The Relationship Between Mindfulness and Psychological Distress in Children with Autism Spectrum Disorder and their Parents: A Systematic Review
Tirza Smits, 10539433 University of Amsterdam
Januari, 2016 Word count: 5638
Bachelor thesis
Table of Contents
Abstract ... 3
Introduction ... 4
Mindfulness for autistic children ... 4
Mindfulness for parents of autistic children ... 6
Present study ... 7
Method ... 9
Selection of studies ... 9
Coding ... 9
Results ... 10
Children’s psychological distress ... 10
Children’s depression. ... 10
Children’s anxiety. ... 11
Children’s stress. ... 12
Children’s externalizing problems. ... 12
Parents’ psychological distress ... 13
Parents’ depression. ... 13 Parents’ anxiety. ... 14 Parent’s stress. ... 15 Discussion ... 16 Limitations ... 17 Further research ... 19 Practical implications ... 20 References ... 21 Table 1 ... 28
Abstract
Children with autism spectrum disorder (ASD) and their parents suffer from more
psychological distress such as depression, anxiety, stress and externalizing problems than families with typically developing children. Recently, mindfulness-based interventions (MBIs) have been found effective for decreasing psychological distress in a normal
population. However, the effect of MBIs on children with autism and their parents has never been systematically studied. The aim of the present paper was to systematically study the relationship between mindfulness and psychological distress in children with ASD and their parents. A multiple field search was conducted in the databases Web Of Science, ERIC and PsycInfo to find empirical studies published after 2005. Results showed insufficient proof for the effect of MBI’s on children’s depression, anxiety and stress. However, children’s
externalizing problems were effectively decreased by MBI’s. For parents, a relationship was found between mindful behaviour and depression, anxiety and stress. These could effectively be decreased by MBI’s. Concluding, evidence for parents is more solid than for children. For practical means, interventions should be given to parents so their psychological distress can be decreased, as children’s distress can possibly decrease from this too. Moreover, follow-up trainings are needed for parents and children for the maintenance of mindfulness.
The Relationship Between Mindfulness and Psychological Distress in Children with Autism Spectrum Disorder and their Parents:
A Systematic Review
Children with Autism Spectrum Disorder (ASD) overall report a lower quality of life than typically developing children (Moyal, Lord & Walkup, 2014). According to the DSM-5, ASD is a pervasive developmental disorder. People who suffer from this disorder have difficulties with social and communicative skills and show restricted repetitive behaviour (McPartland, Reichow, & Volkmar, 2012). Due to these difficulties, children with ASD find it hard to adjust in daily life situations. For example, difficulties in social and communicative skills make it hard for autistic children to make new friends and it increases chances of being bullied (Rowley et al., 2012). These daily life struggles can lead to psychological distress such as depression, anxiety and stress (Bitsika, Sharpley & Bell, 2013; De Gier & Child, 2015). Not only internalizing problems but also externalizing problems such as aggression occur due to the frustrations caused by the difficult situations that autistic children face (Kanne &
Mazurek, 2011). Thus, parents of children with ASD report more externalizing problem behaviour by their children (Kanne & Mazurek, 2011, Lecavalier, Leone & Wiltz, 2006). These internalizing and externalizing problems lead to a lower quality of life reported by children with ASD than by typically developing children.
Mindfulness for autistic children
Recently, mindfulness has been proven effective for reducing psychological distress in a wide population of people with developmental disorders, by learning people to cope with stressors of daily life (Hwang & Kearney, 2013). As ASD is a developmental disorder, it is conceivable that mindfulness could be effective in decreasing the psychological distress of children with ASD. Mindfulness is described as a combination of two components. The first component is attention and awareness, described as: “self-regulation of attention so that it is
maintained on immediate experience, thereby allowing for increased recognition of mental events in the present moment” (Bishop, Lau, Shapiro, Carlson, & Anderson, 2004, p.32). The second component is is acceptance, which is described as: “adopting a particular orientation toward one’s experience that is characterized by curiosity, openness, and acceptance” (Bishop et al., 2004, p.32). Integrating this attention, awareness and acceptance in daily life situation is called mindful behaviour (Thompson & Gauntlett-Gilbert, 2008). Mindful behaviour can help people by coping with stressors through experiencing the present openly and without judgement (Kabat-Zinn, 2003).
There is a growing interest in Mindfulness-based interventions (MBIs) for clinical application. Mindfulness-based interventions are called third wave treatments, following behavioural and cognitive therapy (Hayes, 2004). Most interventions are called Mindfulness-Based Therapy (MBT). Two main types of MBT exist: Mindfulness-Mindfulness-Based Cognitive Therapy (MBCT) and Mindfulness-Based Stress Reduction (MBSR). While the goal of MBSR is to improve mental health, the goal of MBCT is to prevent relapse of depression. Also, MBCT adds a cognitive element to the therapy, for example trying to recognise different kinds of thoughts (Hofmann, Sawyer, Witt & Oh, 2010). However, the aim of MBCT is not to change these thoughts, but to be aware of them and accept them without judgement (Sipe &
Eisendrath, 2012). Another type of MBI is Acceptance and Commitment Therapy (ACT) which focusses on accepting thoughts and feelings instead of avoiding them (Hofmann & Asmundson, 2008). Meditation, the practice of consciously being aware of the body and surroundings, is a key element in all MBIs (Dimidjian and Segal, 2015).
Mindful behaviour may be related to lower psychological distress of children with ASD because it is compatible with the core of the disorder. The core of ASD stays the same from childhood to adulthood because it is a developmental disorder (McPartland et al., 2012). Problems that exist are difficulties with communication, interaction and empathy (Lord et al.,
2000). Research has shown that mindfulness can improve these difficulties by teaching children to be aware of others and to improve their empathic ability (Kingsbury, 2009). Secondly, children and adolescents with ASD have information processing difficulties (Rudie et al., 2011). Mindfulness can improve information processing efficiency, so it can help distressed individuals with interpreting situations more positively (Roberts-Wolfe et al., 2012). Because of the possible effects of mindfulness on the core of ASD as well as on information processing, expectations are that mindfulness can effectively decrease children’s psychological distress.
Furthermore, MBIs can possibly influence children’s distress indirectly through parents. The meta-analysis of Whittingham (2014) focussed on the effects of mindfulness interventions for parents of children with disabilities such as developmental disorders and attention deficit hyperactivity disorders. Results found that parental MBIs could influence the psychological distress of their disabled children. Overall, as ASD is a developmental
disorder, not only a direct effect of children’s intervention on children’s psychological health is expected, but also an indirect effect of parental intervention on children’s psychological health.
Mindfulness for parents of autistic children
Not only children with ASD, but also their parents report a lower quality of life. Coping with the problems of their children and their challenging behaviours can lead to psychological problems of their own. As a result, parents who raise a child with ASD report more
psychological distress, including depression, anxiety and stress (Benson, 2006; Bitsika, et al., 2013). When their children grow older and become adolescents, parents’ anxiety and stress decrease. However, anxiety and stress are still higher when compared to parents of typically developing children (Pozo & Sarriá, 2015). Just as for children, depression, anxiety, stress are the main kinds of psychological distress from which parents of children with ASD suffer (Giallo, Wood, Jellett & Porter, 2013). Overall, not only children with ASD but also their
parents suffer from more psychological distress than parents in families of typically developing children.
By learning how to cope with the difficulties that come with being a parent of an autistic child, mindfulness could be effective in improving the lives of these parents. Parents of children with ASD suffer mostly from depression, anxiety and stress (Giallo, Wood, Jellett & Porter, 2013). As mindfulness in general is effective for reducing depression, anxiety and stress, it is likely that parents can positively benefit from MBIs (Grossman, Niemann, Schmidt, & Walach, 2004; Hofmann, et al., 2010). Furthermore, by mindfulness-training parents can learn to accept the shortcomings and imperfections of their children without wanting to change them, which can lead to more acceptance of the situation. Even if the intervention does not change anything in the child’s psychopathy, then still the intervention can be effective in
reducing psychological distress in parents (Blackledge & Hayes, 2006). Therefore it is expected that mindful behaviour is related to psychological distress, and that mindfulness-based
interventions can effectively decrease parents’ psychological distress. Present study
Previous systematic research has examined the effectivity of mindfulness-based
interventions for improving the psychological distress of adults with ASD. Hwang and Kearney (2013) concluded from a systematic review that people with developmental disorder can be positively influenced by mindfulness. However, this does not prove that mindfulness-based interventions are also effective for children with ASD and their parents. For example, children are often sent to the intervention by others while adults make a well-considered choice to go into therapy. Therefore the group of children could have a higher symptom-severity than the group of adults, which influences the outcomes (Twyman, Maxim, Leet & Ultmann, 2009). As far as our knowledge goes, the effect of mindfulness-based interventions on children with ASD and their parents has never been systematically studied.
For that reason, the current study examines studies that focus on the effects of
mindfulness-based interventions on children with ASD and their parents. Therefore, the main question of this systematic research is: “To what extent are mindfulness and psychological
distress related in children with autism spectrum disorder and their parents?”. The concept
‘mindfulness’ is divided into ‘mindful behaviour’ and ‘mindfulness-based interventions’, both will be studied. When studying mindfulness-based interventions, we will look at interventions directed at parents, directed at children or directed at both. Different types of psychological distress are stress, anxiety, depression, and externalizing problem behaviours. Furthermore, we will look at outcomes on both children’s psychological distress and parents’ psychological distress. Based on previous research, it is firstly expected that directing the mindfulness-based intervention to children will positively affect children’s psychological distress (Kingsbury, 2009; Roberts-Wolfe et al., 2012). Secondly it is expected that directing the mindfulness-based intervention to their parents will positively affect children’s psychological distress
(Whittingham, 2014). Thirdly, it is expected that mindfulness-based interventions directed to the parents will positively affect the parents’ psychological distress (Grossman et al., 2004; Hofmann, et al., 2010).
The outcomes of this review have several implications for clinical practice. Firstly, it is relevant to know if mindful behaviour is related to psychological distress in order to know if it is possibly useful to teach children and parents the concepts of mindfulness. Additionally, by investigating to what extent MBIs are effective, a well-considered choice can be made to use mindfulness-based interventions. Moreover, evidence for which types of psychological distress are related to mindfulness will lead to knowledge about which specific intervention is suitable for which particular outcome. Finally, by knowing if it is more effective to focus the
intervention on children or on their parents, in the future the intervention can be applied to a more specific target group.
Method Selection of studies
A multiple field search was conducted in the databases Web Of Science, ERIC and PsycInfo to find empirical studies published after 2005. Four domains of root terms were used in the search: the ‘mindfulness’ domain (mindful*, acceptance and commitment, meditat*), the ‘target group’ domain (child*, adolescen*, young*, parent*, mother*, father*, famil*), the ‘autism’ domain: (autis*, ASD, asperger) and finally the ‘psychological’ domain (stress*, depress*, anxie*, psychological distress, intern*, extern*). By combining the four sets with AND, the search produced 46 articles.
Three main inclusion criteria were used for selecting the articles. Firstly, the target had to be either children with a diagnoses of Autism Spectrum Disorder, their parents, or both children and parents. Secondly, outcomes had to include depression, anxiety, stress,
externalizing problems or a combination of those. Thirdly, inclusion criteria for interventional studies were that the intervention was either MBT, MBCT, MBSR, ACT or used meditation as a key element.
Based on the inclusion criteria, 26 of the 46 articles were eliminated. For example, they were eliminated because their target population were adults so they could not be included in the recent study. Furthermore, articles were eliminated because they studied children with other diagnoses than ASD. Moreover, some articles had to be eliminated because their interventions were based only on cognitive behaviour therapy, without any element of meditation. Resulting were 20 articles that did meet the inclusion criteria.
Coding
As presented in Table 1, a coding scheme was developed to describe the studies, their target population and the studied outcomes. Firstly, the study design was coded: whether the study was a correlational study looking only at mindful behaviour, or an experimental study using a mindfulness-based intervention as a manipulation. Secondly, the number of
participants and the proportion mothers and fathers were coded. Thirdly, the age of the children was recorded. Moreover, the intervention length, type and intervention target (child or parent) was registered. Finally the articles were coded on outcome-variables: did they study either stress, anxiety, depression, externalizing problems or a combination of those. Also, did the studies focus on child-outcomes, parent-outcomes or both.
Results Children’s psychological distress
Psychological distress in children with ASD was examined. No research focussed on the relationship between children’s or parents’ mindful behaviour and children’s
psychological distress. However, effects of MBIs on children’s psychological distress are examined. A distinction was made between directing the intervention directly to children, and directing the intervention to parents in order to decrease children’s psychological distress. Additionally, different aspects of children’s psychological distress were examined: depression, anxiety, stress and externalizing problems.
Children’s depression. Firstly, the direct effects of children’s MBI on children’s depressive symptoms are examined. Mixed results were found by different studies. In one situation, no differences in depressive symptoms occurred after the intervention (Pahnke, Lundgren, Hursti, & Hirvikoski, 2014). Contrasting results were found by Hwang, Kearney, Klieve, Lang, and Roberts, (2015), teaching mindfulness to children led to a decrease in depressive symptoms. However, the parents of these children had received a MBI prior to that of their children, therefore we cannot say if a direct effect exists of the children’s intervention on the child’s depressive symptoms. When taking the quality of the research into account, Pahnke et al. (2014) used a stronger quasi-experimental design while Hwang et al. (2015) used only a pre-test post-test design without a control group. Presumably, the significant effects found by Hwang et al. (2015) are due to other variables than the mindfulness
Van Steensel, and Bögels (2015) also directed an intervention to children in order to decrease children’s depressive symptoms. A difference was made between different symptoms of depression: rumination and worry. A decrease in rumination was found, but there was no change in worry, suggesting that some depressive symptoms can be influenced by
mindfulness while others cannot. No research is conducted about indirect effects of parental intervention on children’s depressive symptoms. In summary, it seems that not enough evidence exists for the effectivity of MBIs on children’s depressive symptoms, and presumably some depressive symptoms can be influenced by mindfulness while others cannot.
Children’s anxiety. Secondly, the effect of MBIs on children’s anxiety is examined. A first result was that by directly giving an intervention to children with ASD, children’s anxiety symptoms did not change (Pahnke et al., 2014). Anew, contrasting results were found by Hwang et al. (2015), teaching mindfulness to children lead to a decrease in anxiety
symptoms. However, in this case again the parents had received a mindfulness training too so this could indirectly have influenced the anxiety symptoms of the children. Also, the pre-test post-test design by Hwang et al. (2015) is less reliable than the quasi-experimental design by Pahnke et al. (2014). Additionally, results could possibly be due to differences between interventions. For instance, the intervention that was given to children by Pahnke et al. (2014) had a duration of 6 weeks while the intervention that was given to parents by Hwang et al. (2015) lasted 8 weeks. This could have influenced the results, because possibly a longer intervention is more effective than a short intervention, as it offers more time to practice and develop. No research was conducted about the effects of parental intervention on children’s anxiety symptoms. In summary, it seems that not enough evidence is found for the effectivity of MBIs on children’s anxiety symptoms, and that intervention duration could play a part in the effectivity of an intervention.
Children’s stress. Thirdly, outcomes of MBIs on children’s stress were studied. The only study that looked at this relation was conducted by Pahnke et al. (2014). By directing an intervention at children themselves, children’s stress levels decreased. A quasi-experimental design was used, which makes results quite credible due to the control group. However, there was no randomization of groups so selection effects could have occurred. There was
insufficient information about reducing children’s stress indirectly through parental intervention. No research was conducted about the effects of parental intervention on
children’s stress symptoms. In short, results suggest that possibly an effect exists of directing a MBI to children on their stress levels, but this proof is minimal.
Children’s externalizing problems. Finally, research focussed on decreasing externalizing problem behaviour of children using MBI. From one source, it was concluded that children’s intervention effectively decreased children’s externalizing problems (Singh et al., 2010). However, the design of this study was not strong because only three participants were examined based on a multiple-baseline without any control group. No other research examined this direct effect. More research focussed on directing MBIs to parents instead of to the children themselves. All studies found that MBIs decreased children’s externalizing problems (Neece, 2014; Roberts & Neece, 2015; Robinson & Neece, 2015; Singh et al., 2006; Singh et al., 2014). Interestingly, different intervention lengths were used (ranging from 8 to 12 weeks), but all results were significant. Different age groups (2.5-5, 11-13 and 14-17) were studied and for all the ages the results were significant. Also, mother-father proportions did not seem to make any difference. However, it should be kept in mind that these externalizing problems were often reported by parents themselves, using the Child Behaviour Check List. An alternative explanation could be that due to the mindfulness training, children’s
externalizing problems did not so much decrease but that parents’ acceptance towards those problems increased. This is plausible as mindfulness leads to non-judgementally accepting
situations (Bishop et al., 2004). Overall, it seems that mindfulness is related to less externalizing behaviours.
To sum up, for reducing children’s depressive and anxiety symptoms results are mixed. As some significant effects are only found by studies with a qualitative low design, conclusions cannot be drawn with certainty. Therefore, we cannot presume that any effect of MBIs on children’s depressive and anxiety symptoms exists. For reducing children’s stress, an indication exists that child-intervention is effective, but no research focussed on parental intervention. As for externalizing behaviours, evidence is found for the effectivity of children’s MBIs and parental MBIs on reducing children’s externalizing problems. Parents’ psychological distress
Not only children with ASD but also their parents could possibly be influenced by mindfulness. The relationship between mindfulness and the psychological distress of parents of children with ASD was examined in sixteen studies. Some research focussed on the relationship between mindful behaviour and parents’ psychological distress while other research focussed on the effects of MBIs on parents’ psychological distress. When MBIs are studied, the intervention is always directed at the parent in order to decrease parental distress. Different aspects of psychological distress are examined: depression, anxiety and stress. None of the studies focussed on the relationship between mindfulness and parents’ externalizing behaviours.
Parents’ depression. Firstly, the relation between parent’s mindful behaviour and parent’s depression was studied. Mindful parents are found to have less depressive symptoms (Beer, Ward, & Moar, 2013; Jones, Hastings, Totsika, Keane, & Rhule, 2014). When mothers and fathers were examined separately, for both fathers and mothers there was a relation between mindful behaviour and less depression symptoms (Jones et al., 2014). Additionally, self-compassion, which is an important aspect of mindful behaviour, was found to have a
strong negative relationship with depression among parents. The relationship between self-compassion and depression was stronger than the relationship between children’s symptom severity and depression (Neff & Faso, 2015).
In line with these results, directing a MBI at parents significantly reduced parental depression (Blackledge & Hayes, 2006; Dykens, Fisher, Taylor, Lambert, & Miodrag, 2014; Poddar, Sinha, & Urbi, 2015; Ruiz-Robledillo, Sariñana-González, Pérez-Blasco, González-Bono, & Moya-Albiol, 2015). Because good designs were used, varying from
quasi-experimental, (Blackledge & Hayes, 2006; Ruiz-Robledillo et al., 2015) to RCT (Dykens et al., 2014), the evidence can be interpreted as strong. It is notable that the experimental studies used different interventions of different lengths and various age-groups, but all found
significant effects. Seemingly it makes no difference whether the intervention is a 9 week long training (Dykens et al., 2015) or a 2-day intensive training (Blackledge & Hayes, 2006) for reducing depressive symptoms. However, it should be kept in mind that no information about long term effects was given. Perhaps, intervention lengths are indeed important for long-lasting effects. In summary, the relation between mindful behaviour and depression seems feasible, as well as the effect of MBIs on parental depressive symptoms.
Parents’ anxiety. Secondly, the relationship between mindfulness and parental anxiety is examined. Mixed results are found in correlational studies. On the one hand it was found that parents who have more mindful behaviour overall do not have lower anxiety levels (Beer et al., 2013). However, Jones et al. (2014) did find a significant negative relation between mindful parenting and parental anxiety. This relationship was found for mothers, but not for fathers. It is notable that in the study of Beer et al. (2013), 14% of the parents were fathers, but mothers and fathers were not tested separately. Although the percentage of fathers was not large, the group of fathers could have caused the insignificance of the results.
Possibly, a relationship between mindful behaviour and parental anxiety could only exists for mothers but not for fathers.
Not only the relationship between mindful behaviour and parental anxiety, but also the effect of MBIs on parental anxiety is studied. After directing a MBI to parents, effects were found on parental anxiety. A parental mindfulness training significantly reduced parental anxiety levels (Dykens et al., 2014; Poddar et al., 2015; Ruiz-Robledillo et al., 2015). It is notable that mothers and fathers were not examined separately. Therefore, no conclusions can be drawn about differences between effects on mothers and effects on fathers. These
differences could possibly exist, based on the research about mindful behaviour (Jones et al., 2014). The experimental studies used different designs, interventions of different lengths and various age-groups, but all found significant effects. For example, Dykens et al. (2014) used a MBSR intervention, while Ruiz-Robledillo et al. (2015) used MBP intervention and Poddar et al. (2015) used an ACT intervention. However, they all found a reduction in anxiety.
Seemingly, it is the mindfulness component, which they all have in common, that is most effective in reducing parental anxiety. Summarizing, mindful behaviour seems to be related with less parental anxiety, and anxiety can be decreased by MBIs.
Parent’s stress. Thirdly, the relationship between mindfulness and parental stress is examined. Mindful parents overall report lower stress levels (Beer et al., 2013; Conner & White, 2014; Neff & Faso, 2015). Jones et al. (2014) found that there was only a relationship between mindful behaviour and parental stress for mothers, but not for fathers. To sum up, evidence indicates that mindful parents overall have lower stress levels.
In line with these results, parental stress can be influenced by MBI. Conclusions were that after a MBI parental stress levels decreased (Bazzano et al., 2015; Blackledge & Hayes, 2006; Bögels, Hellemans, Van Deursen, Römer, & Van der Meulen; Ferraioli & Harris, 2013; Dykens et al., 2014; Neece, 2014; Roberts & Neece, 2015; Ruiz-Robledillo et al., 2015; Singh
et al., 2014). However, in the studies that had a follow-up period, these results were not found in the follow-up, indicating that results are not present in the long term (Blackledge & Hayes, 2006; Ferraioli & Harris, 2013). Other studies did not have a follow-up so no conclusions can be drawn about long term effects. When Ferraioli and Harris (2013) compared the MBI to a ‘skills-based parenting training’, changes in stress were found for both groups. However, the effects size was larger in the intervention group than in the control group, indicating that a MBI is more effective than a comparative intervention that does not use mindfulness. In the study by Bazzano et al. (2015), all individual parents significantly reported less stress after the intervention. Interestingly, the experimental studies used different designs, interventions of different lengths and various age-groups, but all found significant effects. In short, all studies reported significant negative effects of the MBI on stress levels of parents, although
information about fathers and mothers separately is insufficient.
Overall, parent’s mindfulness seems to be related to less psychological distress. A relation between mindful behaviour and parental depression exists for fathers as well as for mothers. In addition, the relationship between mindful behaviour and anxiety and stress exist for parents, but there is insufficient information to draw this conclusion for mothers and fathers separately. As for the effects of MBI, overall strong effects are found of MBIs on parental depression, anxiety and stress. Studies that used a longitudinal design often did not find significant effects at follow-up, suggesting that effects did not last.
Discussion
The present study examined to what extent mindfulness can affect the psychological distress of children with ASD and that of their parents. We firstly examined the relation between mindfulness and children’s psychological distress. As for children’s psychological distress, no research is done on the relationship between mindful behaviour and children’s outcomes. Insufficient proof exists that MBIs can decrease children’s depression and anxiety. Only one source examined children’s stress, results suggest a positive effect of the MBI on
children’s stress. Strong evidence exists for the effectivity of MBIs on children’s externalizing problems. Secondly, we examined the relation between mindful behaviour and parent’s
psychological distress. For parents’ psychological distress, a relation seems to exists between mindful behaviour and parental depression, anxiety and stress. As for the effects of MBIs, overall strong effects were found of MBIs on parental depression, anxiety and stress. Overall it seems that mindfulness is related more to parents’ psychological distress than that of their autistic children. Only some studies had a follow-up period, these studies reported that effects were not present in the long term. Overall, intervention length and type did not seem to moderate the effects. Furthermore, children’s age did not evidently influence the effectivity of the intervention.
Based on existing literature, some expectations were formed about the relation between mindfulness and psychological distress of autistic children and their parents. The found results for children were not always in accordance with these expectations. It was expected that child-intervention led to a decrease in psychological distress (Kingsbury, 2009; Roberts-Wolfe et al., 2012). However, in the present study this was not the case for depression and anxiety. For children’s stress and externalizing problems however, evidence was found in accordance with the hypothesis, indicating that MBIs positively influences these kinds of distress. Moreover, it was expected that parental interventions led to a decrease in children’s psychological distress (Whittingham, 2014). Results were in accordance with this expectation as overall positive effects were found on children’s psychological health. Furthermore, expectations were that mindfulness was related with less psychological distress in parents (Grossman et al., 2004; Hofmann, et al., 2010). Results of the present study were in accordance with this hypothesis as overall positive results of mindfulness were found on parents’ depression, anxiety and stress.
When interpreting these results, limitations should be taken into account. The limited amount of articles that were found on this subject possessed some shortcomings. However, they were included in this systematic review as only a restricted amount of research exists on this subject.
A first limitation was the lack of specific information about the specific MBI. Most interventions used mindfulness elements as well as non-mindfulness elements. Therefore significant effects were possibly not due to the mindfulness-factors of the intervention but to other aspects of the intervention. For example, MBCT consists not only of mindfulness-elements but also of cognitive-mindfulness-elements. Possibly these cognitive mindfulness-elements were effective in reducing the psychological distress. Only one study compared the mindfulness intervention to a comparative non-mindfulness training.
A second limitation was the weak design of some interventions. The three studies with a multiple base-line design and the six studies with a pre-test post-test design did not have any control group, therefore effects could be due to confounding variables or threats such as maturation or testing. Four studies did have quasi-experimental design with a control group. However, due to the lack of randomized selection, a selection effect possibly occurred. These weak designs influence the internal validity as it is not always sure that effects are caused by the intervention. Additionally, most studies lacked a follow-up period. Therefore, long term effects could not be guaranteed.
A third limitation was the restricted amount of relations that were studied. For example, some studies only examined mothers as others examined fathers and mothers together as ‘parents’. Possibly, results of MBIs are different for mothers and fathers, but most studies did not distinguish between these two groups. Mother/father proportions could have led to alternative explanations as some of the studies that did not find significant results, one study did find a significant reduction for mothers but not for fathers (Jones et al., 2014).
Additionally, for some relations only one source of information could be used, such as for children’s stress symptoms. Therefore, it was difficult to draw solid conclusions about these relations. Moreover, some relations were not studied at all. No research was conducted about children’s mindful behaviour and children’s psychological distress, while this relation is in fact very plausible (Kabat-Zinn, 2003).
Further research
Based on these limitations, suggestions for further research can be done. Firstly, specific information about the intervention should always be reported. When that is the case, different types of interventions can be registered and compared with each other. In that way, conclusions can be drawn about which types of MBIs are more effective than others. Only if the studies do this clearly and complete, systematic research can compare the different kinds of MBI.
Secondly, further research should use a randomized control trial to control for cofounding variables. Using a randomized control trial will improve the internal validity of the research. In that way, it is more useful to compare the results of the different studies with each other. It is important that the participants in the control group participate in a comparable intervention instead of making a wait list comparison. Only in that way, conclusions can be drawn about effectivity of specific mindfulness components. Additionally, longitudinal measurements are needed to see if results are still present in the long term. When follow-up measurements are taken, we will know more about the urgency to introduce follow-up trainings after a mindfulness interventions.
Thirdly, further research should focus on other relevant outcomes for autistic children and their parents, for example the relation between children’s mindful behaviour and
children’s stress. By studying this relations we can find out whether it would be relevant to give mindfulness interventions to autistic children that suffer from stress. Additionally, effects
of parents’ mindful behaviour on children’s specific outcomes should be studied more specific. Another interesting factor that should be studied more is the differences between mothers and fathers, as from one study it was concluded that mothers were influenced by mindfulness while fathers were not.
Practical implications
In conclusion, although the current research on mindfulness contains a lot of flows and shortcomings, it seems that mindfulness is at least related to some aspects of autistic
children’s and their parents’ psychological distress. Based on the results, it may be more effective to direct a MBI to parents of autistic children instead of to the children themselves. When parents learn to practice mindfulness, they can positively influence their own
psychological wellbeing as well as that of their children. Additionally, as effects of the interventions do not always last in the long term, future interventions need follow-up treatments and more time for the children and their parents to make mindfulness their own. Mindfulness is not just a skill that is easily taught. It is a state of mind which needs a lot of practice and time to acquire and retain. Overall, mindfulness is a promising method to decrease psychological distress of children with autism spectrum disorder and their parents. However, research should be done with better designs and for specific outcomes. When more specific research is done, decisions can be made about which type of mindfulness-based intervention is suitable for which specific target and which specific problem. It should not just be assumed that mindfulness is always effective in reducing all kinds of psychological distress for autistic children and their parents.
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Table 1
Summary of Research Characteristics
Year Authors Design N Mothers /fathers Age child Length MBI Type MBI Target MBI Parent outcomes Child outcomes 2015 De Bruin et al. . pre-test post-test 46 18 mothers 11 fathers 11-23 9 weeks MBCT /MBSR Parents and children -c Depression Rumination* Worrying 2015 Hwang et al., pre-test post-test 12 12 mothers 0 fathers
8-15 8 weeks MBSR Parents and children Stress* Depression* Anxiety* 2015 Ruiz-Robledillo et al. quasi-experimental 13 5 mothers 1 fathers
-b 9 weeks MBP Parents Depression*
Anxiety* Stress* -c 2015 Neff & Faso, correlational 51 40 mothers 11 fathers 4-12 -a -a -a Depression* Stress* -c 2015 Bazzano et al. pre-test post-test 66 51 mothers 15 fathers
-b 8 weeks MBSR Parents Stress* -c
2015 Robinson & Neece, pre-test post-test 44 33 mothers 11 fathers
2.5-5 8 weeks MBSR Parents Stress* Externalizing problems* 2015 Roberts & Neece quasi-experimental 43 33 mothers 10 fathers
2.5-5 8 weeks MBSR Parents Stress* Externalizing problems*
2015 Poddar et al. pre-test post-test 5 5 mothers 0 fathers
6-15 8 weeks ACT Parents Depression* Anxiety* -c 2014 Singh et al., multiple baseline 3 3 mothers 0 fathers
11-13 8 weeks MBPBS Parents Stress* Externalizing problems*
2014 Pahnke et al.
quasi-experimental
53 -b 13-21 6 weeks ACT Children -c Depression
Anxiety Stress* 2014 Bögels et al. quasi-experimental 86 77 mothers 9 fathers
2-21 10 weeks MBCT Parents Stress* -c
2014 Dykens et al.
RCT 243 243 mothers 0 fathers
-b 6 weeks MBSR Parents Depression*
Anxiety* -c 2014 Conner & White Correlational 154 154 mothers 0 fathers 4-17 -a -a -a Depression* Stress* -c
2014 Jones et al. Correlational 110 71 mothers 39 fathers 7-16 -a -a -a Depression* Anxiety Stress -c 2014 Neece RCT 46 31 mothers 15 fathers
2.5-5 8 weeks MBSR Parents Stress* Externalizing problems*
2013 Ferraioli & Harris
RCT 15 10 mothers
5 fathers
3-20 8 weeks MBPT Parents Stress* -c
2013 Beer et al. Correlational 28 24 mothers 4 fathers 3-20 -a -a -a Depression* Anxiety Stress* -c 2011 Singh et al. multiple baseline
3 3 mothers 14-17 10 weeks Soles of the Feet Children -c Externalizing problems* 2006 Singh et al. multiple-baseline
3 3 mothers 4-6 12 weeks MBSR Parents -c Externalizing
problems*
2006 Blackledg e & Hayes
Pre- test post test
20 15 mothers 5 fathers
2 days ACT Parents Depression*
Stress*
-c
Note: * p<0.05
a
Correlational studies did not have an intervention so this information is not addressed b
Data not reported by source c
