Interventions that target improvements in mental health for parents of children with autism spectrum disorders: A narrative review.

Prevalence of autism spectrum disorders (ASD) suggest that one in 68 children is affected. With convincing evidence that parenting a child with ASD is associated with elevated distress and mental health problems, researchers have begun to investigate treatments that directly target parents' psychological well-being. We conducted a narrative review of studies that empirically tested the effects of interventions targeting improvements in the mental health of parents of children with ASD. Following a range of search strategies, a total of 13 studies, seven randomized controlled trials (RCTs) and six pre-post test designs, met inclusion criteria. We calculated and reported effect sizes for all RCTs. On average, treatment produced medium to large effect sizes with improvements in parenting stress and general health, and reductions in depression and anxiety. Interventions that appeared promising included: Stress Management and Relaxation Techniques, Expressive Writing, Mindfulness-Based Stress Reduction, and Acceptance and Commitment Therapy. However, only one study conducted a follow-up assessment >3months post intervention. Study populations primarily consisted of English-speaking mothers, ages 39 to 42years. Conclusions were limited by small sample sizes, homogeneity of sample population, and reliance on self-report. Therefore, this body of research contains significant limitations in need of improvement for this field to move forward and benefit a sizable number of parents.

Related papers:

title: Health-related quality of life in parents of school-age children with Asperger syndrome or high-functioning autism
abstract: BackgroundThe estimated prevalence rate of Pervasive Developmental Disorders (PDD) in children is 6 per 1.000. Parenting children who are intellectually impaired and have PDDs is known to be linked to the impaired well-being of the parents themselves. However, there is still little available data on health-related quality of life (HRQL) in parents of children with Asperger Syndrome (AS) and High-Functioning Autism (HFA), or other PDD diagnoses in children of normal intelligence. The present study aimed to evaluate aspects of HRQL in parents of school-age children with AS/HFA and the correlates with child behaviour characteristics.MethodsThe sample consisted of 31 mothers and 30 fathers of 32 children with AS/HFA and 30 mothers and 29 fathers of 32 age and gender matched children with typical development. Parental HRQL was surveyed by the use of the 12 Item Short Form Health Survey (SF-12) which measures physical and mental well-being. The child behaviour characteristics were assessed using the structured questionnaires: The High-Functioning Autism Spectrum Screening Questionnaire (ASSQ) and The Strengths and Difficulties Questionnaire (SDQ).ResultsThe mothers of children with AS/HFA had lower SF-12 scores than the controls, indicating poorer physical health. The mothers of children with AS/HFA also had lower physical SF-12 scores compared to the fathers. In the AS/HFA group, maternal health was related to behaviour problems such as hyperactivity and conduct problems in the child.ConclusionMothers but not fathers of children with AS/HFA reported impaired HRQL, and there was a relationship between maternal well-being and child behaviour characteristics.

title: Assessment of Health-Related Quality of Life Among Primary Caregivers of Children with Autism Spectrum Disorders
abstract: The impact of caring for a child with autism on caregivers’ health-related quality of life (HRQOL) is not fully understood. The objective of this study was to compare the HRQOL scores of caregivers of children with autism to those of the general US population and to identify the factors that influence HRQOL. Caregivers of children with autism had lower HRQOL scores than the general population. Care recipient level of functional impairment, social support, use of maladaptive coping, and burden influenced caregiver mental HRQOL. Care recipient extent of behavioral problems and social support influenced caregiver physical HRQOL. Findings emphasize the use of multi-pronged intervention approach that incorporates components aimed at improving family functioning, increasing support services, and assisting caregivers in developing healthy coping skills.

title: Impairment of quality of life in parents of children and adolescents with pervasive developmental disorder
abstract: BackgroundLittle is known about the Quality of Life (QOL) in parents of children with developmental diseases as compared to other severe neurological or psychiatric disorders. Aims of the present study were: to evaluate QOL in parents of children affected by Pervasive Development Disorder (PDDs), Cerebral Palsy (CP) or Mental Retardation (MR) as compared to a control group (CG); to evaluate QOL of parents of patients with different types of PDDs, namely Autistic Disorder (AD), High Function Autism/Asperger Syndromes (HFA/AS) and Pervasive Developmental Disorder Not Otherwise Specified (PPD-NOS); and to compare the level of impairment in QOL of mothers and fathers within PDDs, CP, MR groups and between AD, HFA/AS, PDD-NOS sub-groups.MethodsThe sample consisted of 212 parents (115 mothers and 97 fathers) of 135 children or adolescents affected by PDDs, MR or CP. An additional sample of 77 parents (42 mothers and 35 fathers) of 48 healthy children was also included and used as a control group. QOL was assessed by the WHOQOL-BREF questionnaire.ResultsCompared with parents of healthy children, parents in the PDDs group reported impairment in physical activity (p = 0.0001) and social relationships (p = 0.0001) and worse overall perception of their QOL (p = 0.0001) and health (p = 0.005). Scores in the physical (p = 0.0001), psychological (p = 0.0001) and social relationships domains (p = 0.0001) and in the physical (p = 0.0001) and social relationships (p = 0.0001) domains were lower compared to the MR group CP group respectively. Little differences were observed between MR, CP and control groups. The level of impairment of physical (p = 0.001) and psychological (p = 0.03) well-being were higher in mothers than in fathers in the PDDs and CP groups respectively; in the other groups, and across all the other domains of QQL impairment was similar. There were no statistically significant differences in the scores between the AD, HFA/AS and PDD-NOS sub-groups, but parents in the HFA/AS sub-group seemed to display a lower QOL compared to the AD sub-group.ConclusionParents of children with PDDs seem to display a higher burden, probably for a combination of environmental and genetic factors. Within this group of parents also those of HFA or AS people have higher stress. These finding must be taken into account in policy making to provide better and more specific supports and interventions for this group of diseases.

title: Hardiness and Social Support as Predictors of Stress in Mothers of Typical Children, Children with Autism, and Children with Mental Retardation
abstract: This study assessed the effects of social support and hardiness on the level of stress in mothers of typical children and children with developmental disabilities. One hundred and twenty mothers participated (40 mothers of children with autism, 40 mothers of children with mental retardation, and 40 mothers of typically developing children). Results indicated significant group differences in ratings of depression, anxiety, somatic complaints and burnout. Regression analyses were conducted to determine the best predictors of the dependent measures. Both hardiness and social support were predictive of successful adaptation. The relationships among hardiness, support and coping are discussed.

title: Systems Analysis of Stress and Positive Perceptions in Mothers and Fathers of Pre-School Children with Autism
abstract: Systemic analyses of psychological functioning in families of children with autism have typically shown that parents report different experiences (e.g., stress) and that siblings may also be affected. The purpose of the present research was more explicitly to address relationships between child, partner, and parent variables. Parents of 48 children with autism (41 mother–father pairs) reported on child characteristics, and their own stress and mental health. Mothers were found to report both more depression and more positive perceptions than fathers. Regression analyses revealed that paternal stress and positive perceptions were predicted by maternal depression; maternal stress was predicted by their children’s behavior problems (not adaptive behavior or autism symptoms) and by their partner’s depression. The future testing of the mechanisms underlying these results is discussed. In addition, the need is emphasized for more systemic analyses to understand the psychological functioning of children with autism and their siblings and parents.

title: Moderators of Stress in Parents of Children with Autism
abstract: Parents of children with autism experience more stress and are more susceptible to negative outcomes than parents of children with other disabilities. The present work examines the relationship between stressors, social support, locus of control, coping styles, and negative outcomes (depression, social isolation, and spousal relationship problems) among parents of children with autism. Fifty-eight parents completed surveys. Results indicated that several coping styles corresponded to negative outcomes. Furthermore, the relationship between stressors and negative outcomes was moderated by social support and coping style. Results are discussed in relation to applications for clinical practice.

title: Factors Contributing to Stress in Parents of Individuals with Autistic Spectrum Disorders.
abstract: The study explores the experiences of parents of individuals with autistic spectrum disorders (ASDs), and examines the influences of parent gender and child age on perceived stress, stress and coping, child-rearing involvement, support and information/education accessed. 
 
 
 
Questionnaires assessed general perceived stress, involvement, stress and coping related to caregiving, social support, and amount of information/education accessed in 23 mothers and 19 fathers of 3- to 18-year-old individuals with ASDs. 
 
 
 
When compared with fathers, mothers were significantly more stressed, more involved, and reported higher levels of stress and coping related to caregiving. Differences were found according to child age, regarding helpfulness of support and access to information/education. Parent gender and child age moderated correlations between some variables. Content analyses identified factors contributing to parental stress and its alleviation. 
 
 
 
The positive relationships between the amount of information accessed and the quality of support received by parents, and between parental stress and involvement vary according to the life stage of the child. Mothers experienced a greater caregiving burden when compared with fathers.

title: Religiosity, Spirituality, and Socioemotional Functioning in Mothers of Children with Autism Spectrum Disorder
abstract: Religious beliefs, religious activities, and spirituality are coping resources used by many mothers of children with autism spectrum disorder (ASD). This study examined whether and how these resources were related to maternal socioemotional functioning. Mothers of children with ASD completed questionnaires assessing religiosity, spirituality, and a wide range of outcome variables, including stress, depression, self-esteem, life satisfaction, positive affect, and sense of control. Analyses revealed that religious beliefs and spirituality were associated with better positive outcomes and, to a lesser extent, lower levels of negative outcomes. Of the two predictors, spirituality accounted for more unique variance in positive outcomes. In contrast, religious activities were related to more negative outcomes and lower levels of positive outcomes.

title: Finding meaning in parenting a child with Asperger syndrome: correlates of sense making and benefit finding.
abstract: This study explored the nature of two construals of meaning, benefit finding and sense making, in parents of a child with Asperger syndrome, and examined relations between both meaning constructs and the Double ABCX family stress model variables (initial stressor and pile-up of demands, appraisal, social support, coping strategies and adjustment) [H.I. McCubbin, J.M. Patterson, Social Stress and the Family: Advances and Developments in Family Stress Theory and Research, Haworth, New York, 1983, pp. 7-37]. A total of 59 parents completed questionnaires. Content analyses of parents' responses to questions inquiring about gains and sense making explanations revealed 8 benefit and 12 sense making themes. Results of correlations indicated that one or more of the meaning variables were related to each of the Double ABCX model predictors of parental adjustment. The meaning variables were positively related to adaptive coping processes: social support, self-efficacy, and problem-focused and emotional approach coping strategies.

title: A Meta-analytic Review of Components Associated with Parent Training Program Effectiveness
abstract: This component analysis used meta-analytic techniques to synthesize the results of 77 published evaluations of parent training programs (i.e., programs that included the active acquisition of parenting skills) to enhance behavior and adjustment in children aged 0–7. Characteristics of program content and delivery method were used to predict effect sizes on measures of parenting behaviors and children’s externalizing behavior. After controlling for differences attributable to research design, program components consistently associated with larger effects included increasing positive parent–child interactions and emotional communication skills, teaching parents to use time out and the importance of parenting consistency, and requiring parents to practice new skills with their children during parent training sessions. Program components consistently associated with smaller effects included teaching parents problem solving; teaching parents to promote children’s cognitive, academic, or social skills; and providing other, additional services. The results have implications for selection and strengthening of existing parent training programs.

title: Parenting Interventions for Children with Autism Spectrum and Disruptive Behavior Disorders: Opportunities for Cross-Fertilization
abstract: Empirical support exists for parent training/education (PT/PE) interventions for children with disruptive behavior disorders (DBD) and autism spectrum disorders (ASD). While the models share common roots, current approaches have largely developed independently and the research findings have been disseminated in two different literature traditions: mental health and developmental disabilities. Given that these populations often have overlapping clinical needs and are likely to receive services in similar settings, efforts to integrate the knowledge gained in the disparate literature may be beneficial. This article provides a systematic overview of the current (1995–2005) empirical research on PT/PE for children with DBD and ASD; attending to factors for cross-fertilization. Twenty-two ASD and 38 DBD studies were coded for review. Literature was compared in three main areas: (1) research methodology, (2) focus of PT/PE intervention, and (3) PT/PE procedures. There was no overlap in publication outlets between the studies for the two populations. Results indicate that there are opportunities for cross-fertilization in the areas of (1) research methodology, (2) intervention targets, and (3) format of parenting interventions. The practical implications of integrating these two highly related areas of research are identified and discussed.

title: Parent training: A review of methods for children with autism spectrum disorders
abstract: Autism Spectrum Disorders (ASD) are common in the general childhood population, and are both serious and lifelong. Tremendous strides have been made in the treatment of these ASD in recent years, particularly with respect to psychological interventions. Given the considerable amount of time and cost involved in providing these interventions, parent training and involvement is a particularly appealing intervention option. This paper is a review and status report on evidence based methods that are available for training parents of children with ASD as therapists. Current trends and future directions are discussed.

title: Parent implemented early intervention for young children with autism spectrum disorder: a systematic review.
abstract: Recent estimates concerning the prevalence of autism spectrum disorder (ASD) suggest that at least one in 200 children is affected. This group of children and families have important service needs. The involvement of parents in implementing intervention strategies designed to help their autistic children has long been accepted as helpful. The potential benefits are increased skills and reduced stress for parents as well as children.



This research review focused on interventions for children aged 1-6 years, and was carried out using systematic methodology: a comprehensive search of psychological, educational and biomedical databases, as well as bibliographies and reference lists of key articles, contact with experts in the field, and hand search of key journals. Only studies which involved a concurrent element of control were included.



The review found very few studies that had adequate research design from which to draw conclusions about the effectiveness of parent-implemented early intervention. Both randomized and controlled studies tended to suggest that parent training leads to improved child communicative behaviour, increased maternal knowledge of autism, enhanced maternal communication style and parent child interaction, and reduced maternal depression.



It seems that parent training can successfully contribute to intervention for young children with ASD. However, the review highlights the need for improved research in this area.

title: A systematic review of training programs for parents of children with autism spectrum disorders: Single subject contributions
abstract: The purpose of this systematic review was to examine research utilizing single subject research designs (SSRD) to explore the effectiveness of interventions designed to increase parents’ ability to support communication and social development in children with autism spectrum disorders (ASDs).  Included studies were systematically assessed for methodological quality (Logan et al., 2008; Smith et al., 2007) and intervention effects. Data examining participant characteristics, study methodology, outcomes, and analysis were systematically extracted.  Eleven SSRD parent-training intervention studies examining 44 participants with ASD were included. Overall, the studies were of moderate quality and reported increases in parent skills and child language and communication outcomes.  The results supported by improvement rate difference (IRD) analysis indicated several interventions demonstrated positive effects for both parent and child outcomes. However, limited generalization and follow-up data suggested only one intervention demonstrated parents’ accurate and ongoing intervention implementation beyond training.

title: A Review of Parent Education Programs for Parents of Children With Autism Spectrum Disorders
abstract: Benefits of parent education have been demonstrated for decades. However, there exists a lack of formative evaluation of parent education for parents of children with autism spectrum disorders (ASD), limiting the interpretation of ongoing and future research. To understand the current status, key characteristics, and evaluation methods of parent education specific to ASD, relevant research was reviewed with an emphasis on presentation format, evaluation methods, and participant demographics. Of the 30 articles that met inclusion criteria, more than half included descriptions of programs for parents of children with ASD ages 3—5 years, 76% involved a one-on-one training approach, 40% relied on a manual or curriculum, 86% included data on parent and child outcomes, and 70% used single-case designs to evaluate program effectiveness. None of the researchers reported data on fidelity of implementation. Suggestions for further evaluation and next-generation research are provided.

title: Comparative Effects of Mindfulness and Skills-Based Parent Training Programs for Parents of Children with Autism: Feasibility and Preliminary Outcome Data
abstract: Parents of children with autism report high levels of stress as compared to parents of typically developing children, children with chronic illnesses, and children with other developmental disabilities. Previous research has supported both parent-focused and child-focused parent training programs as effective in alleviating parental stress and enhancing meaningful parent–child interactions. In the present study, a behavioral skills approach was compared to a parent-oriented model, a mindfulness group. Fifteen parents of children with autism were matched on a measure of parental stress and were randomized to one of the two treatment groups. Each group included an 8-week program that incorporated didactics, discussion, role plays, and homework. Parental stress and global health outcomes were assessed at pre-treatment, post-treatment, and 3-month follow-up. Overall, the mindfulness group alone demonstrated statistically significant improvement on both outcome measures following treatment. Although significant changes were not observed in the skills group, effect sizes suggested moderate to large treatment benefits. The feasibility of the programs as well as implications and future directions of this line of research are discussed.

title: Primary and secondary effects of parenting and stress management interventions for parents of children with developmental disabilities: a meta-analysis.
abstract: A meta-analysis of the group intervention research for parents of children with developmental disabilities was conducted in order to characterize the efficacy of treatments in reducing depressive symptoms and other forms of psychological distress associated with stress in parents of children with developmental disabilities. An extensive search led to the identification of 17 studies which were divided into three categories for comparative purposes: parenting education studies usually based on behavioral parent training, coping skills education studies based primarily on cognitive behavioral training, and studies that combined these methods along with other support services. Studies were rated for the quality of the research designs and of the reports. Consistent positive benefits were found in the form of reductions in parents' distress, and these effects were comparable to those reported in other syntheses of parenting interventions for parents of children without disabilities. The studies were evaluated in order to assess whether or not they met standards for established evidence-based practices. On the basis of the quality and number of the randomized trials, we present evidence to support the claim that there are established evidence-based interventions for reducing psychological distress at least in middle-class mothers in the short term. The interventions for fathers are promising as are the data on somewhat longer-term effects. The need for replications with a more diverse group of parents and longer-term follow-up were discussed. Multiple component interventions addressing both parent well-being and behavioral parent training were significantly more effective than either behavioral parent training or cognitive behavioral training along.

title: The Scottish Centre for Autism Preschool Treatment Programme
abstract: This article evaluates the effectiveness of a developmentally based early intervention programme. Two groups of children were compared, a treatment group and a no-treatment control group. Standardized assessments were administered before and after the intervention period by an independent clinician. Pre-treatment comparisons revealed that the control group had a significantly higher pre-treatment IQ; but the two groups were comparable for age, mental age, socioeconomic status and number of hours of non-experimental therapy. Results demonstrated that children in the treatment group improved significantly more than those in the control group on measures of joint attention, social interaction, imitation, daily living skills, motor skills and an adaptive behaviour composite. A measure of requesting behaviour fell short of statistical significance. The total stress index reduced for treatment group parents and increased for the control group parents (but not significantly). The results of the study are considered to support the efficacy of this treatment approach.

title: Effects on Parental Mental Health of an Education and Skills Training Program for Parents of Young Children With Autism : A Randomized Controlled Trial
abstract: To determine the impact of a parent educ ation and behavior management intervention (PEBM) on the mental health and adjust ment of parents with preschool children with autism.  A randomized, group-c omparison design involving a parent education and counseling intervention to con trol for nonspecific therapist effects and a control sample was used. Two metropol itan and two rural regions were randomly allocated to intervention groups ( n = 70) or control ( n = 35). The parents of consecutive children with autism (21⁄2–5 years old) f rom the autism assessment services for the intervention regions were then ran domly allocated to either a 20week manual-based parent education and behavior man agement intervention ( n = 35) or a manual-based parent education and counseling i ntervention ( n = 35). The main outcome measure of parental mental health was the G eneral Health Questionnaire used preand postintervention and at 6-month follo w-up.  Both treatments resulted in significant and progressive improvement in overall mental health at follow-up ( F = 2, 97, p = .007) and mental health significantly improved o ver time in the 54% of principal caregivers who had the highest levels of mental health problems. The parent education and behavior management interv ention was effective in alleviating a greater percentage of anxiety, insomn ia, and somatic symptoms and family dysfunction than parent education and counse ling at 6-month follow-up.  A 20-week parent education and skills training program for parents of young children newly diagnosed with autism provides significant improvements in parental mental health and adjustment, justifying i ts addition to early intervention programs at least for parents with mental health pr oblems.  Psychiatry, 2006;45(5):561–569.

title: Improving maternal mental health after a child's diagnosis of autism spectrum disorder: results from a randomized clinical trial.
abstract: The prevalence of psychological distress among mothers of children with autism spectrum disorder (ASD) suggests a need for interventions that address parental mental health during the critical period after the child's autism diagnosis when parents are learning to navigate the complex system of autism services.



To investigate whether a brief cognitive behavioral intervention, problem-solving education (PSE), decreases parenting stress and maternal depressive symptoms during the period immediately following a child's diagnosis of ASD.



A randomized clinical trial compared 6 sessions of PSE with usual care. Settings included an autism clinic and 6 community-based early intervention programs that primarily serve low-income families. Participants were mothers of 122 young children (mean age, 34 months) who recently received a diagnosis of ASD. Among mothers assessed for eligibility, 17.0% declined participation. We report outcomes after 3 months of follow-up (immediate postdiagnosis period).



Problem-solving education is a brief, cognitive intervention delivered in six 30-minute individualized sessions by existing staff (early intervention programs) or research staff without formal mental health training (autism clinic).



Primary outcomes were parental stress and maternal depressive symptoms.



Fifty-nine mothers were randomized to receive PSE and 63 to receive usual care. The follow-up rate was 91.0%. Most intervention mothers (78.0%) received the full PSE course. At the 3-month follow-up assessment, PSE mothers were significantly less likely than those serving as controls to have clinically significant parental stress (3.8% vs 29.3%; adjusted relative risk [aRR], 0.17; 95% CI, 0.04 to 0.65). For depressive symptoms, the risk reduction in clinically significant symptoms did not reach statistical significance (5.7% vs 22.4%; aRR, 0.33; 95% CI, 0.10 to 1.08); however, the reduction in mean depressive symptoms was statistically significant (Quick Inventory of Depressive Symptomatology score, 4.6 with PSE vs 6.9 with usual care; adjusted mean difference, -1.67; 95% CI, -3.17 to -0.18).



The positive effects of PSE in reducing parenting stress and depressive symptoms during the critical postdiagnosis period, when parents are asked to navigate a complex service delivery system, suggest that it may have a place in clinical practice. Further work will monitor these families for a total of 9 months to determine the trajectory of outcomes.

title: Emotional Disclosure Through Journal Writing: Telehealth Intervention for Maternal Stress and Mother–Child Relationships
abstract: This study examines emotional disclosure through the activity of journaling as a means of coping with maternal stress associated with parenting a child with disruptive behaviors. Through a randomized control and pre-test post-test study design of an online journal writing intervention, change to maternal stress and quality of mother–child relationship for children with ASD, ADHD and SPD was addressed. Behavioral symptoms were found to be the primary source of parenting stress for mothers and a significant relationship between child characteristics and maternal stress was identified. Emotional disclosure through the online journal writing program (especially in the presence of high disclosure of negative emotions) was shown to reduce maternal stress and improve the quality of mother–child relationship. These findings suggest cost-effective telehealth interventions may support maternal health. Important clinical implications are discussed.

title: Mindfulness training effects for parents and educators of children with special needs.
abstract: Parents and teachers of children with special needs face unique social-emotional challenges in carrying out their caregiving roles. Stress associated with these roles impacts parents' and special educators' health and well-being, as well as the quality of their parenting and teaching. No rigorous studies have assessed whether mindfulness training (MT) might be an effective strategy to reduce stress and cultivate well-being and positive caregiving in these adults. This randomized controlled study assessed the efficacy of a 5-week MT program for parents and educators of children with special needs. Participants receiving MT showed significant reductions in stress and anxiety and increased mindfulness, self-compassion, and personal growth at program completion and at 2 months follow-up in contrast to waiting-list controls. Relational competence also showed significant positive changes, with medium-to-large effect sizes noted on measures of empathic concern and forgiveness. MT significantly influenced caregiving competence specific to teaching. Mindfulness changes at program completion mediated outcomes at follow-up, suggesting its importance in maintaining emotional balance and facilitating well-being in parents and teachers of children with developmental challenges.

title: Use of a Relaxation Technique by Mothers of Children with Autism: A Case-Series Study
abstract: Mothers of children with autism are subject to considerable stress by having to adjust to the disorder and to cope with practical and social issues. Evidence on the effects of relaxation training on stress of these mothers is scarce. The purpose of this pilot case-series study was to examine the role of a simple 6-week daily stress management technique on mothers of children with autism. Mothers' stress measurements and children's functionality were assessed using validated instruments. Participants were 11 mothers of children with autism seen consecutively in the autism clinic of a children's hospital. Statistically significant median reductions of perceived and parental stress were noted after the 6-week intervention. Median stress scores were lower by 37.1% and 33% from the baseline values of the perceived stress scale and parental stress index, respectively. Stress was not significantly correlated with children's functioning. Stress management seems to have benefits for mothers of children with autism.

title: Reducing Distress in Mothers of Children With Autism and Other Disabilities: A Randomized Trial
abstract: Compared with other parents, mothers of children with autism spectrum disorder or other neurodevelopmental disabilities experience more stress, illness, and psychiatric problems. Although the cumulative stress and disease burden of these mothers is exceptionally high, and associated with poorer outcomes in children, policies and practices primarily serve the identified child with disabilities.  A total of 243 mothers of children with disabilities were consented and randomized into either Mindfulness-Based Stress Reduction (mindfulness practice) or Positive Adult Development (positive psychology practice). Well-trained, supervised peer mentors led 6 weeks of group treatments in 1.5-hour weekly sessions, assessing mothers 6 times before, during, and up to 6 months after treatment. Mothers had children with autism (65%) or other disabilities (35%). At baseline, 85% of this community sample had significantly elevated stress, 48% were clinically depressed, and 41% had anxiety disorders.  Using slopes-as-outcomes, mixed random effects models, both treatments led to significant reductions in stress, depression, and anxiety, and improved sleep and life satisfaction, with large effects in depression and anxiety. Mothers in Mindfulness-Based Stress Reduction versus Positive Adult Development had greater improvements in anxiety, depression, sleep, and well-being. Mothers of children with autism spectrum disorder improved less in anxiety, but did not otherwise differ from their counterparts.  Future studies are warranted on how trained mentors and professionals can address the unmet mental health needs of mothers of children with developmental disabilities. Doing so improves maternal well-being and furthers their long-term caregiving of children with complex developmental, physical, and behavioral needs.

title: Using Acceptance and Commitment Training in the Support of Parents of Children Diagnosed with Autism
abstract: Parents of autistic children face enormous challenges, but very little attention has been paid to their psychological needs. Acceptance and Commitment Therapy (ACT) has previously been tested with parents as part of a comprehensive package, but not yet alone. The present study used a within-subject, repeated measures design to test the effects of a 2-day (14 hour) group ACT workshop on 20 normal parents/guardians of children diagnosed with autism. Parents were assessed three weeks before the workshop, one week before, one week after, and three months after. No significant change occurred while waiting for treatment, but pre to post improvements were found on the Beck Depression Inventory-II (BDI-II), and the Global Severity Index (GSI) of the Brief Symptom Inventory (BSI). Significant pre to follow-up improvements were observed on the BDI-II, BSI, and the General Health Questionnaire-12. Processes measures of experiential avoidance and cognitive fusion also changed and there was some evidence that these changes mediated outcomes seen. Results suggest that ACT may have promise in helping parents better adjust to the difficulties in raising children diagnosed with autism.

title: Problem Solving Therapy
abstract: This paper describes how problem solving therapy (PST) would be applied to the treatment of Sylvia (I. Caro, 2001), a 27-year-old depressed wife and mother of three. PST involves training individuals in five major processes: problem orientation, problem definition and formulation, generation of alternatives, decision making, and solution implementation and verification. We briefly describe a problem solving model of depression that highlights the moderating nature of problem solving ability regarding the stress–depression relationship. Based on this model, we then delineate how PST can be specifically applied to Sylvia. This is followed by a brief overview of the research base supporting the efficacy of PST for depression.

title: Writing About Emotional Experiences as a Therapeutic Process
abstract: For the past decade, an increasing number of studies have demonstrated that when individuals write about emotional experiences, significant physical and mental health improvements follow The basic paradigm and findings are summarized along with some boundary conditions Although a reduction in inhibition may contribute to the disclosure phenomenon changes in basic cognitive and linguistic processes during writing predict better health Implications for theory and treatment are discussed

title: Mindfulness : A proposed operational definition
abstract: There has been substantial interest in mindfulness as an approach to reduce cognitive vulnerability to stress and emotional distress in recent years. However, thus far mindfulness has not been defined operationally. This paper describes the results of recent meetings held to establish a consensus on mindfulness and to develop conjointly a testable operational definition. We propose a two-component model of mindfulness and specify each component in terms of specific behaviors, experiential manifestations, and implicated psychological processes. We then address issues regarding temporal stability and situational specificity and speculate on the conceptual and operational distinctiveness of mindfulness. We conclude this paper by discussing implications for instrument development and briefly describing our own approach to measurement.

title: Positive psychology in clinical practice.
abstract: Positive psychology is the scientific study of positive experiences and positive individual traits, and the institutions that facilitate their development. A field concerned with well-being and optimal functioning, positive psychology aims to broaden the focus of clinical psychology beyond suffering and its direct alleviation. Our proposed conceptual framework parses happiness into three domains: pleasure, engagement, and meaning. For each of these constructs, there are now valid and practical assessment tools appropriate for the clinical setting. Additionally, mounting evidence demonstrates the efficacy and effectiveness of positive interventions aimed at cultivating pleasure, engagement, and meaning. We contend that positive interventions are justifiable in their own right. Positive interventions may also usefully supplement direct attempts to prevent and treat psychopathology and, indeed, may covertly be a central component of good psychotherapy as it is done now.

title: Authentic Happiness: Using the New Positive Psychology to Realize Your Potential for Lasting Fulfillment
abstract: In this important, entertaining book, one of the world's most celebrated psychologists, Martin Seligman, asserts that happiness can be learned and cultivated, and that everyone has the power to inject real joy into their lives. In "Authentic Happiness", he describes the 24 strengths and virtues unique to the human psyche. Each of us, it seems, has at least five of these attributes, and can build on them to identify and develop to our maximum potential. By incorporating these strengths - which include kindness, originality, humour, optimism, curiosity, enthusiasm and generosity - into our everyday lives, he tells us, we can reach new levels of optimism, happiness and productivity. "Authentic Happiness" provides a variety of tests and unique assessment tools to enable readers to discover and deploy those strengths at work, in love and in raising children. By accessing the very best in ourselves, we can improve the world around us and achieve new and lasting levels of authentic contentment and joy.

title: Acceptance and Commitment Therapy, Relational Frame Theory, and the Third Wave of Behavioral and Cognitive Therapies.
abstract: The first wave of behavior therapy countered the excesses and scientific weakness of existing nonempirical clinical traditions through empirically studied first-order change efforts linked to behavioral principles targeting directly relevant clinical targets. The second wave was characterized by similar direct change efforts guided by social learning and cognitive principles that included cognitive in addition to behavioral and emotive targets. Various factors seem to have set the stage for a third wave, including anomalies in the current literature and philosophical changes. Acceptance and Commitment Therapy (ACT) is one of a number of new interventions from both behavioral and cognitive wings that seem to be moving the field in a different direction. ACT is explicitly contextualistic and is based on a basic experimental analysis of human language and cognition, Relational Frame Theory (RFT). RFT explains why cognitive fusion and experiential avoidance are both ubiquitous and harmful. ACT targets these processes and is producing supportive data both at the process and outcome level. The third-wave treatments are characterized by openness to older clinical traditions, a focus on second order and contextual change, an emphasis of function over form, and the construction of flexible and effective repertoires, among other features. They build on the first- and second-wave treatments, but seem to be carrying the behavior therapy tradition forward into new territory.

title: BIOFEEDBACK TRAINING FOR ANXIETY TENSION REDUCTION *
abstract: Biofeedback is defined as the immediate ongoing presentation of information to a person concerning his own physiological processes. A patient looking at his own ongoing electrocardiographic (EKG) record is, by definition, getting biofeedback; if he trys to manipulate the heart through internal processes in some way while watching his record, using EKG feedback for guidance, he is trying biofeedback training. Feedback for control of the striate muscles (voluntary nervous system) is the way in which every skill is learned-driving a car, for example-but it was not recognized until recently that the autonomic (involuntary) and central nervous systems could be self-regulated to a significant degree with the aid of biofeedback. In some way that is not yet ful ly understood, immediate knowledge of results develops awareness of normally undetected (normally unconscious) existential cues whose manipulation results in the changes desired. It should be noted that this process of control includes striate behavior. N o one really knows how any volitional act is accomplished. All we know is that as babies we begin to practice controlling the striate system (probably because feedback is always available), but it is still unknown how we move our hands from one position to another. We visualize what we wish to do, give the “command” (whatever that is), and the act is carried out . Autogenic feedback training for self-regulation of temperature (blood flow) has already been shown to be clinically effective in many patients in control of migraine headache.’,‘ Raynaud’s disease, a deficiency of circulation in pcripheral parts of the body, also has been reported in pilot work to yield to temperature training.”,’ Tension headache yields to electroniyographic (EMG) feedback training,” and a host of cardiovascular studies is showing promise for clinical control of a number of cardiac disabilities and hypertension.”.” Very recently Sterman and Friar“ have shown that epilepsy may be brought under control through EEG feedback training for elicitation in the sensory-motor brain region of a 12-14 Hertz (cycles/second) rhythm, and Poirier”’ has reported self-regulation of epilepsy through training of alpha rhythm (8-13 Hz) in the occipital portion of the brain. Although the foregoing reports of biofeedback research and application involve the use of specific physiological signals for the self-regulation of specific identifiable somatic or psychosomatic disabilities, some biofeedback training is especially useful in combatting generalized anxiety tension reactions. Haugen, Dixon, and Dickel” showed that a relaxation program aided on occasion by EMG feedback was useful in training patients to handle their own tension reactions, eventually “turning them off’ without drugs. It is interesting that the described psychiatric problems were often solved in the process. Recently Paul

title: The autistic child and family functioning: A developmental-family systems perspective
abstract: Autism is a severe, long-term developmental disorder that potentially has substantial influence on different aspects of the family system. Principles from family-systems theory are considered as they relate to the autistic child within the family. A selective and critical review is presented of research findings on the influence of the autistic, child on the functioning and interactions of family members, including parents, siblings, and the family as a whole. Research findings are also reviewed on resources associated with successful family adaptation to the autistic child. Suggestions are offered for improved research to assess the relationship between certain child variables and measures of family functioning.

title: Happiness is everything, or is it? Explorations on the meaning of psychological well-being.
abstract: Reigning measures of psychological well-being have little theoretical grounding, despite an extensive literature on the contours of positive functioning. Aspects of well-being derived from this literature (i.e., self-acceptance, positive relations with others, autonomy, environmental mastery, purpose in life, and personal growth) were operationalized. Three hundred and twenty-one men and women, divided among young, middle-aged, and older adults, rated themselves on these measures along with six instruments prominent in earlier studies (i.e., affect balance, life satisfaction, self-esteem, morale, locus of control, depression). Results revealed that positive relations with others, autonomy, purpose in life, and personal growth were not strongly tied to prior assessment indexes, thereby supporting the claim that key aspects of positive functioning have not been represented in the empirical arena. Furthermore, age profiles revealed a more differentiated pattern of well-being than is evident in prior research.

title: Written emotional expression: effect sizes, outcome types, and moderating variables.
abstract: A research synthesis was conducted to examine the relationship between a written emotional expression task and subsequent health. This writing task was found to lead to significantly improved health outcomes in healthy participants. Health was enhanced in 4 outcome types--reported physical health, psychological well-being, physiological functioning, and general functioning--but health behaviors were not influenced. Writing also increased immediate (pre- to postwriting) distress, which was unrelated to health outcomes. The relation between written emotional expression and health was moderated by a number of variables, including the use of college students as participants, gender, duration of the manipulation, publication status of the study, and specific writing content instructions.

title: Parenting stress in mothers of children with autism spectrum disorders.
abstract: The purpose of this paper is to describe the sources of parenting stress in mothers of children with Autism Spectrum Disorders (ASD) and examine the relationship between parenting stress and maternal psychological status (depression and well-being).



A descriptive correlational design was used. Data were collected via mailed questionnaires.



Behavioral symptoms were the primary source of parenting stress for mothers. There was no relationship between child characteristics and parenting stress. Mothers reporting more parenting stress had more depressive symptoms and lower levels of well-being.



Our findings have implications for interventions with mothers to help them manage their children's behavior and focus on stress reduction and well-being.

title: Cognitive self-statements in depression: Development of an automatic thoughts questionnaire
abstract: A 30-item questionnaire was devised to measure the frequency of occurrence of automatic negative thoughts (negative self-statements)associated with depression. Male and female undergraduates were asked to recall dysphoric experiences and to report associated cognitions. One hundred representative cognitions were selected and administered to a second sample, along with the MMPI D scale and the Beck Depression Inventory. Thirty items discriminating between criterion groups of psychometrically depressed and nondepressed subjects were identified. The resultant 30-item automatic thoughts questionnaire (ATQ-30)was cross-validated and found to significantly discriminate psychometrically depressed from nondepressed criterion groups. No differences were found between males and females on the measure. Factor analysis indicated a four-factor solution, with a large first factor reflecting Personal Maladjustment, a second factor indicative of Negative Self-Concept and Negative Expectations, and two lesser factors. The ATQ-30 may provide a means of testing basic theory relating cognitive content to behavioral and affective processes and assessing change in cognitions associated with experimental manipulation or psychotherapeutic intervention.

title: The CES-D Scale
abstract: The CES-D scale is a short self-report scale designed to measure depressive symptomatology in the general population. The items of the scale are symptoms associated with depression which have been used in previously validated longer scales. The new scale was tested in household interview surveys and in psychiatric settings. It was found to have very high internal consistency and adequate test- retest repeatability. Validity was established by pat terns of correlations with other self-report measures, by correlations with clinical ratings of depression, and by relationships with other variables which support its construct validity. Reliability, validity, and factor structure were similar across a wide variety of demographic characteristics in the general population samples tested. The scale should be a useful tool for epidemiologic studies of de pression.

title: A SELF-RATING DEPRESSION SCALE.
abstract: The fact that there is a need for assessing depression, whether as an affect, a symptom, or a disorder is obvious by the numerous scales and inventories available and in use today. The need to assess depression simply and specifically as a psychiatric disorder has not been met by most scales available today. We became acutely aware of this situation in a research project where we needed to correlate both the presence and severity of a depressive disorder in patients with other parameters such as arousal response during sleep and changes with treatment of the depressive disorder. It was felt that the general depression scales used were insufficient for our purpose and that the more specific scales were also inadequate. These inadequacies related to factors such as the length of a scale or inventory being too long and too time consuming, especially for a patient

title: The structure of psychological well-being revisited.
abstract: A theoretical model of psychological well-being that encompasses 6 distinct dimensions of wellness (Autonomy, Environmental Mastery, Personal Growth, Positive Relations with Others,  Life, Self-Acceptance) was tested with data from a nationally representative sample of adults (N = 1,108), aged 25 and older, who participated in telephone interviews. Confirmatory factor analyses provided support for the proposed 6-factor model, with a single second-order super factor. The model was superior in fit over single-factor and other artifactual models. Age and sex differences on the various well-being dimensions replicated prior findings. Comparisons with other frequently used indicators (positive and negative affect, life satisfaction) demonstrated that the latter neglect key aspects of positive functioning emphasized in theories of health and well-being.

title: Position Paper: The Use and Interpretation of Quasi-Experimental Studies in Medical Informatics
abstract: Quasi-experimental study designs, often described as nonrandomized, pre-post intervention studies, are common in the medical informatics literature. Yet little has been written about the benefits and limitations of the quasi-experimental approach as applied to informatics studies. This paper outlines a relative hierarchy and nomenclature of quasi-experimental study designs that is applicable to medical informatics intervention studies. In addition, the authors performed a systematic review of two medical informatics journals, the Journal of the American Medical Informatics Association (JAMIA) and the International Journal of Medical Informatics (IJMI), to determine the number of quasi-experimental studies published and how the studies are classified on the above-mentioned relative hierarchy. They hope that future medical informatics studies will implement higher level quasi-experimental study designs that yield more convincing evidence for causal links between medical informatics interventions and outcomes.

title: Meta-analysis of MFT interventions.
abstract: This article briefly reviews 20 meta-analyses of marital and family interventions. These meta-analyses support the efficacy of both MFT for distressed couples, and martial and family enrichment. Those effects are slightly reduced at follow-up, but still significant. Differences among kinds of marital and family interventions tend to be small. MFT produce clinically significant results in 40-50% of those treated, but the effects of MFT in clinically representative settings have not been much studied. The article also introduces the concept of meta-analytically supported treatments (MASTs), which are treatments that meet certain criteria for efficacy in meta-analysis, and which remedy certain problems in the empirically supported treatment (EST) literature. The article concludes with recommendations for doing better meta-analyses.

title: Statistical Power Analysis for the Behavioral Sciences
abstract: Prefaces. The Concepts of Power Analysis. The t-Test for Means. The Significance of a Product Moment rs (subscript s). Differences Between Correlation Coefficients. The Test That a Proportion is .50 and the Sign Test. Differences Between Proportions. Chi-Square Tests for Goodness of Fit and Contingency Tables. The Analysis of Variance and Covariance. Multiple Regression and Correlation Analysis. Set Correlation and Multivariate Methods. Some Issues in Power Analysis. Computational Procedures.

title: Experimental and Quasi-Experimental Designs for Generalized Causal Inference
abstract: from “I don’t want to hear about this,” and “Oh my God!” to “I’m confused.” Colleagues of a certain age, those who remember punching Fortran code onto cards or tape, were not surprised at all. Another colleague said “These issues are completely unknown to us.” The text provides thorough coverage of the numerical issues that a social scientist will face. The context provided by a good number of specific applications is particularly helpful in not only emphasizing that the consideration of numerical issues is important, but also in motivating the reader to think about numerical issues in his or her own applications. The writing is generally clear (despite somewhat frequent typos), and the focus on estimation problems is appropriate for most fields in the social sciences. My major disappointment with this book is that it misses its target audience by a wide mark. As the authors outline in the Preface, this book will be useful primarily for graduate students and practitioners in quantitative fields. Indeed, it fills a hard-felt gap between our statistical training and our daily research activities. But quantitative social scientists are a very small minority among social scientists. Most social scientists have not taken any formal statistics courses more advanced than analysis of variance, and many of those courses are offered by their own departments, so issues of concern to statisticians are completely foreign to them. For example, many users of ANOVA techniques were never taught that ANOVA actually fits a model to their data. What these users are looking for is a p value, and they will ignore much of the output provided by SAS or SPSS. These are the social scientists who most need to know about the issues raised in this text, and they will not be able to read past page 7, where the authors present “a simple Poisson generalized linear model with a log link function.” It is perhaps not the authors’ goal to reach this audience, the title of their text notwithstanding. However, the treatment of technical information is sufficiently uneven to make this a rough read for even a quantitative audience. Section 5.3, for example, presents Markov chain theory at a very advanced level, which I think is completely unnecessary and detracts from the goals of the chapter. A text aimed at the typical social scientist, even the quantitative social scientist, does not need to present probability in topological terms. In my final analysis, Numerical Issues in Statistical Computing for the Social Scientist this is an excellent text. It has the potential to be enormously influential across the social sciences, but at present only fairly sophisticated quantitative modelers will be able to appreciate it. For those modelers, this text will be invaluable. It should be required reading for everyone who performs statistical computing at an advanced level. Chapters 1 and 2 should be required reading for anyone who intends to publish the results of a statistical analysis using a commercial statistics package.

title: Premature termination from treatment among children referred for antisocial behavior.
abstract: The present study examined differences between children and families who complete treatment versus those who terminated prematurely. Children (N = 81, ages 7-13 years) referred to outpatient treatment for severe antisocial behavior and their families participated. It was predicted that families who terminate treatment prematurely would show greater dysfunction in four domains: child severity and breadth of antisocial behavior, maternal stress, maternal psychopathology, and socioeconomic disadvantage. The results indicated that among cases who terminate treatment prematurely children evinced more severe conduct disorder symptoms and more delinquent behaviors; mothers reported greater stress from their relations with the child, their own role functioning, and life events; and families were at greater socioeconomic disadvantage than those who remained in treatment. The implications of the present findings for the design and implementation of treatment of antisocial children and their families are discussed.

title: Ethnicity and Mental Health: Research and Policy Issues
abstract: The relationship between social science research and public policy/program advocacy has been controversial. One position is that policy advocacy should be preceded and guided by research findings that clearly provide a rationale for the advocacy. Another position is that promotion of policies may be wise even in the absence of a strong research justification, because research findings are often inconclusive and the urgency of many social issues demands immediate action. Citing ethnic mental health research, I argue that the critical issue is the intertwining of research with policy recommendations, not whether one precedes or follows the other.

title: Brief report: Early intervention in autism
abstract: Autism is a condition that generally results in lifelong disability and dependence. This paper briefly reviews findings from comprehensive early intervention studies published in peer-reviewed journals and formulates major questions that need to be answered for the field to establish efficacious, accessible treatment for very young children with autism. At least six comprehensive treatment programs designed to stimulate widespread changes in young children with autism have published positive outcome data in peer-reviewed journals. Highlights of the findings of these six studies appear in Table I. It is important to point out that none of these studies used the most rigorous experimental designs, involving random assignments of children to groups and the use of evaluators blind to all aspects of the study. The studies differed in many ways, including different curricula, different settings and ratios, different ages and functioning levels, different ways of measuring progress, and different kinds of comparison groups or strategies for looking at change. However, many commonalities occurred in the results of the six studies. All the studies reported (a) significant acceleration of developmental rates, resulting in significant IQ gains; (b) significant language gains in the treated children; (c) improved social behavior and decreased symptoms of autism. Furthermore, these gains were accomplished, for most programs, within 1 to 2 years of intensive preschool intervention. The majority of treated children (73%) had useful speech by the end of the intervention period (generally age 5). Although only two studies had a longitudinal component, both indicated that the children maintained their gains for years after the intervention program ended.

title: Directionality of change in youth anxiety treatment involving parents: an initial examination.
abstract: This randomized clinical trial compared cognitive behavioral therapy (CBT) with minimal parent involvement to CBT with active parent involvement in a sample of 119 youths (7-16 years old; 33.6% Caucasian, 61.3% Latino) with anxiety disorders. The dynamics of change between youth anxiety and parent variables (positive-negative behaviors toward the child, conflict in the parent-youth relationship, and parental anxiety) in both treatment conditions over pretreatment, posttreatment, and 12-month follow-up were also examined. Results indicated that youth anxiety was significantly reduced with both treatments and that the dynamics of change may not solely flow from parent to youth but also from youth to parent. Findings highlight the need for research on directionality and mechanisms of change to move from evidence-based treatments toward evidence-based explanations of treatment outcome.

title: Parenting Stress Reduces the Effectiveness of Early Teaching Interventions for Autistic Spectrum Disorders
abstract: This community-based study examined the influence of early teaching interventions on children diagnosed with Autistic Spectrum Disorders, and the dynamics between the time intensity of the interventions and parenting stress, on child outcomes. Intellectual, educational, and adaptive behavior and social functioning were all measured. Sixty-five children were divided into four groups, based on the levels of time intensity of their intervention, and on their parents’ stress levels. There were gains in intellectual, educational, and adaptive behavioral and social skills, and there was a positive relationship between the time intensity of the early teaching interventions and child outcome gains. More importantly, however, high levels of parenting stress counteracted the effectiveness of the early teaching interventions.