Effects of Stress Management Training by Using Cognitive-Behavioral Method on Reducing Anxiety and Depression among Parents of Children with Mental Retardation

doi:10.4236/sm.2013.31011

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Sociology Mind

2013. Vol.3, No.1, 62-66

Published Online January 2013 in SciRes (http://www.scirp.org/journal/sm) http://dx.doi.org/10.4236/sm.2013.31011

Effects of Stress Management Training by Using

Cognitive-Behavioral Method on Reducing

Anxiety and Depression among Parents of

Children with Mental Retardation

Abbas Ali Hosseinkhanzadeh1, Taiebeh Yeganeh2, Nouradin Rashidi3,

Ghasem Zareimanesh3, Nouradin Fayeghi4

1University of Guilan, Rasht, Iran

2Young Researchers Club, Tonekabon Branch, Islamic Azad University, Tonekabon, Iran

3M.A. in Counseling, Kermanshah, Iran

4M.A. in Psychology, Kermanshah, Iran

Email: [email protected]

Received September 28th, 2012; revised November 3rd, 2012; accepted November 18th, 2012

Present study is designed to investigate the effects of stress management training by using cognitive be-

havioral method on anxiety and depression among parents of children with mental retardation. This study

is a quasi-experiment that designed as pretest and post-test with control group. The statistical population

of study included all parents with mental retarded children from city of Babol in 2011-2012. Sample

population was including 40 parents that were selected cluster sampling and allocated in experimental and

control groups (20 parents for experimental group and 20 for control group). The experimental group

trained during 10 sessions of stress management with method of cognitive-behavioral, whereas during this

period the control group did not received any intervention. Both groups in pre-test and post-test assessed

by using anxiety and depression scale and results were analyzed by using independent t-test. The results

of t-test showed that there were no significant differences between two groups in pre-test, but stress man-

agement training with method of cognitive-behavioral in experimental group were significantly reduced

scores of anxiety and depression. The results of this study showed that stress management by using cogni-

tive-behavioral method decreases depression and anxiety scores compared with the control group. Due to

psychological problems of parents with mental retarded children, cognitive-behavioral stress management

training program can be used as intervention method to reduce anxiety and depression in order to decrease

vulnerability.

Keywords: Stress Management; Cognitive-Behavioral Method; Anxiety; Depression

Introduction

During the last two decades movements of institutions has

been changed focusing of primary care from psychiatry hospi-

tals into community mental health centers, and because of bu-

dget, resources and facility limitations, families of patients had

to take responsibilities such as being practical assistance or

emotional supports (Gutierrez-Maldonado et al., 2005). In the

past, children who were in institutions, but now they are living

in family environment which is better for their development but

on the other hand these changes have great pressures on fami-

lies (Pelchat & Lefebvre, 2004). Generally interesting to the

issue of psychological needs of caregivers goes back to 1950

(Honea et al., 2008). Some experts underline that role of care-

givers often accompanied by set of rewards and positive rein-

forcement (Picot, 1996).

The birth of a child with a disability affects the dynamic and

interaction among family members which could leads to crisis

within family. Specially issue of mental retardation in children

is very serious because family with mental retarded children

have problems in parental system, marital relationships, sibling

relationships, even it affects their external system such as friend,

family, neighbors, school and will cause more pressure within

the system, at this point emotional state and physiological

thoughts become abnormal then leads to vulnerability in cogni-

tive activities which outcome of these behavioral problems will

bring out depression and anxiety (Hernandez, 2005). Regarding

to this issue, Goffman (1963) believes that experiences of stig-

ma not only affect people who carrying stigmatized traits, but

also will expand to those have directly relationship with people

who carry negative attributions. Affiliates could internalize their

stigma and affect their life, so they might face with contagious

stigma which is complex phenomenon (Gray, 1993; Green,

2003).

The birth of a child with mental retardation could lead to

deep impact on families, thus parents of children with special

needs are facing more problems than parents of normal children

which affect their psychological well-being (Rohini, 2012).

This kind of birth is one of the most stressful events among

individual’s life (Mc Conkey et al., 2008). Some factors such as

advances in medicine and technology, effect mental retarded

children to live longer and healthier (Saloviita, Itallina, & Lei-

A. A. HOSSEINKHANZADEH ET AL.

nonen, 2003). The continuing care of children with mental re-

tardation is often stressful for parents (Esdaile & Greenwood,

2003). The effects on family unit can be economic, social, and

emotional in nature. Researchers have indicated that parents of

children with mental retardation are generally at risk for a vari-

ety of emotional difficulties (Beckman, 1991; Khamis, 2007).

The cumulative impact of daily hassles and difficulties in deal-

ing with disabled children represent significant stressors that

may subsequently affect parents and family functioning. In par-

ticular, a great deal of evidence points to associations between

the severity and frequency of behavior problems of children

with intellectual disabilities and parental stress and psychiatric

problems such as depression and anxiety (Baker, Blacher, Crnic, &

Edelbrock, 2002).

Severe and long term stresses can affect adaptation ability,

and reduce pleasure which results with depression (Kiecolt-

Glaser, 2002). According to the studies, adapting to mental re-

tarded children has some stages, in the first stage family en-

counters with crisis such as anger and denial. Then family will

experience emotional turmoil, anger, guilt, depression and shame

that can reduce their self esteem, at this point child will be un-

der excessive care or ostracized by family and finally child will

be accepted by family (Heyward, 2000).

Varies studies have confirmed that parents of mentally re-

tarded children showed higher levels of stress than children

with normal status. The results of Shieve and colleagues re-

search in 2007 showed that the presence of stresses among

parents of children with special needs are 44% which this amount

among parents with normal children are 11%. Also research of

Cushner-Weinstein and colleagues in 2008 have been reported

amount of stresses among parents with epilepsy children is

around 45%.

The most important problems of these parents are: 1) Diffi-

culty in accepting mental retarded children; 2) Fatigue of care-

giver; 3) Issued that related to leisure time; 4) Financial prob-

lems of family; 5) Medical things (Khamis, 2007). All those

cases make stresses on families, especially on mothers, because

mothers are spending more time to care their children due to the

traditional role of “care”, also they are more under risk of de-

pression compared with men (McConkey et al., 2007; Pin-

quart & Sorensen, 2006). Also they might abandoned by their

spouse for reasons such as lack of willingness to accept addi-

tional responsibilities or stigma (Rohini, 2012).

Some features such as the nature of disabilities, behavioral

problems of children, emotional status, lack of social support,

presence of additional disabilities in children, stressful resources

associated with the inability of children can lead to increasing

anxiety even depression among parents (Kaplan, 2010; Zaid-

man-Zait, 2007), that in turn, existence of these psychological

abnormalities significantly contribute to reducing quality of life

(Sakakura et al., 2007).

One of the variables that directly correlated with parental

stress is severity of disability. Children who are born with se-

vere injuries are more likely to make the family anxious be-

cause their family has more responsibility toward their children

(Dabrowska & Pisula, 2010). According to the extent of the

severity, their needs will increase so then they need more ser-

vices from their family. Additional role is imposed on parents

in the birth of children with disabilities especially on mothers

make lots of stress. In addition mothers also have responsibility

such as educating their children (Parrette & Brotherson, 1996).

Parette & Brotherson discuss reasons that underline need of

providing educational services to parents. From their view point

parents with mental retardation experience high level of anxiety

and stress thus this requires specialized and training to identify

them. These children often need special cares because of de-

laying or failure to obtain customs such as toilet training, dres-

sing, eating, clothing, and problems such as bed-wetting and

seizures. In order to achieve diagnosis and treatment, parents

become strict and this might result with financial loss, energy

and time in order to take care of themselves or other members

of family.

The subject of stress management by using cognitive-be-

havioral method tends to be very important issue now a day, be-

cause it particularly affects function of family and relationship

within the family members which might results to caught vi-

cious cycle. Family experiences anxiety and then causes vari-

ous psychological problems among members of family, thus

this gradually will lead to negative effect on family function. A

child that develops in dysfunctional family that faces with many

conflicts is more likely to have emotional, behaveioral and

educational problems. These problems have a negative impact

on family members and this cycle continues and becomes more

complex every day. For breaking this cycle stress management

training by using cognitive-behavioral method is important

because this method focuses on cognitive-behavioral approach.

Stress management increases the ability of individual in or-

der to coping with stressful situation to reduce the level of

stress. This method of intervention consist of elements such as

raising awareness about stress, relaxation training, identifying

inefficient thoughts, cognitive restructuring, problem solving,

anger management, self management and planning activities

(Linden, 2005; Anderson, 2006; Antoni et al., 2009). Such in-

terventions are necessary because the level of psychological

well-being of parents directly associated with positive and ef-

fective interaction between them (Ruhuny, 2012). Considering

the fact that there exists a significant hiatus in the examination

of parental stress and psychological distress among parents of

children with mental retardation in Iran, present study investi-

gates whether stress management training by using cognitive-

behavioral method reduces the anxiety and depression among

parents of children with mental retardation or not?

Method

The Sample and Sampling

Present study is quasi-experiment designed as pre-test and

post-test with control group. Samples consist of all parents with

mental retarded children from city of Babul in 2011-2012.

Sample population was including 40 parents that were selected

by cluster sampling and allocated randomly in experimental and

control groups (20 parents for experimental group and 20 for

control group).

Research Tools

In this study to gather data from pre-test and post-test, scale

of anxiety and depression of SCL-90-R questionnaire is used.

This scale in addition to psychiatric patients, are useful and

appropriate in the case of alcohol and drug addicts, patients

with cancers, patients with heart failure and those who are under

stressful situation. This scale chosen from authors, because it

has short, simple and brief buoy of anxiety and depression, also

with respecting to the low educated patients was the best scale

A. A. HOSSEINKHANZADEH ET AL.

in comparing with other scales in order to measure depression

and anxiety. It is based on Likert scale of five choices (Not at

all, Little, Partly, High, Very high) and scored as (0, 1, 2, 3, 4).

In an Iranian study on depression and anxiety, coefficient vali-

date scale is reported as 92% and 86% (Khorramabady et al.,

2009). In the study of Riahi and colleagues (2010) reliability

coefficient was calculated for the scale of mental health based

on its reliability is equal with 0.932 which shows extreme har-

mony between the items of this scale.

Introducing the Intervention Program

After running the pre-test on the both groups, experimental

group attended in stress management program by using cogni-

tive-behavioral method and after intervention, test scores were

collected. Program of stress management by using cognitive-

behavioral method (Antoni, Ironson, & Schneiderman, 2007)

includes 10 session of 90 minutes in experimental groups was

performed as follows: In general, each session consists of two

parts, first steps contains techniques of stress management and

second part includes relaxation exercises.

First Session: Describe the factors of causing stress, response

to factors of causing stress, awareness of the physical effects of

stress and its possible consequences on health-muscle relaxa-

tion for 16 groups of muscles.

Second Session: Stress and awareness (of automatic thoughts

and physical sensations)—muscles relaxation for 8 muscles.

Third Session: Describe the relationship between thoughts

and emotions-diaphragmatic breathing, muscle relaxation for 4

groups of muscles.

Fourth Session: Identification of negative thinking and cog-

nitive distortions-breathing, illustration and passive muscle re-

laxation.

Fifth Session: Replacement of logical thoughts—Self-train-

ing for being heaviness and heat.

Sixth Session: Learn to deal effectively—Self-training for

heart rate, respiration, abdomen and forehead.

Seventh Session: Implementation of effective coping re-

sponse—Self-training with illustration and self-induction.

Eighth Session: Anger management training and mantra me-

ditation.

Ninth Session: Gary expresses training—Counting breath

meditation.

Tenth Session: Social Support—Overview of program and

personal stress management program.

The presentation of material in each session was first to re-

view the material of last meeting, then materials of that session

were presented, and at the end of that session the new materials

were reviewed and finally new task has been given to them.

After completing program, post-test were administrated to both

groups in order to determine degree of anxiety and depression.

Results

In order to determine the effect of cognitive behavioral stress

management training in the both experimental and control

groups, first scores on the variable of depression and anxiety in

the pre-test and post-test was calculated. Table 1 shows profile

of the sample.

In order to compare experimental and control groups in terms

of effectiveness of stress management training on anxiety and

Table 1.

Means and standard deviation of experimental and control groups.

N MEAN SD

Experimental 20 41.07 4.35

Control 20 40.67 5.8

depression, the independent t-test was used where the total ave-

rage difference between pre-test scores—post-test (d score) has

been compared in two groups (One of the common statistical

methods in the design of pre-test and post-test is with control

group). The results are shown in Tables 2 and 3.

According to Table 2, there is no significant difference in

average of two groups of control and experimental, but after

stress management training and in comparison of averages in

post-test, test, results of t-test indicated that there are significant

differences between two groups in terms of anxiety variable.

Final amount of t is outcome of immunization effect on anxiety

−4/1 which is on P ≤ 0.001 and is meaningful with 1% alpha, in

other words we can say that the effect of immunization training

in reducing anxiety is significant.

The data in Table 3 also shows that there is no significant

difference between two groups in pre-test in terms of depress-

sion variable, but after stress management training, results of

independent t-test indicates that there are significant differences

between two groups in terms of depression variables. The final

amount t outcome of immunization effect on depression is −3/4

which is on P ≤ 0.001 and is meaningful with 1% alpha. In

other words stress management training, significantly reduced

depression. Overall, there are significant differences between

scores of pre-test and post-test in control and experimental

groups on anxiety and depression. These findings indicate that

cognitive-behavioral stress management training is effective

and reduces anxiety and depression in parents of children with

mental retardation.

Discussion and Conclusion

Pressure of psychiatric care that is imposed on caregiver re-

duces the quality of care and can jeopardize their mental and

physical health and releasing these tensions and pressures

without treatment and intention can lead to reducing physical

and mental health of home caregivers as hidden patient (Goode

et al., 1998).Therefore, some strategies to reduce stress for the

parents seems to be necessary, such as family counseling, cop-

ing skills training, inadequate social support and providing pro-

fessional classes for the parents. Providing such interventions

defined as mental health professionals to reduce tensions from

home caregivers (Riebscheger et al., 2008; Gutierrez-maldo-

nado & Caqueo-Urizar, 2007).

Therefore, this study examines the impact of cognitive-be-

havioral stress management training in reducing anxiety and

depression among parents of children with mental retardation.

The results of this study has been proved that cognitive-be-

havioral stress management training reduce depression and an-

xiety scores in experimental group comparing with control

group, findings of this result are consistent with the results of

the research study Baron (1994), Keogh et al. (2005), Vivian

Khamis (2006), Sheehy & Horan (2004), Rohini (2012). Find-

ings of these researchers also indicated that stress management

by using cognitive-behavioral method help people to deal with

A. A. HOSSEINKHANZADEH ET AL.

Table 2.

Results of independent t-test in order to compare experimental and control groups on anxiety.

N Mean SD T SIG

Experiment 20 18.8 1.86

Pre-test

Control 20 18.6 1.18

0.35 0.73

Experiment 20 16.13 1.4

Post-test

Control 20 18 1.25

−3.84 0.001

Experiment 20 −2.66 1.34

Test score difference

Control 20 −0.6 1.35

−4.1 0.001

Note: DF = 38.

Table 3.

Results of independent t-test in order to compare scores between control and experimental groups on depression.

N MEAN SD T SIG

Experiment 20 28.53 3.25

Pre-test

Control 20 27.73 3.01

0.69 0.49

Experiment 20 24.4 3.2

Post-test

Control 20 27.4 2.85

−2.7 0.012

Experiment 20 −2.66 1.34

Test score difference

Control 20 0.6 1.35

−0.4 0.002

Note: DF = 38.

particular pressures in order to improve quality of their life.

Husting & Beck (2004) investigated group intervention pro-

gram with the aim of reducing anxiety among parents of chil-

dren with mental retardation. They believe that parents of chil-

dren with mental retardation are increasingly vulnerable to

stress and other psychological problems such as depression and

anxiety thus, they need to interceptive programs in order to

decrease stress. Review of Husting & Beck has shown that

among intervention programs, the cognitive-behavioral method

have the greatest effective impact in reducing stress. The above

findings can be explained by cognitive-behavioral strategies.

By using cognitive stress management training try to identified

unreasonable thoughts, inefficient, and factors that arousing

anxiety and depression and try to help them to have insight in

order to replace rational thoughts. This will enhance their self-

esteem and psychological adequacy thus will lead them to achi-

eve more resources to help their disabled child. As Lazarus &

Folkman (1984) argue that when individual coping with stress,

if resources are available to help, will show less vulnerability to

stress.

The nature of this type training has been effective in reducing

the stress of people, because the parents all were well trained

group. Berg & colleagues (1998) underline nature of all prob-

lems based on social and interpersonal. Participation in those

kinds of trainings give them chance to share their problems,

understand problems of others, learn new ways to solve prob-

lems and learn constructive plans in order to cope with stress.

Actually, this is kind of social support, emotional and informa-

tional support (Thoits, 1986). Social support affect life satisfac-

tion in two ways: first way is direct effect or general effect of

social support on life satisfaction without considering the level

of distress experienced by individual, it effects the life satisfac-

tion, and second way consists of indirect effect or mediator

effect that protect people in facing with stressful conditions

(Van Leeuwen et al., 2010).

In order to provide another explanation, Lazarus and Folk-

man (1984) underline that major issue is how individual per-

ceive or deal with stress that might affect outcome, thus if peo-

ple find more ways to compromise to cope with environmental

stressors and reduce level of stress.

In the present study aim was to teaching various ways in or-

der to challenge with negative thoughts and attitudes associated

with having a mental retarded child, and to reduce symptoms of

anxiety and depression and as a result improve and resolve

impaired functions of activities, life satisfaction, self-esteem

and social relationships. Prevalence of anxiety and depression

among parents of children with mental retardation is in high

level, thus therapies such as cognitive-behavioral therapy be-

side other methods seems to be necessary, because those treat-

ments can teach parents to learn how deal with their children in

order to adapt their social situation. Thereby, improving com-

pliance, while reducing the harmful effects of these disabilities

will help to children and parents in order to comply with the

disease and also will help them find the best solutions (Wil-

liams et al., 2003). In sum, increasing the mental health leads to

physical health and finally to healthy society. The final point

that must be pay attention is that importance of continuing to

improve the level of psychiatric services for these individuals

and their families (Awad & Voruqanti, 2008). So, in further

studies suggested that to use other methods of therapy and com-

pare them with each other which have been proven that are ef-

fective in reducing anxiety and depression for parents.

A. A. HOSSEINKHANZADEH ET AL.

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