Caregivers of children suffering from Autism Spectrum Disorder (ASD) usually experience elevated levels of stress and poor physical health. Parents of such children, in most instances, experience such mental health issues as general distress, psychopathology, and stress (Cachia et al., 2016). Young patients with ASD exhibit restricted, repetitive behaviors, as well as speech impairments and social maladjustment. Cumulative developmental deficiencies exhibited by underage ASD patients often reduce the health-related quality of parents’ life and leads to negative psychological outcomes. When parents first discover their children’s condition, confusion and parenting stress are common behaviors (Kuhlthau et al., 2014). Many adults assume the role of being the primary caregivers and sometimes feel guilty for their children’s conditions. After diagnosing and during the treatment, parents suffer economic, social, marital, and personal difficulties that impact their physiological and psychological well-being (Hartley et al., 2017). Consequently, caregivers suffer exhaustion and tend to be pessimistic about the future.
Since ASD is usually irreversible, at least in the short-term, quick acceptance of the non-normative conditions becomes unavoidable for parents. Acceptance and Commitment Therapy is one of the most effective interventions since it lacks the weaknesses of other techniques, such as behavioral parent training (BPT) (Bach & Hayes, 2002). BPT overlooks caregivers’ personal experiences and their ability to learn. ACT emphasizes the importance of accepting situations that are beyond one’s control and contributes to changing the factors that will improve the parents’ quality of life.
Purpose of the Study
The main objective of this study was to determine the efficacy of a group-based ACT intervention in caregivers of children with ASD, as well as a novel population. Also, the task was to evaluate changes in parents’ positive self-reported experiences of caregiving. Acceptance and Commitment Therapy is considered a more effective intervention than behavioral parent techniques since it considers caregivers’ experience and their ability to learn (Bach & Hayes, 2002).
Autism Spectrum Disorders (ASD)
Autism spectrum disorder (ASD) is a developmental and neurological condition that afflicts people from their childhood throughout their adult life. This condition influences how a person interacts and communicates with other people. Additionally, ASD impacts the cognitive development of patients afflicted with this ailment. The disease is known as a “spectrum” disorder because patients exhibit a range of symptoms. According to Cachia et al. (2016), some of the main symptoms of ASD include repetitiveness in speech, restricted interests, and slowness. Children with ASD often repeat sentences a few times and spend much time putting things in order. Young patients suffering from this condition are prone to throwing temper tantrums, as well as obsessive, destructive, ritualistic, and self-stimulating behaviors (Lindsey & Barry, 2018). The severity of the condition ranges from mild to extreme and is manifested distinctively in different people. By 2018, it was estimated that one of 160 children suffered from the condition. The number of young patients afflicted with ASD in the United States rose from one of 150 to one of 168 between 2000 and 2016 (Cachia et al., 2016, p. 1).
Characteristics of Parents of Children with ASD
Parents of children with ASD, which is often referred to as autism, are at a high risk of suffering from a caregiver syndrome that causes a range of issues. Some of the main symptoms of the condition include rage, anger, guilt, and exhaustion (Lindsey & Barry, 2018). These indications result from constant care for chronically ill dependents. The caregiver burden culminates in a changing attitude from positive to negative. Eventually, caregivers will become indifferent due to the incessant demand of caring for a dependent child. Several studies have pointed out that parents who are the primary caregivers of children with autism experience higher rates of anxiety, stress, fatigue, bodily pain, and significantly low quality of life. These conditions are the direct consequences of sleep interruption and assistance to the daily living skills of young patients. According to Kuhlthau et al. (2014), some of these behaviors may cause harm to caregivers themselves, as well as close family members and friends.
Additionally, such parents exhibit various psychological disorders that lower their quality of life significantly. In the study by Schnabel et al. (2020), the authors argue that 33% of these parents develop anxiety disorders, more than 30% have depressive disorders, 10% have obsessive-compulsive conditions, 4% of them have personality issues, 2% struggle with alcohol and substance abuse dependence, and 1% is prone to schizophrenia. Other mild personality characteristics exhibited by these primary caregivers include the development of a melancholic personality, some traits that indicate post-traumatic stress, and bipolar disorders (Li et al., 2017). Further studies have established that parents of children with ASD have higher rates of comorbidity than their counterparts whose children grew normally. These findings suggest that these parents carry a greater psychological burden than others.
Due to the extreme physical and mental exertion that such parents suffer, they exhibit unusual personal traits that are not manifested by those with normally growing children. This population has a limited opportunity to interact with other people, and they have problems with verbal and non-verbal communication (Lindsey & Barry, 2018). This leads to a condition called broad autism phenotype (BAP) that affects parents’ language, personality, and social interaction (Li et al., 2017). Several studies have established that the parents of children with autism are generally irritable, stubborn, nonchalant, self-centered, and are not adaptable to changes in their lives. Moreover, they are often reticent, introverted, and unlikely to exhibit thrill-seeking behavior.
Sources of Stress of Parents as Primary Caregivers
According to Cachia et al. (2016), parents of children with ASD suffer from stress that eventually leads to depression since they have to cope with the child’s inability to communicate appropriately. These caregivers typically struggle to know what their kids need since their speech is impaired. Repetitive sentences that characterize their talking are often incoherent, and parents have to comprehend attentively (Lindsey & Barry, 2018). Additionally, children who have autism usually isolate themselves from other healthy kids for fear of stigmatization, and the psychological impact of this process becomes a stressor for the primary caregiver (Lindsey & Barry, 2018). Moreover, young patients usually have challenges while carrying out daily self-care duties, and parents have the obligation of assisting them in performing routine tasks.
In many cases, there is a systemic lack of information about the disease, and some parents often blame themselves for their child’s condition. Consequently, primary caregivers of such kids usually suffer stigmatization, particularly in cultures where a child’s mental health is considered a generational curse (Lindsey & Barry, 2018). Further, ignoring the disease creates confusion about the behavior of the child, which delays the diagnosis and proper treatment. Moreover, parents with kids who have ASD suffer higher levels of stress due to symptom severity (McStay et al., 2014). Several studies prove that an increased level of hyperactivity is a significant concern for caregivers of such young patients. Lastly, people who provide care for hyperactive, autistic children worry about their safety since kids continually put themselves in danger.
The existing research about the levels of stress experienced by parents has yielded mixed results. Hartley and Schultz (2015) state that mothers of kids with autism have heightened stress than fathers. Additionally, parents of children with ASD usually face economic difficulties due to the costs of caring for their dependent young ones. Recent statistics prove that families with children with autism spend between three and five dollars more than families that have normal-growing children every day (Lindsey & Barry, 2018). Moreover, since caregivers spend more time taking care of young patients than they do for leisure, many of them struggle to find a proper job that could cater to the needs of the family. The increased financial stressor reduces parents’ resources, which leads to poverty.
Constant conflicts among couples have been identified as one of the leading causes of changes in marital satisfaction in the long term. Consequently, married parents who have autistic children and poor social skills often isolate themselves emotionally and physically from their spouses. Such constraints are often catastrophic for the institution of marriage and sometimes lead to divorce. Hartley et al. (2017) found out that autism in children causes many conflicts among couples, principally about the division of labor in the caregiving efforts of both parents. Much of the existing research supports the assertion that in couples who have children with ASD, a rate of divorces is higher when compared to parents with normally growing kids (Benson, 2010). Conflicts about caregiving are the most common source of argument for such parents. Moreover, both fathers and mothers of dependent children report low levels of conflict resolution, and barriers to normal communication are a common phenomenon.
The primary caregivers of children suffering from autism are prone to placing personal expectations on each other. Husbands expect their wives to take care of kids, whereas females expect fathers to help with upbringing (Benson, 2010). In most cases, males tend to avoid providing care by preoccupying themselves and looking for sustenance for the family. In such cases, women place financial expectations on their husbands, and men appraise their wives by considering how well their children with ASD are looked after and taught. On the other hand, the social life of caregivers is adversely affected due to the limited time that parents can spare for leisure and interacting with others (Lindsey & Barry, 2018). Additionally, the stress that results from adults’ constant efforts to take care of kids with autism limits their ability to hold jovial conversations with their friends. Furthermore, when caregivers face stigmatization, they develop the habit of social distancing, which breaks down many relationships.
Many scholars of the impact of caregiving on parents of children with ASD consider cultural factors the stressors that reduce the quality of adults’ life (Benson, 2010). In many communities, particularly those in which information about the condition is limited, parents are often stigmatized. Such societies cause parents of children with autism to blame themselves for the conditions of their children’s growth and a severe diagnosis.
Coping and Quality of Life
The ability of caregivers to adapt to a new state of caring for an autistic child depends on parental and contextual factors. These facets subsequently account for the degree to which an adult is affected by the nurture of an autistic kid. Focusing on maternal factors, mothers caring for autistic children tend to receive more social support than those of the opposite gender (Manning et al., 2011). Therefore, such individuals can cope well and will not experience significant stress, despite the existing circumstances. Income and the educational level of a parent also affect one’s ability to endure. A struggling adult with no employment and very little or no source of income has trouble when caring for an autistic child. This is due to the fact that young patients’ needs are different and more expensive to meet than for a typical child. Therefore, it becomes challenging to support such a patient comprehensively, and is hard for a caregiver to cope well. However, due to education, one becomes knowledgeable and gains exposure to deal with such cases.
The situation when a caregiver cannot fathom his or her child’s condition is detrimental. Without education, there is a risk of confusion since parents tend to accept every type of information about their children. An unschooled caregiver is more likely to believe what the community says about a kid’s condition than rely on evidence-based data. Such individuals find it challenging to cope and are significantly affected by the resulting stress from caring for an autistic youngster. On the other hand, contextual factors affecting the level of coping focus on the social support system of an individual. Caregivers with strong societal backing will cope well compared with ones without a reliable network (Gray, 2006). The primary relative factors include support from the family and the community. Moreover, being in a dysfunctional household makes it hard for a caregiver to adapt well to a new system of living as opposed to a functional family system. Community support measures include factors in caregivers’ environment, for instance, the presence of a hospital and an educational facility specifically designed to care for autistic children, which are of benefit to a young patient.
Various models have been used to explain coping mechanisms and the quality of life of caregivers for autistic children. One translational model used is the double ABCX approach that explains coping in different families with autistic children. The theory assesses various factors, including the stressful events present in families, available resources to handle the stressors, strategies of coping employed, and the outcomes (Manning et al., 2011). One major stressor in most families is having children with developmental disabilities, including autistic spectrum disorders. Parents in these families, who are the primary caregivers, struggle with depression due to the difficulties in caring for autistic children.
The double ABCX model defines family resources as the psychological and social strengths vital in handling the family stressor. Such resources include social support from closed ones and the community as prerequisites for good mental health. When families lack enough resources to handle stressors, coping becomes extremely challenging. The ability to cope will depend on available resources and the meaning that caregivers attach to these resources.
Another model used in understanding the principles of overcoming challenges and enhancing the quality of life for caregivers is the process model of coping by Lazarus and Folkman, which, as Kelso et al. (2005) argue, is the method that focuses on how an individual interprets and gives meaning to severe stressors. The background of the process theory is how one’s endurance determines the effect the stressor will have on an individual. The inability to cope well means poor quality of life, while skill to deal with psychological irritants adequately translates to good mental well-being. Five resource categories have been cited as being vital in aiding coping in persons (Kelso et al., 2005). These include possessing essential skills for solving problems, strong networking systems, belief in oneself, a good state of physical health, and economic resources, such as money.
Studies have shown four main coping styles exhibited by caregivers of autistic children. They include active avoidance, coping by spiritual means, cognitive restructuring, and solving problems (Lai & Oei, 2014). Aggressive avoidance involves intentionally distracting oneself from thinking about the situation at hand. It may encompass such behaviors as ignoring the needs of the child, distancing oneself from people more likely to bring up the topic of autism, and denying the fact that a kid has an autistic spectrum disorder. Coping by spiritual means involves turning to religion as a source of solace, peace, and encouragement. It also involves participating in religious activities, such as praying about one’s situation and reading sacred books to find the words of hope.
The cognitive restructuring follows acceptance and modifying one’s thoughts to appreciate the positivity in caring for an autistic child. A caregiver may change his or her expectations in life to adjust that of living with a young patient. There is also an appreciation of the child’s qualities, which makes life enjoyable. Finally, solving the issues includes situations when a parent seeks to find treatment for a child’s condition. In this case, this includes seeking the help of medical professionals and asking for support from various agencies to take care of the child’s needs comprehensively.
Relationship Between Psychological Flexibility and Self-efficacy in Relationship to Adaptive Coping
Flexibility in a psychological state and self-efficacy also have a pivotal role in adaptive coping for caregivers. As Williams et al. (2012) note, psychological flexibility is the ability to maintain a good state of mental health, being in tandem with reality, and not losing sight of the present due to current situations, which, in most cases, are not palatable. Self-efficacy, on the other hand, is the confidence that one has in achieving specific set goals regardless of obstacles along the way. A caregiver with self-efficacy and psychological flexibility is able to easily cope with the demands of taking care of an autistic child. Caring for young patients requires much determination and self-commitment, which are crucial components of a favorable treatment environment.
The fact that an autistic child is chronically dependent on a caregiver makes it harder to achieve success, and mental stability is critical if one is to succeed. Most of the parents suffer from depression and cannot adequately take care of their kids with ASD. Psychological flexibility has been described as the cornerstone of good mental health; it is a necessity for parents to facilitate coping (Kashdan & Rottenberg, 2010). Children with an autistic spectrum disorder will live with the condition in their entire lifetime. In most cases, supportive therapy works to aid in endurance with other individuals who are different from them. Therefore, self-efficacy is crucial for the lifelong support of children with ASD.
Protective Factors for Stress
Protective factors against distress for parents as caregivers will depend on the unique characteristics of such adults and specific contextual factors. While shifting the focus to the unique features of parents, protective drivers will include the level of education, employment status, income level, marital status, and age. An educated caregiver has a good understanding of autistic spectrum disorder concerns. This person is thus in a better condition to understand the needs of a child and respond to him or her adequately. Such a caregiver understands that an autistic child will have problems when interacting with other people, face the behavior of repetitiveness, and prefer things to be done in a particular manner repeatedly. For instance, autistic children will want toothpaste to be arranged in a certain way, and any interference with such an arrangement makes them angry. An educated caregiver will understand these factors about a child and give the necessary support, thus being protected against stress.
A caregiver with a good source of income is able to take care of an autistic child who, on most occasions, will have numerous needs. There is, therefore, no stress over the inadequacy of enough money to support the child. A married caregiver is most likely to enjoy care from the spouse, and this protects against anxiety and irritation. Finally, the older the individual is, the better is he or she protected against stress. Mature individuals have better psychological development and problem-solving skills than younger caregivers do. Thus, the aforementioned contextual factors play a significant role as protective drivers.
Treatments for Parents of Children with ASD
Various psychotherapy treatment approaches may be employed for those who have children with ASD. One of the principal psychotherapeutic courses is cognitive behavior therapy. Since it is difficult to deal with autistic children, most parents may end up with cognitive distortions that interfere with their mental health and overall life quality. Possible cognitive distortions that can develop include focusing solely on the negative and ignoring the positive, always expecting adverse outcomes for whatever situation, and personalization whereby an individual takes on excessive responsibility. Cognitive-behavioral therapy has a role in modifying the stated distortions, aiding with the emotional health of parents, and altering behavior to suit the existing situation (Leichsenring et al., 2006). The treatment is also vital in the management of anxiety disorder, which may develop in parents of children with ASD.
Another essential form of treatment for parents is group therapy. When participating in such a treatment program, parents can join individuals grappling with different issues and challenging situations, which, in turn, might also affect them. One of the advantages of group therapy is the fact that all the treatment sessions are conducted by a trained psychotherapist. Due to this type of intervention, parents find an avenue of sharing their emotions and the burdens of caring for children with such a disability as ASD. Self-gratification itself is vital in letting out deep emotions and, thus, a boost to the mental health of therapy participants.
Medical therapy also plays an essential role in treating parents of children with ASD. When a parent experiences severe depression or anxiety due to caring for young autistic patients, medical therapy may be referred to as a potentially successful intervention. Groups of medications that are vital in these conditions will include antidepressants, such as TCAs (Tricyclic Antidepressants), MAO (Monoamine Oxidase) Inhibitors, and SSRIs (Selective Serotonin Reuptake Inhibitors). Classes of drugs that are crucial when managing anxiety will include benzodiazepines and beta-adrenoceptor antagonists.
Choosing an Appropriate Treatment
Choosing an appropriate treatment will depend on the clinical presentation of a parent, the severity of symptoms, the presence of a social support system, and the affordability of a therapy method. A parent with psychological symptoms resulting from caring for a child with ASD will receive treatment in the form of either psychotherapy, psychopharmacotherapy, or both. If symptoms are severe enough to impair a parent’s functionality, there will be a need to first institute medications and then supplement the treatment procedure with pharmacotherapy.
In case a parent experiences mental instability but is still able to function well and take care of a child, psychotherapy will play a significant role. It is also crucial to know the socio-economic status of an adult before instituting treatment. Taking care of an autistic child is an expensive task due to a variety of intervention rules that are to be observed. Thus, it will be unfair also to subject a parent to a costly mode of treatment. An adult should be given the autonomy to decide on an effective medication that he or she can afford.
Acceptance and Commitment Therapy
ACT is a form of behavioral therapy with an emphasis on the relational frame theory and an end goal to achieve psychological flexibility. As Gaudiano (2011) notes, it focuses on critical processes, including mindfulness, acceptance, commitment, and behavior change. The evolution of ACT occurred in three distinctive phases, starting in the late 1970s, initially as comprehensive distancing (Gaudiano, 2011). The comprehensive distancing between the late 1970s and 1985 emphasized extending the basic psychoanalytical approaches to include the use of verbal behavior. An individual’s verbal behavior was found to play a critical role in shaping human conduct. Thus, it was helpful in clinical psychology to manage abnormal behaviors. The second phase in the evolution of ACT began in 1986 (Gaudiano, 2011). At that time, the basis of ACT was on the Relational Frame Theory (RFT). The final phase of ACT evolution began in 2000 and has been relevant until the present (Zettle, 2011). Research on ACTs increased in this period, thereby leading to the international dissemination and use of the approach.
The ACT model focuses on six core processes that have profound effects on the psychological flexibility of individuals. The six facets include the willingness to accept, cognitive defusion, being available and present, self as a context, values, and committed actions (Hayes et al., 2006). The willingness to accept involves embracing events that happen in one’s life, neglecting the need to alter the manner or frequency in which they occur (Harris, 2019). For instance, a person struggling with anxiety learns how to go through this negative emotional state without trying to avoid it.
Cognitive defusion implies utilizing ACT to modify the purpose of a specific idea rather than altering the thought (Fletcher & Hayes, 2005). Being present refers to an individual’s ability to interact with the events of one’s surrounding environment as they are, instead of passing judgment. Values in ACT represent qualities in life that a person develops gradually by following an intentional action done periodically. Finally, committed action involves using ACT to establish a constant pattern of activity, which leads to the establishment of targeted values.
ACT has its philosophical basis on functional contextualism that focuses on predicting events and influencing them with much precision. The process attempts to explain individuals’ psychological background as a product of internal actions interacting differently with various contexts, such as historical events and environmental shifts. As opposed to descriptive contextualism, ongoing internal actions in individuals can be considered for pragmatic use in functional contextualism, while the former phenomenon follows the principle of ontology. The application of functional contextualism in the topic in question is the utilization of values as a criterion for implementing the ability of the six core processes of the ACT model.
ACT has its emphasis on the Relational Frame Theory that is the main tool differentiating the model from behaviorism and cognitive behavioral therapy. The method emphasizes the fact that the development of human language and higher functions is a result of the ability to create an arbitrary link among different concepts (Hayes, 2016). Human language results in two main natural effects that include cognitive fusion and experimental avoidance. Cognitive fusion involves modifying the manner and frequency of a private event, even if such an action harms an individual’s behavior. On most occasions, it supports experimental avoidance that implies altering the form and sensitivity of one’s thoughts and feelings even though harm is a direct consequence.
Relational frames have three main features, including mutual entailment, combinatorial entailment, and transformation of functions (Hayes, 2016). In mutual entailment, if an individual notices that X leads to Y, he or she will have it in mind that Y is also connected to X. In combinatorial entailment, if X is related to Y and Y to Z, an individual understands that all three variables are interrelated. Finally, in the transformation of functions, if X and Y are related, and Z that is related to one of the two letters is included, an individual understands that the relationship between X and Y will not remain the same. The concepts of the relational frame theory with increased probability for cognitive defusion and experimental acceptance have been integrated into ACT.
The psychopathological description of ACT has its bearing on the relational frame theory (Hayes, 2016). Based on the ACT, psychopathological problems occur when the interaction of human language and higher functions with the context of an individual impairs the ability to persist in purposeful action to produce intended values. A significant form of psychopathology that is its consequences is psychological inflexibility. According to ACT, inflexibility results from poor contexts that do not have sustainable control over the development of human language. An example of a weak context is the aspect of literality, which involves interpreting symbols directly as one would with referents. The modalities of treatment for ACT include its application in psychotherapy and cognitive behavioral therapy.
Empirical Literature for ACT
Studies have demonstrated the robustness of ACT in managing stress among people providing care to children with ASD. Hayes et al. (2009) define ACT as an approach concerned with the acceptance of life determinants that seem impossible to change and the commitment towards changing. In their study, Asih and Saraswati (2019) implemented ACT among four parents of children living with ASD. Stress and strain were assessed prior to and after ACT implementation. The measurement of strain score and the findings assume a significant improvement in stress management among the parents who are the primary caregivers (Asih & Saraswati, 2019). In addition, the participants report positive feelings, control over negative emotions, and have improved capacity to sustain troubling events in their lives. The members of the study also note that they have acquired skills and knowledge regarding stress as they provide care to children with ASD. In this case, the effectiveness of ACT in stress and strain reduction among parents providing care to autistic children is evident.
Poddar et al. (2015) study four indicators of stress among caregivers before and after enrolment into the ACT. Five parents are defined as primary caregivers to children with ASD. They are monitored by the assessment of the five indicators of stress, including depression, psychological flexibility, anxiety, and life quality. After the treatment, the levels of different indicators are assessed before and after the enrolment (Poddar et al., 2015). The administration of ACT to the participants produced a characteristic improvement in stress indicators.
The study by Singh et al. (2014) evaluates the reduction in stress among caregivers for ASD adolescents. The research findings suggest the caregivers who undergo training in mindfulness-based practices during the ACT sessions report a reduction in stress levels. There was a reduction in stress in mothers who participated in the course to completion (Singh et al., 2014). The researchers also explain the reduction in stress among the mothers as associated with the positive behavior support model applied in training (Singh et al., 2014). Furthermore, the participants learn how to engage their intuition and behavioral contingencies while taking care of their ASD children.
Application of ACT to Parents of Children Living with ASD
Parents of children living with ASD have a risk of manifesting stress and associated disorders. Studies have shown that the application of ACT to these adults can help reduce stress symptoms (Bluth et al., 2013). The ACT program may be applied to the parents of young patients with ASD in the form of a mindfulness intervention approach. This method enables adults to adapt to mindfulness-based stress reduction. Secondly, behavior change has been identified as the main pillar of the therapy. For instance, parents can learn how to communicate mindfully with their children living with ASD. This training enables both parents to adopt a friendly communication approach while maintaining psychological flexibility (Bluth et al., 2013). In turn, adults are aware of the strategies for dealing with their ASD children.
Gould et al. (2017) delve into the impact of the ACT on parents of children living with ASD. The application of ACT improves stress outcomes among these adults, which is a positive outcome. The ACT is a behavior training approach that is applicable to both parents and caregivers to enhance their adaptability to the situation of children (Robbins et al., 1991). The study by Robbins et al. (1991) shows that this method is easy to implement when applied to adults in cases when parents are not primary caregivers.
Treatment Conceptualization of ACT for Caregivers
The ultimate goal of ACT for caregivers is to impart a mindful change among adults towards ASD children. Caregivers need to adopt a positive mindset for them to reduce mental engagements in the entire process of care provision (Hayes et al., 2009). The ACT method cannot achieve its intended purpose without considering the critical components of the psychological flexibility model. These variables form the main target of the mindful change. Acceptance, willingness, and cognitive decision are essential in enhancing the success of ACT. Hayes and Watson (2013) report that caregivers who embrace the acceptance of the situations of children living with ASD demonstrate a significant reduction in stress and are more satisfied with their work. The willingness to accept the situation and remain open-minded about young patients has been shown to further improve stress outcomes among caregivers (Hayes & Watson, 2013). Cognitive defusion has also been shown to support caregivers’ willingness to continue assisting ASD children.
The ACT also targets to ensure continuous engagement of the present without making prejudgements of situations. Both the psychological and environmental occurrences are taken into consideration as they take place. The main target of engaging a continuous approach is to ensure that caregivers can directly experience children’s situations (Hayes & Watson, 2013). This experience can help caregivers to adopt a more flexible psychological approach.
On the other hand, the idea of self a concept is anchored on the value of self in a relational frame. The ACT approach depends on caregivers’ ability to value themselves and perceive their role as necessary to young patients. This mentality has the power to affect the spiritual standing of adults and improve their perception of their target audience (Blackledge & Hayes, 2006). There is evidence showing that self as a context can also impact caregivers’ language, including empathy and the theory of mind.
Caregivers’ values may be tested by the quality of their actions towards children. In the ACT, adults are educated on how to apply values to help their target audience to define their life directions. The use of verbal communications is encouraged in ACT, which may result in clients settling on life decisions based on avoidance or social compliance. This approach is considered successful when the patients finally make constructive decisions based on their intuition but not social influence (Bond et al., 2011). As Barnes-Holmes et al. (2002) argue, committed actions link the patterns of effective actions to caregivers’ values. This leads to the incorporation of a committed step in the ACT to enforce behavior change as a way of enhancing care for children living with ASD.
The study by Poddar et al. (2015) has been carried out in the hospital environment to investigate the indicators of stress among parents before ACT and after administration of the therapy. The states of depression, anxiety, psychological state, and flexibility were evaluated. The study results demonstrate an improvement in the variables assessed. There was a 51.6 BDI reduction in the state of anxiety following the treatment. Psychological flexibility has increased from 78.4 to 84.4 AAQ, while depression is the most improved stress indicator having reduced by half from 20.6 to 10.2 BDI at a P-value of 0.04 (Poddar et al., 2015). This study demonstrates the critical role of ACT in reducing stress indicators and, in particular, depression.
Another study by Singh et al. (2006) assesses the states of anxiety, depression, aggression, and psychological flexibility of caregivers and parents of children with ASD. The participants have improved in their ability to handle stress and reduce anxiety (Singh et al., 2006). These outcomes are the basis of recommendations for the implementation of ACT among parents and caregivers to alleviate stress when interacting with ASD children.
Integration of ACT and Caregivers
Autism Spectrum Disorder (ASD) is a neuro-degradative disease that results in poor coordination in language, social behavior, and communication functions among its victims (Asih & Saraswati, 2019). The majority of people living with ASD are children who require care from both their parents and other caregivers. The family dynamics are significantly affected by the presence of a child living with such a diagnosis. Those parents who are the primary caregivers face the daunting task of learning how to care for a child newly diagnosed with this disorder (Taylor & Warren, 2012). The most affected population includes adults who have to cope with their children’s disorder. These parents struggle with such challenges as trying to understand the communication of their ASD child, the unpredictable expression of emotions, and language impairment expressed by a young patient.
The ASD-affected children may occasionally show repetitive movements and become too aggressive. Parents and caregivers have to always check for these symptoms and respond to them adequately (Singh et al., 2014). In addition, the audience in question is expected to nurture and satisfy all the basic needs of these children. In light of all the additional responsibilities that caregivers have to undertake, they may be at a high risk of developing stress and depression symptoms. According to Thornton and Travis (2003), adults are strained by their roles, particularly when the target patients to care for are their own children.
Another study by Catalano et al. (2018) shows that those parents who take care of ASD children experience high levels of stress compared with the untreated group who does not have such a responsibility. Most of the factors associated with ASD cause a high-stress level among parents and caregivers, as discussed above. However, some elements are associated with either high levels of anxiety or no stress. This has been witnessed mostly among those parents who learn and adjust to the unique needs of young patients. The analysis of parents’ behavior, who have undergone mindful training, shows that they have lower levels of stress and can interact with children with maintaining a positive mindset (Singh et al., 2006). Therefore, this training is essential for parents, and attending ACT sessions may bring positive outcomes.
Conceptualization of the Parent of a Child with ASD Using ACT Perspective
Parents of children living with ASD have additional responsibilities to take care of them. This disorder causes a significant developmental delay of the affected population, including mental communication and physical health indicators. These children are unable to take care of themselves, and the situation is complicated by the fact that parents have to remain alert to patients’ aggressive behavior. This added responsibility exerts pressure on adults and causes moral exhaustion. In the study by Lambrechts et al. (2015), the researchers demonstrate high-stress levels among parents and prove the problem exists. This population may experience rejection and the belief that the situation of their child cannot be changed, which may affect their efforts to seek help.
Despite the principle of ACT, which focuses on the process of behavior and psychological change, it is not concerned with the thought process of a person. The main idea of ACT is to improve mental flexibility regardless of individuals’ thoughts. This mechanism of ACT has been cited as an inadequacy of the therapy (Zhang et al., 2018). According to Hayes et al. (2009), psychological flexibility may be improved by influencing an individual’s thoughts, yet the ACT method does not consider this vital strategy. In addition, Hayes et al. (2013) demonstrate the inability of ACT to challenge ideas and logical reasoning. Instead, the authors state that this approach adopts a behavior change model not linked to the thought processes (Hayes et al., 2013). In this case, the ACT is a psychological process anchored on philosophical principles.
The belief that stress associated with parenting children with ASD is not different from the stress as a result of the reaction to circumstances has been disputed in academic literature. For instance, Miranda et al. (2019) present evidence to support the high intensity of stress associated with parenting children with ASD. Some of the sources of stress that have been proposed include difficulties in dealing with patients’ behavior, developing strategies for parents, and addressing children’s aggressive and violent conduct (Miranda et al., 2019). The degree of the signs of ASD has also been shown to increase the level of stress among parents. Such factors delineate the level of stress experienced by parents of ASD children from the level of stress caused by a normal reaction to circumstances (Bluth et al., 2013). Despite evidence in the literature, which supports the notion that anxiety encountered by parents of children with ASD is unique, their nature of stress remains the same, and the outcomes are the same. The interpretation of evidence presents the challenge of distinguishing between a normal stress reaction and the anxiety caused by interaction with ASD children.
The ethical perspective of ACT has been raised with disagreement on whether the method is a violation of social principles. For instance, there is an argument that the ACT method does not consider parents’ feeling bad about daily situations that the parents of children with ASD have to face. Adults feel sorry for their children whose life cannot be improved. Eventually, depressive and stressful conditions develop in parents as primary caregivers (Dindo et al., 2017). The necessary treatment for stress reduction is through the optimized mental assessment model as opposed to the behavior change perspective indicated by ACT. Therefore, alternatively, the ACT method may be viewed as a violation of common social principles.
The approach adopted in the ACT method focuses primarily on the effectiveness of behavior and the application of psychological flexibility to reduce stress among caregivers and parents of children with ASD. The capacity of this integrated mechanism is manifested in its ability to improve the thought of caregivers. For instance, adults who experience constant stress may develop functional behavior after ACT sessions. Kanter et al. (2006) show the effectiveness of ACT in the alleviation of stress-related symptoms among caregivers who are troubled by thoughts of attending to children with ASD. Most notably, there is a significant reduction in depression among the participants, which is a positive result.
Cognitive Fusion and the Influence of Experiential Avoidance
The effect of cognitive fusion stems from the tenant that the suffering endured by a human is due to psychological inflexibility. The concept of cognitive fusion and experiential avoidance are strongly interrelated and affect the process of distress and psychopathy. Consequently, distress and psychopathy are the causes of the manifestations of stress and related disorders (Bardeen & Fergus, 2016). The influence of both cognitive fusion and experimental avoidance has been studied with respect to the indicators of stress.
ACT in Practice
The ACT practice depends on the availability of training resources to incorporate it as a necessary skills training program for parents. The use of specific instructions to impart basic ACT knowledge to adults can help enhance the process of care provided to children while reducing the psychological effects on parents and caregivers (Batink et al., 2016). According to the necessary behavioral change principles, parents can be trained on how to perceive the situation of their children positively and take the measures needed to improve the situation. Maintaining psychological flexibility is a critical skill that adults should be trained in.
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