, 1984). Suzuki et al. (2016) define over-reactivity as follows: “Over-reactivity refers to an authoritarian and harsh parenting style, in other words, one that involves using threats
and harsh punishment”. Over-reactive parenting increases problematic behavior and decreases prosocial behavior in children. Lecavalier, Leone and Wiltz (2006) reported a bi-directional link between parental stress and child behavior problems in children and adolescents with ASD. Parental stress and behavior problems exacerbated each other (Lecavalier et al., 2006).
For parents, to understand the effect of parental reactivity on problematic behavior in children may have benefits for parents’ own psychological health (Beer, Ward, & Moar, 2013). Parents may also benefit from treatment targeting parenting skills (coping with difficult behavior, seeking social support, reframing and understanding the behavior of the child), to enhance their resilience and to decrease stress and depressive feelings (Van Steijn, Oerlemans, Van Aken, Buitelaar, & Rommelse, 2013). There is, therefore, a need for parent-centred interventions to be individually tailored around the unique etiological factors that underlie stress for parents of children with ASD (Keenan et al., 2016).
Mindful Parenting Training (MPT; Bögels & Restifo, 2014) focuses on practices for the specific obstacles and needs of parents of children with ASD. MPT is part of MYmind, a mindfulness-based program for families with parallel sessions for children, mindfulness-based on the Mindful Parenting manual as described in Bögels & Restifo (2014). Mindful Parenting has been defined by Kabat-Zinn and Kabat-Zinn (1997) as: “paying attention to your child and your parenting in a particular way:
intentionally, here and now, and nonjudgementally”. Mindful Parenting Training gives parents tools to stay calm, not to over-react, and to accept themselves and their child as they are (Bögels, Lehtonen, & Restifo, 2010). It is a new application of mindfulness with the aim to improve parenting by increasing the quality of paying unbiased attention to the child, becoming aware of own boundaries, increasing awareness of stress, reducing parental reactivity, to bring (self-)compassion in their parenting and decreasing the intergenerational transmission of dysfunctional parenting (Beer et al., 2013; Bögels & Restifo, 2014). Adaptations for parents of children with ASD were made; they learn to deal with specific stressful parenting situations; develop awareness of automatic reactions toward the child´s behavior and learn to respond calmly, open-minded and accepting toward the autism, and the specific needs of their child (Ridderinkhof, de Bruin, Blom, & Bögels, 2017). Mindfulness techniques teach parents to slow down their reactions and to be aware of their intention to act prior to taking action.
Parents are taught regular meditation practices based on Mindfulness-Based Stress Reduction Kabat-Zinn (1982) and Mindfulness-Based Cognitive Therapy (Segal, Williams, & Teasdale, 2012). For example, they learn to take a breathing space before responding to difficult behavior of their child that may trigger impulsive and emotionally intense reactions.
As is shown by the first study into this program for parents of children with ASD, to take a breathing space before responding to difficult behavior of their child that may trigger impulsive and emotionally intense reactions, might reduce parental reactivity (De Bruin, Blom, Smit, van Steensel, & Bögels, 2014). Parents perceived themselves as less reactive after the Mindful Parenting training. They were better able to observe and describe their thoughts and emotions without getting caught up in them, better able to listen with full attention to their child, less judgmental, and better able to regulate themselves and their child through calmly reacting. Most of these effects lasted into follow-up (De Bruin et al., 2014). Ridderinkhof et al. (2017) found a reduction in parenting stress as well as an improvement on children´s emotional and behavioral problems in ASD. Practicing mindfulness leads to a lower general stress level, as reflected in decreased stress and increased calmness (Ridderinkhof et al., 2017). Through a lower baseline stress level, parents may experience less frequent or less intense outbursts in stress responses to difficult situations. A reduction in parental stress and/or an increase in mindfulness have been shown to indirectly lead to lowered psychopathology of the child (De Bruin et al, 2014; Ridderinkhof et al., 2017). Ridderinkhof et al. (2017) suggest the combination of training parents, and their children in mindfulness may be reinforcing and therefore, most beneficial for these families. Other studies investigated mindfulness-based programs for the parents of children with various mental disorders and found as well a reduction in parent´s self-reported stress and reactivity (Neece, 2014; Hwang, Kearny, Klieve, Lang, & Roberts, 2015; Meppelink et al., 2016). No gender differences, in effect, seems to be measured for MPT (De Bruin et al., 2014; Neece., 2014;
Ridderinkhof et al., 2017).
Mothers of a child with ASD, seems to experience higher levels of stress, and experience a greater caregiving burden when compared with fathers (Tehee, Honan, & Hevey, 2009). Flippin & Crais (2011) suggest that involving fathers in their child’s intervention may relieve some of the pressure mothers experience and in turn may affect positively the entire family system. Therefore, to
engage both parents in MPT may be beneficial to share responsibilities and thereby reduce familial stress that accrues from the challenges of parenting a child with ASD. Several studies reported that both gender parents experienced partner-related stress in families with a child with ASD (Flippin & Crais, 2011). Parents may use mindfulness techniques not only in the relationship with their child, but also with their partner, which may improve the partner relationship (Bogels et al., 2010). Parent involvement in children’s treatment for ASD can improve the child’s social skills and communicative abilities as well as parent functioning, the parent-child relationship and parents own well being (McConachie & Diggle, 2007). Burrell and Borrego (2012) note it is important to consider all ways in which parents of children with ASD can be incorporated into treatment to ensure it is feasible and effective for the family and meets the individual child's needs.
The Present study
Although the results, from previous studies investigating Mindful Parenting Training for parents of a child with ASD, are promising, further research is required to investigate whether these effects can be supported and extended. This study examined the effectiveness of Mindful Parenting Training, in families with a child with ASD, on parental stress and over-reactivity. This study adds to the preliminary findings on mindful parenting training, for parents of a child with ASD. In addition, differences in gender- and parent participation were examined.
The first hypothesis was to find parental stress and over-reactivity to be reduced over time (De Bruin et al., 2014; Ridderinkhof et al., 2017). Secondly, it was expected to find greater effect on parental stress in mothers, since previous research showed mothers experience higher levels of stress compared to fathers and might benefit more from MPT (Tehee et al., 2009). The third hypothesis was to find greater effect on parental stress and over-reactivity, when both parents participated in MPT. As it is shown that parent participation in children’s treatment for ASD, can improve parent functioning, the parent-child relationship, the partner-relationship and parents own wellbeing (McConachie & Diggle, 2007; Bogels et al., 2010; Flippin & Crais, 2011). Parents, will be distinguished from each other in two groups; one group where both parents in a family participated in MPT and one group
where one parent in a family participated in MPT. The last hypothesis was to find an association between parental stress and over-reactivity (Belsky, 1984).
Method Participants
Hundred-seventeen parents (Mage = 47.36; SD=5.38; 64 mothers and 53 fathers), of 64 children (age range 8-23 years; Mage = 13.55; SD=3.09) diagnosed with an autistic spectrum disorder according to the Diagnostic and Statistical Manual of Mental Disorders (DSM IV; American
Psychiatric Association, 2013), participate in the present study. Within this group of parents, several parents filled in the questionnaires but did not participate in the training, or vice versa. In addition, some parents only completed one of the two questionnaires, partly because it was too time-consuming to fill in all questionnaires and partly because participants who perceived less benefits from the training were less willing to participate in the study. Inclusion criterion of this study is that all
children, and one or both parents had attend the mindfulness- based program for a minimum of at least 5 out of nine sessions (see Table 1 for more detailed information). Exclusion criterion was inadequate mastery of the Dutch language.
Table 1. Characteristics of participating families
Children (n = 64) Mothers (n = 64) Fathers (n = 53)
Age (M and SD) 13.55 (3.09) 46.50 (5.37) 48.38 (5.26) Male 49 (77%) ASD Diagnosis Classic autism 13 (20%) Asperger syndrome 18 (28%) PDD-NOS 33 (52%) Comorbid diagnosis ADHD 13 (20%) Internalizing disordera 6 (9%) ADOS classification Autism 17 (27%)
Autism spectrum disorder 27 (42%) One-point beneath cut-off 4 (6%) No ASD classification 4 (6%) Medication use 15 (23%) Additional psychotherapyb 1 (2%) 3 (5%) 2 (4%) Parent counseling Family therapy 1 (2%) 1 (2%) 1 (2%) CBT
Combination of therapies Education type Regular education 60 (94%) Special education 4 (6%) Educational level Primary education 23 (36%) Secondary education 32 (50%) 9 (14%) 7 (13%) Vocational training 1 (2%) 4 (8%) Higher education 3 (5%) 26 (41%) 15 (28%) University 1 (2%) 17 (27%) 19 (36%) Family situation Married/living together 43 (67%) Divorced/separated with co-parenting 17 (27%) Living with mother 2 (3%) Working situation
Full time 19 (29%) 31 (58%)
Part time 26 (41%) 6 (11%)
Not workingc 6 (9%) 6 (11%)
SD standard deviation, ASD autism spectrum disorder, PDD-NOS pervasive developmental disorder- not otherwise specified, ADHD attention deficit/hyperactivity disorder, CBT cognitive behavior therapy a Internalizing disorders included depressive disorder, dysthymic disorder, obsessive compulsive
disorder, panic disorder, general anxiety disorder, anxiety disorder-not otherwise specified b Received psychotherapy between the start of the intervention and the booster session
c Not working category includes housewife, long-term ill, and unemployed Procedure
Families were referred to mental health care clinic UvA minds (Amsterdam, The Netherlands) because of their child’s psychopathology and their own perceived stress. In consultation with the psychiatrist of the treatment centre, parents were given the opportunity to participate in the MYmind program, and they were invited to participate in the study. Written informed consent was given for the parents and to the children aged 12 years and older. This study is part of the project of Ridderinkhof et al. (2017). The study was conducted in the Academic Treatment Centre for parents and Children, which is a centre where children with diagnosed or nor yet diagnosed psychopathology and learning disorders are treated according to the latest scientific standards (evidence-based). The Medical Ethics Committee of the Academic Medical Centre (AMC) in Amsterdam approved the study
(NL43720.018.13). A repeated measures study design was used with five measurement occasions: waitlist (two months before the training started), one-week pre-intervention, directly post intervention, 2-month follow-up, and 1-year follow-up. Parents were asked to fill out questionnaires at all
measurement occasions. However, since not enough families completed the questionnaires at waitlist and 1-year follow-up, I did not include these measurement occasions in the current study.
The children and one or both parents took part in MYmind, a mindfulness-based program for families of a child with ASD. MYmind contains nine weekly parallel sessions, lasting 1.5 h.,
separately for children and their parents. This is followed by an additional booster session nine weeks after the final session, to encourage continuing with practices.
All trainers were child and family mental health care professionals with experience in ASD and had completed an 8-day-long advanced teacher training of MYmind for youth with ASD and their parents. Besides that, all trainers completed a mindfulness training for themselves, at least one 4-day meditation retreat, and a year’s experience with their own mindfulness practice.
Child Program
All children in the MYmind child program were learned to enhance and direct their attention, increase their awareness of bodily sensations, feelings, and thoughts, as well as to increase their self-control (Ridderinkhof et al., 2017). They practiced mindfulness exercises, which includes breathing meditation, the body scan, the 3-minutes breathing space and yoga practices, based on Mindfulness-Based Stress Reduction Kabat-Zinn (1982) and Mindfulness-Mindfulness-Based Cognitive Therapy (Segal et al., 2012). They learned to apply mindfulness in specific situations, which are stressful for children with ASD (Ridderinkhof et al., 2017). For example, situations like, dealing with unexpected changes, disturbing sounds and repetitive thoughts.
Parent program
Mindful Parenting, based on the Mindful Parenting manual as described in Bögels and Restifo (2014) focuses on practices for the specific obstacles and needs of parents of children with ASD. Mindful Parenting Training gives parents tools to stay calm, not to overreact, and to accept themselves and their child as they are (Bögels et al., 2010). It is a new application of mindfulness with the aim to improve parenting by increasing the quality of paying unbiased attention to the child, becoming aware of own boundaries, increasing awareness of stress, reducing parental reactivity, to bring (self-)
compassion in their parenting and decreasing the intergenerational transmission of dysfunctional parenting (Beer et al., 2013; Bögels & Restifo, 2014). Adaptations for parents of children with ASD were made; they learn to deal with specific stressful parenting situations; develop awareness of automatic reactions toward the child´s behavior and learn to respond calmly, open-minded and
accepting toward the autism and the specific needs of their child (Ridderinkhof et al. 2017). Through home-practices, parents apply mindfulness practices to daily situations.
Measures
Over-reactivity of parents
Parents filled in the Parenting Scale at pre-test, post-test and follow-up, for measuring over-reactivity of parents (PS; Arnold et al., 1993). The Parenting Scale is a 7-point Likert-scale 30-item questionnaire consists of the subscales Laxness, Over-reactivity, and Verbosity. For this study, we used the subscale Over-reactivity, which includes 10 items. An example question is, ‘When I am upset or under stress, I am picky and on my child’s back’. Intern reliability for this scale was found to be satisfactory with a Cronbach’s α of .81 for mothers and .78 for fathers.
Stress of parents
Stress of parents was measured using the Perceived Stress Scale (PSS; Cohen, Kamarck & Mermelstein, 1983), a 10 item questionnaire that uses a 5-point Likert type scale to assess how overwhelming and uncontrollable participants perceived their lives to be over the last month. Items were designed to tap how unpredictable, uncontrollable, and overloaded respondents find their lives. The scale also includes a number of direct queries about current levels of experienced stress. An example of question is, “In the last month, how often have you been upset because of something that happened unexpectedly?”. Intern reliability for this questionnaire was found to be satisfactory α = .88 for mothers and α = .87 for fathers.
Data Analyses
Data were normally distributed. There was no violation of skewness and kurtosis. A Shapiro-Wilk’s test (p > .050) and a visual inspection of histograms, normal Q-Q plots and box plots showed that all data were approximately normally distributed for parental stress and over-reactivity. According to the Little’s MCAR test, data were missing at random. Missing data values (27.9% for
over-reactivity and 32.4% for stress) were replaced using an Expectation Maximization (EM) algorithm (Dempster, Laird, & Rubin, 1977).The effects of MPT on parental stress and over-reactivity were
examined by one-way repeated-measures ANOVA. Dependent variables were the outcome’s parental stress and over-reactivity, while time (pre-, post- and follow-up measurement) was entered as a predictor. Parents who participated in the training and filled in one of the two questionnaires were added as participants for this first analyses (n = 86 for over-reactivity; 50 mothers and 36 fathers; n = 71 for stress; 42 mothers and 29 fathers ). The effect sizes for the ANOVAs were presented in terms of partial eta squared (ηp 2: .01 = small, .06 = medium, .14 = large). In addition, Two Way repeated
measures ANOVAs were used to examine differences in gender- and parent participation as between factors. Parents were distinguished from each other in two groups for measuring parent participation; one group in which both parents participated in MPT, and both filled in a questionnaire (n =22 couples for over-reactivity; n = 17 couples for stress); and one group in which only one parent participated in the training (n = 29 for over-reactivity, 15 mothers and 14 fathers; n = 25 for stress, 12 mothers and 13 fathers), and both parents filled in a questionnaire. Mean scores were measured for each couple.
Finally, difference scores between pre-test, post-test and follow-up of all parents who filled in both questionnaires (n = 96, 54 mothers and 42 fathers), no matter if they participated in the training, were calculated for parental stress and over-reactivity. Pearson’s correlation coefficients were calculated between the difference scores of stress and over-reactivity in order to see whether changes in these two aspects were associated.
Results Preliminary Analyses
Table 3 and 4 presents the descriptive statistics (means, standard deviations and range) for both variable’s stress and over-reactivity of parents.
Table 3. Results of mothers and fathers on Stress and Over-reactivity: Descriptives (Means, Standard deviations and Range)
Pre-measurement Post-measurement Follow-up
M (SD) Range M (SD) Range M (SD) Range
Stress
Mothers 1.51 (0.54) 2.14 1.32 (0.50) 2.07 1.18 (0.48) 2.29
Both parents 1.48 (0.54) 2.43 1.35 (0.51) 2.21 1.27 (0.50) 2.29 Over-reactivity Mothers 3.86 (1.01) 5.20 3.30 (1.05) 4.60 3.17 (1.10) 5.20 Fathers Both parents 3.90 3.86 (0.95) (0.98) 5.20 5.40 3.51 3.36 (0.90) (0.99) 3.40 4.60 2.99 3.29 (0.98) (1.04) 4.20 5.20
Table 4. Results of parent participation on Stress and Over-reactivity: Descriptives (Means, Standard deviations and Range)
Pre-measurement Post-measurement Follow-up
M (SD) Range M (SD) Range M (SD) Range
Stress One parent 1.38 (0.43) 1.64 1.32 (0.44) 1.93 1.26 (0.33) 1.20 Both parents 1.55 (0.39) 1.32 1.44 (0.36) 1.36 1.31 (0.26) 0.93 Over-reactivity One parent 3.55 (0.64) 2.90 3.06 (0.57) 2.38 3.01 (0.55) 2.50 Both parents 3.05 (0.73) 2.50 3.36 (0.70) 2.90 3.31 (0.67) 2.80 Stress
The results of the repeated-measures ANOVA showed a significant effect of Time on parental stress, F(2, 140) = 7.9, p = .001, ηp 2=.10. Bonferroni post hoc tests showed that parents reported a
significanty lower level of stress at post-test (M = 1.35; SD = 0.51) compared to pre-test (M = 1.48; SD = 0.54) and again parents reported significantly lower stress at two-month follow-up (M = 1.27; SD = 0.50) compared to post-test. This result supports the hypothesis that Mindful Parenting training has an effect on stress of parents with a child with ASD. Specifically, it suggest that MPT reduces stress of parents with a child with ASD.
The results of the ANOVA also showed that no significant effect of gender on parental stress was found, F(1, 69) = 0.48, p = .492, ηp 2 = .01. In addition, a significant interaction effect was found
for gender and time on stress, F(2,138) = 3.19, p = .044, ηp 2 = .04. Mothers reported significantly
lower levels of parental stress (M = 1.17; SD = 0.48) than fathers at two-month follow-up (M = 1.39;
SD = 0.51). This evidence supports the hypothesis to find greater effect of MPT on parental stress in mothers, since previous research showed mothers experience higher levels of stress compared to fathers and might benefit more from MPT (Tehee et al., 2009). No significant effect of parent
participation on parental stress was found, F(1, 40) = 1.17, p = .286, ηp 2 = .028 and no significant
interaction effect was found for parent participation and time on parental stress, F(2,80) = 0.57, p
=.570, ηp 2 = .01. This evidence does not supports the hypothesis to find greater effect of MPT on
parental stress when both parents participated in MPT. These findings suggest that it makes no difference if one or both parents participate.
Over-reactivity
The results of repeated-measures ANOVA showed a significant effect of Time on over-reactivity of parents, F(2,170) = 26.9, p < .001, ηp 2 = .24. Bonferroni post hoc tests showed that
parents reported a significantly lower over-reactivity at the post-test (M = 3.36 ; SD = 0.99) compared to pre-test (M = 3.86 ; SD = 0.98) and again parents reported a significantly lower over-reactivity at two-month follow-up (M = 3.29 ; SD = 1.04) compared to post-test. This evidence supports the hypothesis that Mindful Parenting training has an effect on over-reactivity of parents with a child with ASD. Specifically, these findings suggest that MPT reduces over-reactivity of parents with a child with ASD.
In addition, the results of the ANOVA showed that there was found no significant effect for gender on parental over-reactivity, F(1, 84) = 0.6, p = .443, ηp 2 = .01 and there was no significant
interaction effect for gender and time on over-reactivity, F(2,168) = 1.5, p = .215, ηp 2 = .02. It also
showed that no significant effect was found for parent participation on over-reactivity, F(1, 49) = 3.8,
p = .056, ηp 2 = .07 and no significant interaction effect was found for parent participation and time on
over-reactivity, F(2.98) = 0.0, p =.991, ηp 2 = .00. This evidence does not supports the hypothesis to
find larger improvements on over-reactivity when both parents participated in the Training. These findings suggest that it makes no difference if one or both parents participate.
Predictors associated with effects over Time
Difference scores between pre-test, post-test and follow-up, of all parents who participated in the MPT, and filled in one of the two questionnaires, were calculated for parental stress and
over-reactivity. Mean difference scores were calculated and used to see whether changes in parental stress and over-reactivity were associated to parent´s- or children´s age, attendance rate, educational level, additional therapy and home situation. Pearson’s correlation coefficients were calculated between the mean difference scores of stress and over-reactivity, in order to see whether changes were associated to the variables as mentioned above. Effects of these variables are only described when correlated. Educational level of parents
A negative correlation between parental stress over time and educational level of parents was found r (71) = -.25, p = .034. This evidence indicates that lower educational levels of parents were associated with greater stress reduction, and vice versa. Specifically, this might indicate that MPT has greater effect on parental stress of parents with a lower educational level than on parents with a higher level of education.
Children’s age
A negative correlation between parental stress over time and the age of the children was found
r (71) = -.25, p = .035. This evidence indicates that parents of younger children were associated with greater reduction of parental stress, and vice versa. Specifically, this might indicate that MPT training has a greater effect on parental stress among parents of younger children with ASD, than on parents of older children with ASD.
Association between Stress and Over-reactivity
A strong correlation between parental stress and over-reactivity was found at post-test r (96) = .35, p < .001 and follow-up r (96) = .22, p = .031. This evidence supports the hypothesis about an association between stress and over-reactivity. Reduction in stress correlated positively with a reduction in over-reactivity.
Discussion
Mindful Parenting Training, part of MYmind, is a new application of mindfulness with the aim to improve parenting, with adaptations made for parents of children with ASD, and their specific needs. The present study, evaluated whether parental stress and over-reactivity change after the
Mindful Parenting Training; if differences in gender- and parent participation were found, and if there was an association between parental stress and over-reactivity. The study was carried out in a sample of 117 parents of 64 children aged 8-23, diagnosed with an autistic spectrum disorder. Significant differences were found between pre-test, post-test and 2-month follow-up. In particular, parents reported lower stress and lower over-reactivity at post-test compared to pre-test and again at 2-month follow-up compared to post-test. A difference in effect was found between mothers and fathers on parental stress. Mothers seems to benefit more from MPT on parental stress. No significant differences were found for gender and parent involvement into these effects.
The first aim of this study was to examine whether parental stress and over-reactivity had changed after the Mindful Parenting Training, as reported by parents themselves. Parental stress and over-reactivity both reduced. If the positive change in parental stress and over-reactivity can be attributed to the Mindful Parenting Training, this result is in line with earlier results from previous studies who found as well a decrease in parent´s self-reported stress en over-reactivity (Neece, 2014; Hwang et al., 2015; Meppelink et al., 2016; Ridderinkhof et al., 2017). A possible interpretation for the reduction in parental stress and over-reactivity is that parents in MPT are given awareness of stress, tools to respond calmly, not to overreact, and to accept themselves and their child as they are (Bögels et al, 2010).
The second aim of this study was to examine gender differences in the effects of MPT on parental stress and over-reactivity. A significant interaction effect was found for gender and time on stress. Mothers reported higher levels of parental stress at pre-test and significant lower levels of parental stress at two-month follow-up, compared to fathers. This is in line with previous research (Tehee et al., 2009) and indicates that MPT has a greater effect on parental stress in mothers.
The third aim of this study was to examine differences in parent participation in the effect of MPT on parental stress and over-reactivity. No differences were observed between the parents. These findings suggest that it makes no difference if one or both parents participate. This result is not in line with previous literature and earlier mentioned expectations. Research suggests that involving fathers in their child’s intervention may relieve some of the pressure mothers experience, and in turn may affect positively the entire family system (McConachie & Diggle, 2007; Flippin & Crais, 2011). Expected
was to find greater effect on parental stress and over-reactivity in couples when both parents participated in MPT. This discrepancy can be explained by the fact that some parents, in couples where one parent participated in the training, were fathers. Besides that, the parent who participated in the training might have experienced higher levels of stress and over-reactivity and therefore, selected themselves for the training. Finally, the sample size for this analyzes was rather small, so results should be interpreted and generalized with caution.
Association was found between parental stress and over-reactivity over time. Reduction in stress was accompanied by a reduction in over-reactivity. Which is theoretically supported by Belsky (1984), as stress was found to cause over-reactivity in parents. This is in line with several studies, who found association between parental stress and reactivity (Neece, 2014; Hwang et al., 2015; Meppelink et al., 2016; Ridderinkhof et al., 2017).
Mindful parenting is a relative new application of mindfulness that seems to be effective on for parents with children with ASD, by reducing parental stress and over-reactivity. An important aspect of the present study is the difference between mothers and fathers on parental stress. Mothers seems to benefit more from MPT, on parental stress.
Clinical implications
The issues discussed in this study can be presented in clinical settings who work with mindfulness-based programs for children with ASD. Parent participation in a mindfulness-based program for families of a child with ASD, might reduce parental stress and over-reactivity and therefore, might improve children´s emotional and behavioral problems in ASD (Suzuki et al., 2016; Ridderinkhof, 2017). As is shown in this study, and in previous studies, mothers experience higher levels of stress, in families with a child with ASD (Tehee et al., 2009) and might benefit more from MPT. However, it is suggested to involve fathers in MPT as well. First of all, to reduce parental stress in themselves, but also in mothers, to share responsibilities and thereby reduce familial stress that accrues from the challenges of parenting a child with ASD (Tehee et al., 2009; Flippin & Crais, 2011). Parent participation in a mindfulness based program for children with ASD might improve the child’s social skills and communicative abilities, as well as parent functioning, the parent-child relationship
and parents own well being (McConachie & Diggle, 2007; Ridderinkhof et al., 2017). Important to note is that should be considered all ways in which parents of children with ASD can be incorporated into treatment, to ensure it is feasible and effective for the family and meets the individual child's needs (Burrell & Borrego, 2012).
Limitations
This study has some limitations. First of all, outcomes on parental stress and over-reactivity are based on parent report. Objective outcomes, such as physiological markers of stress were not measured. Second, this study did not include a control group. Results does not warrant the conclusion that the MPT is responsible for the positive changes on parental stress and over-reactivity. There are other possible factors that may have played a role in the reduction of parental stress and over-reactivity, such as family improvement, partly as a result of the MYmind family program. However, differences in effect for parent participation were measured between parent couples. Despite that, the sample size for this analyse was too small. Therefore, outcomes need to be interpreted carefully. Thirdly, missing data could influence the results. Not all participants completed both questionnaires at all measurement occasions, partly because it was too time-consuming to fill in all questionnaires, and partly because participants who perceived less benefits from the training were less willing to
participate in the study. Missing data values (28.7% for reactivity and 35.1% for stress) were replaced using Expectation Maximization (EM) algorithm. Due to aforementioned limitations, results should be interpreted and generalized with caution.
Conclusion
This study is the first study, to the best of my knowledge, which has explored gender- and parent participation differences, in the effect of Mindful Parenting Training on parental stress and over-reactivity, in families with a child with ASD. Despite the limitations, this study is in line with previous research that also found a reduction in parent´s self-reported stress and over-reactivity. In addition, it showed a greater effect of MPT on parental stress in mothers. This study offers an idea for
future research, to explore gender- and parent participation differences in the effects of MPT, for families with a child with ASD.
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