Current Psychology

https://doi.org/10.1007/s12144-022-03760-1

Effects of Acceptance and Commitment Therapy‑based interventions

on the mental states of parents with special needs children:
Randomized controlled trial
Ecem Çiçek Gümüş1 · Selma Öncel2

Accepted: 12 September 2022

© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2022

Abstract
This study is consisted of a randomized controlled trial with two groups using a pre‐test, post‐test, and follow‐up design to
detect the effect of interventions based on Acceptance and Commitment Therapy (ACT) implemented with parents of children
with special needs regarding parents’ levels of psychological inflexibility, depression, anxiety, stress, and caregiver burden.
A total of 60 eligible parents were recruited and randomly assigned to the intervention and control group. The intervention
group participated in ACT-based interventions consisting of 6 sessions. The control group, only participated in routine
training sessions organized at the school. Data were analyzed using t-tests for independent and depedent samples, ANOVAs,
and the Mann–Whitney U test. It was determined that the ACT-based interventions implemented with parents were effective
in decreasing parents’ levels of psychological inflexibility, depression, anxiety, stress, and caregiver burden. These observed
changes continued over time. The ACT-based interventions results showed that the interventions were effective and had
positive effects on the mental states of parents with special needs children. Findings of this study add important knowledge
about the effect of ACT-based intervention on psychological inflexibility, depression, anxiety, stress, and caregiver burden
of parents with special needs children. Considering the findings, the present study provides both important and practical
contributions to the current literature. It appears that ACT is effective for supporting the mental states of parents with children
with special needs. Registration number: The study is registered at ClinicalTrials.gov NCT04307706.

Keywords Parent · Child · Nursing · Caregiver burden · Psychological inflexibility · Mental states · Depression-anxiety-
stress levels · Acceptance and Commitment Therapy

Introduction depression by leading them into confusion and uncertainty.

All parents dream of bringing a healthy child into the world.
However, when they learn that their new-born babies have special
needs, they may experience great sorrow, shock and anguish
(Köksal & Kabasakal, 2012). The child with special needs
(CSN), who causes disruption to routine situations in family life,
has a negative effect on the experiences, emotions and behaviors
of family members (Al-Krenawi et al., 2011). The change in
roles of parents with CSN may cause them to experience deep
* Ecem Çiçek Gümüş
egumus@bartin.edu.tr; ecem8986@hotmail.com
1
Departments of Public Health Nursing, Faculty of Health
Science, University of Bartın, Merkez, Bartın, Turkey
2
Departments of Public Health Nursing, Faculty of Nursing,
University of Akdeniz, Konyaaltı, 07070 Antalya, Turkey
Parents show a tendency to hold themselves responsible for
their children and at the same time, to feel ashamed. Due to a
combination of factors, parents experience a high level of chronic
stress (Al-Krenawi et al., 2011; Poddar et al., 2015).
Families are often lack coping skills with intense stress
and long-term family problems. In this case, they may
experiences a range of mental and behavioral problems.
Studies have shown that parents of children with special
needs have high rates of stress (Hamarta & Özteke-Kozan,
2019; Karadağ, 2009; Weiss et al., 2013), anxiety (Dykens
et al., 2014; Özmen & Çetinkaya, 2012), depression (Azeem
et al., 2013; Hodge et al., 2011; Kaçan Softa, 2012) increase
in care burden (Opoku et al., 2020), economic, social and
various psychological problems (Takuri, 2014), loneliness,
mental and behavioral problems. It has been suggested that
parents may experience many problems such as inability
to cope (Carlson & Miller, 2017) and adjustment problems

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within the family (Al-Krenawi et al., 20111). However, it is
also clear that not all mothers are highly stressed. Totsika
et al. (2011) found that 60% of mothers with a child with an
intellectual disability did not report experiencing emotional
problems at the clinical level even though they experienced
some level of stress. Child behavioral and emotional
problems are clearly contributing factors to this variation in
stress.
In addition, some research shows that having a child with
special needs has positive consequences, such as doing the
best for the child, becoming a better person, developing new
skills, and increasing spirituality. In Muslim societies with
a belief in Allah (as in the society in which current study
was conducted), parents feel better because they believe that
Allah presents some difficulties as a test for beloved serv-
ants, and they see the special child as a test. This situation
leads them to see themselves as a ‘’beloved servant’’ to
strengthen their spirituality. In addition, there are also par-
ents who are happy who believe that Allah has given them
a blessing (Ercan et al., 2019; Kanbir, 2018). In the same
way, religious or spiritual coping strategies, such as pray-
ing to God or ancestors, participating in activities related
to religion or spirituality, and going to church/tombs/the
mosque have been used by many parents of children with a
disability in other settings globally (Asa et al., 2021). How-
ever, according to a systematic review examining coping
strategies, although they feel good for people for a while,
the methods used individually are insufficient or do not
work. It is also stated that parents experience psychologi-
cal inadequacy in general (Vernhet et al., 2019).
In general, these studies related to parents of a CSN are
mostly descriptive and generally focus on the problems expe-
rienced by parents or coping strategies. Studies conducted in
Turkey, show as the coping strategies of parents of a CSN
indicate the following coping strategies are used including
religion and spirituality, asylum to religion, acceptance,
avoidance and separation, professional psychological help
and family support (Eren & Doğan, 2020; Eyüboğlu, 2019;
Odabaş, 2020). These studies emphasized that many of these
coping strategies were insufficient, and parents were seeking
and should receive professional support.
Background
The child with special needs (CSN), who causes disrup-
tion to routine situations in family life, has a negative
effect on mental health of family members. Since parents
of CSN become stressed and depressed, and their life qual-
ity decreases, this also has a negative effect on all other
family members (Sawyer Cohen & Semple, 2010). These
families cannot gain satisfaction from their marriages,
their caregiver burden increases, and compliance prob-
lems emerge within the family (Al-Krenawi et al., 2011).
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Current Psychology
Other studies indicate that parents of a CSN experience
high rates of stress, anxiety and depression (Dykens et al.,
2014; Tura, 2017; Weiss et al., 2013). For this reason,
parents with CSN require support in a number of issues.
Public health nurses who work with individuals and fam-
ilies play an important role in preserving and supporting the
mental health of those individuals and families. Healthcare
priorities among public health nurses include identifying
and protecting special and risk groups and improving their
health (Maurer & Smith, 2014). In this context, public
health nurses must identify the primary healthcare needs
of parents or caregivers of CSN. Accordingly, practices
aimed at increasing and supporting individuals’ social wel-
fare should be carried out by public health nurses and other
public healthcare providers (Schoon et al., 2018; Truglio-
Londrigan & Lewenson, 2017).
Based on the research literature, ACT-based interventions
were used in this study, a method whose effectiveness
has been proven and which is used in many areas. ACT
is a Cognitive-Behavioral Therapy, developed by Steven
C. Hayes, is a proven effective method used in many
settings. ACT also called the "third wave" is an approach
to psychological intervention defined in terms of certain
theoretical processes, not a specific technology. In theoretical
and process ACT can be defined as a psychological
intervention based on modern behavioral psychology,
that applies mindfulness and acceptance processes, and
commitment and behavior change process leading to the
creation of psychological flexibility (S. C. Hayes et al.,
2006). The purpose of using the ACT is to change the
relationship between negative annoying thoughts, unpleasant
emotions, painful memories or disturbing experiences by
using approaches involving acceptance and spontaneity.
Reducing symptoms (thoughts, memories, feelings, bodily
sensations, etc.) and changing the content of symptoms are
in no way included in the purpose of ACT (Davies & Nagi,
2017). Instead, the purpose is to teach individuals a set of
skills that will enable them to cope effectively with painful
thoughts and feelings in order to reduce their impact. In this
way, it aims to support parents to reach a more meaningful,
rich and full life by using ACT methods. ACT is not only
used in clinical practice but can also be used effectively in
non-clinical areas (A-Tjak et al., 2018; Frögéli et al., 2016).
Some of the studies in which ACT has been applied
to parents of a CSN are summarized as follows: Aware-
ness-based strategies to support parents of a CSN psycho-
logically and socially (Sawyer Cohen & Semple, 2010);
reducing parental stress and depression (Blackledge &
Hayes, 2006); increasing psychological flexibility, reduc-
ing difficulties in caring for children, and supporting par-
ents. Cognitive studies have been conducted to reduce
cognitive defusion (Fung et al., 2018; Kowalkowski,
2012; Whittingham et al., 2016). A systematic review
Current Psychology
examining ACT's work to support parents cites ACT as
an intervention to help parents manage the stress and dif-
ficulties associated with children, particularly those with
autism, chronic pain, and physical health needs (Byrne
et al., 2021). Another recent systematic review and meta-
analysis study reported that there is evidence that ACT
can help with depressive symptoms in children with spe-
cial healthcare needs (SHCN) and psychological resil-
ience in their parents. Research on the effectiveness of
ACT for children with SHCN and their parents is particu-
larly limited and future research is needed (Parmar et al.,
2021). A recent study aimed at evaluating the feasibility
of a novel, manualized ACT group intervention (Naviga-
tor ACT) in parents of children with disabilities suggests
that parents experienced significant improvements in
wellbeing following the intervention. The results indicate
that the treatment is feasible and should be evaluated in
a randomized controlled trial (Holmberg Bergman et al.,
2022). As a differently, ACT is an effective model and
its use is recommended in studies where it is applied not
only to parents but also to individuals with special needs
(McConachie et al., 2014; Molander et al., 2015).
Studies have shown that ACT is an effective interven-
tion for strengthening of parents of a CSN. Also ACT-based
studies for this group are found effective, they are quite
insufficient in number. In terms of the reviewed literature,
in Turkey, no study has been conducted by nurses or other
professional groups in this field. This study is essential due
to the lack of randomized controlled trials (RCT) in previous
studies and lack of application of RCTs by nurses.
The study
Aim
The aim of this study is to determine the effect of ACT-
based interventions applied to parents of CSN on their levels
of psychological inflexibility, depression, anxiety, stress, and
caregiver burden.
Design
A randomized controlled experiemental study was imple-
mented including a pretest, posttest and follow-up.
Hypotheses
H1a: ACT-based interventions are effective in reducing
levels of psychological inflexibility in parents of CSN.
H1b: ACT-based interventions are effective in reducing
levels of depression in parents of CSN.
H1c: ACT-based interventions are effective in reducing
levels of anxiety in parents of CSN.
H1d: ACT-based interventions are effective in reducing
levels of stress in parents of CSN.
H1e: ACT-based interventions are effective in reducing
caregiver burden in parents of CSN.
Location and date of research
The research was carried out in two central districts of
Gaziantep province located in the southeast of Turkey.
These districts were chosen because there are schools that
offer special education to students. The study was con-
ducted in eight Special Education Practice Schools affili-
ated with the Gaziantep Provincial Directorate of National
Education. Pretests, interventions, posttests, and follow-up
were conducted between April and December 2019.
ACT interventions were conducted at different loca-
tions, depending on the preferences of the participants.
Included were a specified room at the school or the
researcher's office which included standard conditions.
Standard office and room conditions were provided for
the participants. The interviews were conducted by the
same person in a private setting with a letter on the office
door stating a meeting was in progress. Parents were
interviewed individually, and nobody accompanied them
in a comfortable and communicative environment.
Sample
Special education schools teach students with mental dis-
orders and autism spectrum disorder (ASD).. The study
sample consisted of parents of 300 students attending eight
special education practice schools who met the above cri-
teria for inclusion in the study. The Zarit Caregiver Burden
Scale (ZCBS) was applied to all parents whose children
were attending stage I and II in the eight special education
practice schools. In total, 132 parents volunteered for the
study and completed forms. The G*Power 3.1 was used to
perform a G*Power analysis to determine a sample size.
The study sample was calculated as 60 parents (95% reli-
ability/80% power). Sixty parents with a mean ZCBS score
of 40 or higher were included in the sample. All of the
participants completed all sessions. No data loss occurred
at the end of the research (Fig. 1).
Criteria for inclusion in scope of research
Parents who
1. lived in central districts of Gaziantep,
2. had not previously received therapeutic support such as
ACT or any kind of psychiatric treatment,
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 Current Psychology

Fig. 1  CONSORT flow diagram

for intervention and control Evaluated for eligibility (N = 132)
groups of study

Enrollment
Not meeting inclusion criteria (N = 72)
Meeting inclusion criteria (N = 60) Unwilling to participate in study (N = 10)
Having mean ZCBS score below 40 (N = 62)

Study group (N = 60)

Allocated for the intervention (N=30)

Allocation

Allocated for the intervention (N=30)

Intervention Group Control Group

Follow-up

Left the intervention (N = 0) Left the follow-up (N = 0)

Analysis

Analysed (N=30) Analysed (N=30)

3. were not receiving any continuing psychological or psy-
chiatric treatment (determined according to participant’s
self-declaration),
4. were open to interaction and collaboration and were lit-
erate, and
5. agreed to take part in the study, were included in the
research.
Study exclusion criteria
Parents who
1. had a cognitive deficiency,
2. had substance/alcohol dependency problems, and
3. spoke a language other than Turkish, were excluded
from the study.
Blinding and prevention of bias
To ensure random selection from the universe of parents
included in the study and to assign them to the interven-
tion and control groups without bias, a simple randomi-
zation method was used. Selection was made blindly in a
computer environment by a person other than the researcher
using the Statistical Package for the Social Sciences (SPSS
23) software program. To prevent bias in the result measure-
ments, precautions were taken in the coding of the data and
statistical evaluations. The pretest data for the control and
intervention groups were collected by the researcher. The
questionnaires used in the study were completed by the con-
trol group at the posttest and follow-up stages via WhatsApp.
The questionnaires were sent to the parents via WhatsApp
and their responses were also obtained via WhatsApp. As
for the intervention group, however, since the posttest data
were gathered after the sessions, bias could not be avoided.
The follow-up data of the intervention group were collected
in the same way as those of the control group via What-
sApp. To prevent bias in evaluation of the data, the statistical
analyses of the data coded on the prepared database were
performed independently of the researcher by a statistician
from the Statistical Consultation Unit of Akdeniz University.
The codings that were made for the control and intervention
groups were explained after the statistical analyses of the
study and the tables relevant to the results of the study had
been made and the research report had been written. Thus,
blinding from a statistical and reporting point of view was

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Current Psychology

made possible. In this way, selection, attrition, statistical and Table 2  Homogeneity of variance test
reporting bias were controlled. Mean caregiver burden score Levene statistic df1 df2 Sig

Intervention Group 49.97 ± 1.463 .068 1 58 .795

Randomization Control Group 48.10 ± 1.605

Randomization on the basis of school: Firstly, all special

education schools (15 schools) were evaluated in terms of
Depression, Anxiety and Stress Scale (DASS-21), and Zarit
suitability for the study. Schools that lacked a counseling
Care Burden Scale (ZCS).
service, had mildly disabled students, and provided stage
III education (N = 7) were not included in the sample. All
Data Collection Tools
schools to be included in the research that had moderately
and severely disabled students, provided stage I and II edu-
Personal information form Researchers prepared the per-
cation, and had a counseling service, were listed (N = 8). The
sonal evaluation form which consisted of open-ended and
remaining eight schools were included in the sample without
multiple-choice questions. The form comprises a total of
performing randomization. A total of 60 parents who had
9 questions including participants’ statements related to
mean caregiver burden scores of 40 and above and who met
gender, age, education level, employment status, financial
the criteria were selected from these eight chosen schools.
situation, number of CSN, whether they benefited from
Table 1 indicates that the socio-demographic character-
social services, whether they engaged in social activities,
istics of the parents in the intervention and control groups
and whether they received childcare support.
selected for the study did not differ. The mean caregiver
burden scores used as the basis for both groups were homo-
Depression Anxiety Stress Scale (DASS 21) This scale,
geneous as determined by the homogenicity variance test
which consists of 42 items, was developed by Lovibond and
(Table 2) (p > 0.05).
Lovibond (1995). The adaptation of the 21-question short
form of the scale (DASS-21) used in the study was made by
Data collection Henry and Crawford (2005). The adaptation of the scale for
Turkish was made by Yılmaz et al. (2017). The scale has
The data were collected using the Personal Informa- a 4-point Likert-type rating system ranging from 0: “did
tion Form, Acceptance and Action Form-II (KEF-II), not apply to me at all” to 3: “applied to me very much”.

Table 1  Comparison of socio-demographic characteristics of parents included in study

Identifying Characteristics Intervention Control
(n = 30) (n = 30)
n % n % X2/t p*

Gender Female 30 100 30 100

Age 36–40 5 16.7 6 20.0 .134 .894
41–45 13 43.3 11 36.7
46–50 7 23.3 9 30.0
51 and over 5 16.7 4 13.3
Education level Primary school 25 83.3 27 90 .577 .706
High school 5 16.7 3 10
Employment status In employment 29 97.7 29 97.7 .000 1.000
Not in employment 1 3.3 1 3.3
Financial situation Poor 25 83.3 29 97.7 2.964 .195
Average 5 16.7 1 3.3
Number of children with special needs 1 26 86.7 27 90 .162 1.000
2 4 13.3 3 10
Receipt of caregiver assistance Receiving 30 100 30 100
Engagement in social activities No engagement 27 90 28 93.3 .218 1.000
Limited engagement 3 10 2 6.7
Receipt of support for care of child Not receiving 30 100 30 100
(spouse, family, friend…)

X2: Chi-square test, Fisher’s exact test, t: t-test, *p > .05

13

The Cronbach’s alpha values for each sub-dimension of the
adapted scale were calculated as 0.808 for anxiety (7 items),
0.819 for depression (7 items), and 0.755 for stress (7 items)
(Yılmaz et al., 2017). According to the score levels obtained,
scores are classified as normal, mild, moderate, severe and
extremely severe (Lovibond & Lovibond, 1995). For this
study, a Cronbach’s alpha value of 0.93 was obtained.
Acceptance and Action Questionnaire (AAQ‑II) The Accept-
ance and Action Questionnaire was developed by Steven C.
Hayes (2004) to measure psychological flexibility. Since the
internal consistency coefficient of the scale was not high,
the scale was revised. Thus, the AAQ-II consisting of seven
items was developed on a scale rated from 1: “Never true” to
7: “Always true”. The adaptation of the AAQ-II for Turkish
was made by Yavuz et al. (2016). All items contained state-
ments with negative meanings. A high score obtained from
the scale indicated a high level of psychological inflexibility.
A Cronbach’s alpha value of 0.84 was calculated for the
adapted scale (Yavuz et al., 2016). In this study, the Cron-
bach’s alpha value is 0.84.
Zarit Caregiver Burden Scale (ZCBS) This scale, which is
used to evaluate stress experienced by caregivers of indi-
viduals with special needs or the elderly, was developed by
Zarit et al. (1980). The Turkish validity and reliability study
was conducted by İnci and Erdem (2008). The scale consists
of 22 items that determine the effect of caregiving on the
life of the individual. The scale is of the five-point Likert
type and is rated as “never”, “rarely”, “sometimes”, “often”
and “always”. According to scores obtained from the scale,
scores of 88–61 are rated as heavy burden, 60–41 as moder-
ate burden, 40–21 as mild burden, and below 21 as little or
no burden (Zarit et al., 1980). In the Turkish validity and
reliability study, a Cronbach’s alpha value of 0.95 was found
(İnci & Erdem, 2008). A Cronbach’s alpha value of 0.85 was
determined for this study.
Intervention programme
Preparation of ACT‑based intervention protocol
The ACT based interventions and sesions prepeared under
guidence of the basic ACT training that had been received
by the first author (EÇG), the reviewed litrature, sam-
ple sessions of ACT protocols, and ACT books. (Broten,
2014; Harris, 2019; Luoma et al., 2017). ACT is based
on the scientific approach called functional contextual-
ism and the relational frame theory (Relational Frame
Theory). ACT sessions are based on a theoretical frame-
work that addresses cultivation of psychological flex-
ibility. The interventions based on six core therapeutic
processes in ACT include contacting the present moment,
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Current Psychology
defusion, acceptance, self-as-context, values, and com-
mitted action. The sessions were prepared based on six
components of psychological flexibility found at the basis
of ACT (Supplementary file 1). After preparation of the
ACT intervention protocol, specialists in the field con-
tributed to the final intervention. The interventions were
delivered by first author (EÇG). To maximize the level of
appropriateness for individuals’ problems in the sessions,
the researcher may decide to change the order of the psy-
chological flexibility components, ignore certain compo-
nents or review certain components. Nevertheless, in the
interviews, the order of the list of components below was
observed. Situations arose in which some of these compo-
nents were debated or discussed in more than one session.
Flexibility lies at the basis of applications of ACT. The
psychological flexibility components and sessions used
are listed below (Table 3).
Pilot testing of prepared ACT‑based interventions
The pilot test included two sessions per week with two par-
ents who had ZCBS scores of 40 and over. Following the
pilot test, the training periods and methods of implementa-
tion of the material to be used were determined. Parents who
took part in the pilot test were not included in the scope of
the main research.
Implementation: First of all, the aim, implementation type
and process of the research were explained to the parents,
and their informed consent was obtained. The research data
were collected from the intervention group between April
and December 2019, and from the control group between
April and September 2019 in the form of pretests, posttests
and follow-up tests.
Intervention group
First stage: Prior to the intervention, a preparatory ses-
sion was organized. The Personal Information Form,
AAQ-II, DASS-21 and RSA-21 were administered to the
parents. In the preparatory session, a schedule was made
Table 3  Psychological flexibility components and seasons
Sessions Psychological Flexibility Components
1. Session Values: Clarifying values
2. Session Values
Creative hopelessness
3. Session Defusion
4. Session Acceptance and Contact with the Present Moment
5. Session Self-as-context,
Values and Committed Action: Doing what matters
6. Session Values and Committed Action: Doing what matters
Current Psychology
for the other sessions and parents were informed that they
would be sent a reminder by SMS or telephone call one
day before each session.
Second stage: The interventions prepared in line with
ACT were administered individually to the parents (six
sessions). The interviews were conducted in an office per-
mitted for use by the school or in the researcher’s office.
The sessions lasted 60 min on average. One session was
carried out with each parent per week. In the sixth ses-
sion, the posttest was implemented and parents were
informed that they would be contacted again and that the
follow-up test would be conducted in three months’ time.
Therefore, they took part in routine training at the school
attended by their children.
Final stage: When it was time for the follow-up, the par-
ticipants were reminded by telephone, the forms were sent
by SMS, and they were asked to complete them.
Control group
Parents were contacted by telephone and data were gathered
through face-to-face interviews at the schools where their
children studied. The Personal Information Form, AAQ-II,
DASS-21 and RSA-21 were administered to the parents. The
intervention was not conducted with the control group. They
took part in routine training at the school attended by their
children. The pretests were administered prior to the training
sessions. The posttests were applied at the end of the school
semester. The follow-up tests were conducted three months
after the posttests.
Routine training at the school: The training and seminars
carried out in special education schools are organized and
determined by the guidance service of the schools and the
Ministry of National Education. Parents are encouraged to
actively participate in training and seminars. The trainings
organized during the process of the study were related to the
fight against addiction, protection from abuse, communica-
tion skills, peer bullying, developmental characteristics and
prevention of absenteeism.
Ethical considerations
Before commencement of the research, ethical approval
was obtained from the Clinical Research Ethics Com-
mittee of XXX University (Decision no: 2018/228,
Date:10.10.2018). Institutional approval was obtained
from the District Directorate of National Education to
which the schools were affiliated (No: 34659092/605.01-
E.22640244, Date: 23.11.2018).
Informed consent of the participants was obtained
during the study. The study was carried out taking into
account the Helsinki declaration. The confidentiality
of data was respected. Participants were informed that
their information would not be shared with anyone by
the researcher and their identities would be held confi-
dential. The ACT-based interventions were implemented
with parents in the control group on a voluntary basis
with parents who wished, after the parents’ follow-up
data had been collected.
Data analysis
The data of the research were evaluated using the IBM
SPSS 23 software program. The results were evaluated
within the p < 0.05 significance level and 95% confidence
interval. For categorical variables frequency distribution
and for numerical variables descriptive statistics (mean
and standard deviation) were used. Statistical analyses
were made using assessment of homogeneity between
intervention and control groups; descriptive statistics
(mean, standard deviation, percentage), chi-square, Fish-
er’s exact test, and independent samples t-test. The reli-
ability of the scale was tested using Cronbach's alpha val-
ues. Evaluation of findings for intervention and control
groups prior to intervention; t-test for independent sam-
ples, Mann–Whitney U test were used. Statistical anal-
yses were made using for between-group comparisons
of pretest, posttest and follow-up findings; independent
sample t- test, Mann–Whitney U test. Variance analysis
(Pillai's Trace Test) was made using repeated measure-
ments in the comparison of the groups within themselves
(ANOVA for repeated measures). The Bonferroni test
was used for multiple comparison analysis where group
or group differences occurred. For Bonferroni post-hoc
test analyses, a significance level of p < 0.0166 was set.
Results
In this study, the effect of ACT-based interventions admin-
istered to parents of CSN on their levels of psychological
inflexibility, depression, anxiety, stress, and caregiver burden
were examined. Findings obtained in the study are provided
under two headings.
Within‑group comparisons of parents’ levels
of psychological inflexibility, depression, anxiety,
stress, and caregiver burden
The mean scores for parents in the intervention group for
Psychological Inflexibility and Depression, Anxiety and
Stress decreased. In terms of difference in scores between
measures, there was a statistically significant difference
in mean posttest and follow-up scores compared with
mean pretest scores (p < 0.001), and the difference had a
large effect size (4.220). In further analysis it was noted in
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 Current Psychology

the intervention group, there was a statistically significant
difference between the pretest and posttest, and between
the pretest and follow-up (p < 0.05). In the control group,
however, no statistically significant difference was found
between measures of pretest, posttest and follow-up total
mean scores for Psychological Inflexibility, or Depres-
sion, Anxiety and Stress (p˃0.05) (Table 4).
It was determined that while total mean pretest scores
for Caregiver Burden of parents in the intervention
group were 49.97 ± 8.015, their mean scores decreased
to 20.1 ± 5.241 in the follow-up. It was noted that mean
follow-up test scores for caregiver burden were lower
compared to the pretest and that the difference in scores
between measures was statistically significant (p < 0.001),
and that in terms of effect size, this difference had a large
effect size (4.021). No statistically significant difference
was found between measures for total mean caregiver bur-
den scores in the control group (p˃0.05) (Table 4).
Between‑group comparisons of parents’ mean
scores for psychological inflexibility, depression,
anxiety, stress, and caregiver burden
Mean pretest scores of the intervention and control groups
for psychological inflexibility were found to be high and
similar. No statistically significant difference was seen
between the groups (p˃0.05). When the mean posttest and
follow-up test scores between groups were examined, it was
determined that levels of psychological inflexibility in the
intervention group decreased, whereas in the control group,
no difference was observed and levels continued to be high.
It was found that mean scores for psychological inflexibility
were much lower in the intervention group than in the con-
trol group, and the difference between groups was found to
be statistically significant (p < 0.001) (Table 5). Therefore,
the ­H1a hypothesis related to the ACT-based interventions
was accepted.

Table 4  Within-group comparison of mean scores of parents in intervention and control groups for psychological inflexibility, depression, anxi-
ety and stress, and caregiver burden
Groups Pretest Posttest Follow-up Test Test and Significance* Effect Size Power
(X ± SS) (X ± SS) (X ± SS)

Psychological Inflexibility (AAQ-II) Post-hoc Test

Intervention Group (N = 30) 40.33 ± 6.06 12.17 ± 2.26 12.20 ± 2.22 F = 447.04 6.084 1.000
p = .000
Control Group (N = 30) 41.4 ± 4.96 40.57 ± 4.92 41.77 ± 4.93 F = 7.70
p = .661
Depression Anxiety Stress (DASS-21)
Intervention Group (N = 30) 50.20 ± 14.63 10.99 ± 4.27 15.87 ± 4.8 F = 268.24 5.501 1.000
p = .000
Control Group (N = 30) 50.23 ± 8.09 48.27 ± 8.58 51.10 ± 7.73 F = 12.623
p = .58
DASS-21 (Subdimensions)
Depression Intervention Group 18.13 ± 3.58 5.47 ± 1.77 6.00 ± 1.72 F = 340.41 5.036 1.000
(N = 30) p = .000
Control Group (N = 30) 18.20 ± 2.78 17.57 ± 2.90 18.37 ± 2.97 F = 4.09
p = .209
Anxiety Intervention Group 14.57 ± 4.94 4.37 ± 1.81 5.53 ± 2.11 F = 78.26 2.706 1.000
(N = 30) p = .000
Control Group (N = 30) 13.67 ± 4.03 13.53 ± 4.43 14.13 ± 3.86 F = 1.96
p = .159
Stress Intervention Group 17.50 ± 3.44 4.70 ± 1.70 4.33 ± 1.98 F = 366.29 5.811 1.000
(N = 30) p = .000
Control Group (N = 30) 18.40 ± 2.44 17.50 ± 2.61 18.15 ± 2.36 F = 8.78
p = .921
Caregiver Burden (ZCBS)
Intervention Group (N = 30) 49.97 ± 8.01 20.10 ± 5.24 t = 26.37 4.022 1.000
p = .000
Control Group (N = 30) 48.03 ± 8.71 47.97 ± 8.28 t = 0.105
p = .917

Post-hoc test: G*Power 3.1 program, 95% Cl and α = 0.05, F: Analysis of variance for repeated measures (Pillai’s trace test, post-hoc test; Bon-
ferroni test), t: t-test for independent samples, *p < .001

13
Current Psychology

Table 5  Between-group Intervention Group Control Group (N = 30) Test and Significance*
comparison of mean scores (N = 30) (X ± S.S) (X ± S.S)
of parents in intervention and
control groups for psychological Psychological Inflexibility (AAQ-II)
inflexibility, depression, anxiety
Pretest 40.33 ± 6.06 41.40 ± 4.96 MWU = -.631 p < .528
and stress, and caregiver burden
Posttest 12.17 ± 2.26 40.57 ± 4.92 MWU = -6.677 p < .000
Follow-up Test 12.20 ± 2.22 41.77 ± 4.93 MWU = -6.676 p < .000
Depression Anxiety Stress (DASS-21)
Pretest 50.20 ± 14.63 50.23 ± 8.09 MWU = -.801 p < .423
Posttest 10.99 ± 4.27 48.27 ± 8.58 t = -19.217 p < .000
Follow-up Test 15.87 ± 4.80 51.10 ± 7.73 t = -21.195 p < .000
DASS-21 (Subdimensions)
Depression
Pretest 18.13 ± 3.57 18.20 ± 2.78 t = -.081 p < .936
Posttest 5.47 ± 1.77 17.57 ± 2.90 t = -19.446 p < .000
Follow-up Test 4.33 ± 1.98 18.30 ± 2.36 t = -19.696 p < .000
Anxiety
Pretest 14.57 ± 4.94 13.67 ± 4.03 t = .772 p < .443
Posttest 4.37 ± 1.81 13.53 ± 4.43 t = -10.489 p < .000
Follow-up Test 5.53 ± 2.11 14.13 ± 3.86 t = -10.691 p < .000
Stress
Pretest 17.50 ± 3.44 18.40 ± 2.44 t = -1.168 p < .248
Posttest 4.70 ± 1.70 17.50 ± 2.61 t = -22.490 p < .000
Follow-up Test 4.33 ± 1.98 18.30 ± 2.36 t = -24.754 p < .000
Caregiver Burden (ZCBS)
Pretest 49.97 ± 8.01 48.03 ± 8.71 t = .895 p < .375
Follow-up Test 20.10 ± 5.24 47.97 ± 8.28 t = -15.573 p < .000

MWU: Mann–Whitney U Test, t: t-test for independent samples, *p < .001

No statistically significant difference was found
between mean pretest scores of the intervention and con-
trol groups for depression, anxiety and stress (p˃0.05).
When the mean posttest and follow-up test scores of the
intervention and control groups for depression, anxi-
ety and stress were examined, however, it was revealed
that mean scores of the intervention group were lower
than those of the control group. It was determined that
between groups, total mean posttest and follow-up test
scores for depression, anxiety and stress were lower in
the intervention group, and that that the difference in
mean scores between groups was statistically significant
(p < 0.001) (Table 5). According to this result, the H1b,
H1c and H 1d hypotheses related to the ACT-based inter-
ventions were accepted.
The pretest scores of the intervention and control
groups for caregiver burden were determined to be at a
moderately severe level. No statistically significant differ-
ence was found between the groups (p˃0.05). With regard
to mean posttest and follow-up scores between groups,
however, it was determined that the mean scores of the
intervention group indicated little or no burden, whereas
those of the control group continued at a moderately severe
level. It was revealed that levels of caregiver burden of
parents in the intervention group decreased and that the
difference in mean posttest and follow-up test caregiver
burden scores between groups was statistically significant
(p < 0.001) (Table 5). Consequently, the H 1e hypothesis
related to the ACT-based interventions was accepted.
Discussion
In this study, the effect of ACT-based interventions imple-
mented with parents of CSN on the parents’ levels of psy-
chological inflexibility, depression, anxiety, stress, and
caregiver burden has been examined. In a review of the
existing literature, only a limited number of studies could
be found in which ACT-based interventions were used
for parents of CSN. However, no study could be found
related to caregiver burden whose effectiveness we have
evaluated. In this regard, the research findings have the
quality of being the first in the literature. The findings
are discussed with the related literature in line with the
hypotheses of the research.

13

Effect of ACT‑based interventions implemented
with parents of CSN on parents’ levels
of psychological inflexibility
One of the most important findings of this study is that com-
pared with the control group, levels of psychological inflex-
ibility decreased in the intervention group to a significant
extent, and that this continued over time. Another striking
result is that in parallel with this, a significant increase in
parents’ levels of psychological flexibility was observed. In
that content, the increase in psychological flexibility at the
end of the ACT-based program and this continued effect
over time shows that the intervention applied was well-struc-
tured and effective. Similar to this study, it was determined
in a number of conducted studies that levels of psychologi-
cal inflexibility were high in parents of CSN (Blackledge &
Hayes, 2006; Chong et al., 2019; Fung et al., 2018; Gould
et al., 2018; Kowalkowski, 2012; Poddar et al., 2015).
In a study in which ACT interventions were implemented
to support parents of CSN, it was seen that following the
implementation, there was a significant increase in par-
ents’ levels of psychological flexibility, and that the posi-
tive change occurring in psychological flexibility continued
over time and its effect was maintained (Fung et al., 2018).
In a similar study, it was stated that a significant increase in
parents’ rates of psychological flexibility was experienced
and that the observed effects and gains continued in the
parents, who were monitored for six months (Gould et al.,
2018). Moreover, in three studies conducted with parents
of CSN, it was reported that following implementation of
ACT, there were important changes in psychological flex-
ibility over time, while levels of psychological inflexibility
were reduced (Hahs et al., 2018; Poddar et al., 2015). It
was also stated that in follow-ups made after ACT-based
interventions, the significant improvements that occurred in
psychological inflexibility continued (Hahs et al., 2018). In a
study made with parents of children diagnosed with asthma,
it was determined that ACT-based interventions resulted in
higher levels of psychological flexibility compared with the
control group and among themselves, and that this continued
in the follow-up test (Chong et al., 2019).
Unlike this study, in repeated measures of ACT-based
interventions implemented with parents of children with
ASD, a high rate of reduction in psychological inflexibility
scores was determined. It was stated that this decrease did
not constitute a significant difference compared to the routine
treatment applied, but that it was an effective intervention
(Chong et al., 2019; Kowalkowski, 2012). It is emphasised
that high psychological inflexibility and low psychologi-
cal flexibility in parents are accompanied by various psy-
chological symptoms and that these need to be supported
through various interventions (Whittingham et al., 2013).
In the conducted studies, it is also stressed that intervention
13
Current Psychology
based on ACT can be effective in increasing psychological
flexibility and that its use is essential (Blackledge & Hayes,
2006; Chong et al., 2019; Kowalkowski, 2012).
Considering the psychological rigidity of parents of
CSN and the problems that this could bring; initiatives to
support and strengthen parents in their parenting roles are
extremely important. In this way, empowering parents will
support more effective childcare and social participation and
satisfaction in parenting. It appears that ACT is effective for
parents of CSN but that it is not yet widely used, and that its
use needs to be extended. Consequently, it is important for
public health, family health and school health nurses, who
are in frequent interaction with parents, to receive training
in ACT and to provide parents with support in this area.
Considering the findings obtained, it can be said that the
present study is very important and practicable in terms of
the contribution it will make to the literature.
Effect of ACT‑based interventions implemented
with parents of CSN on parents’ levels of depression,
anxiety and stress
In this study, it was seen that parents had high levels of
depression, anxiety and stress. The findings of existing
studies also show that parents of CSN experience depres-
sion, anxiety and stress (Akça & Özyürek, 2019; Dykens
et al., 2014; Fung et al., 2018; Hahs et al., 2018; Lunsky
et al., 2018). At certain times, instead of focusing on val-
ues they are committed to in their lives, people waste their
lives struggling to overcome various psychological problems
that they experience, such as depression, anxiety and stress.
ACT is used successfully for reducing various psychologi-
cal problems like depression, anxiety and stress (Blackledge
& Hayes, 2006). In this study, it was determined that par-
ents’ levels of depression, anxiety and stress were high at
the beginning, but that following implementation of ACT,
depression, anxiety and stress levels decreased significantly
in the intervention group and fell to normal levels, and that
the interventions were effective. These results are an impor-
tant finding in that they show the effectiveness and applica-
bility of the ACT-based intervention program for parents of
CSN. ACT-based intervention for depression, anxiety, and
stress contributes to the growing body of evidence on ACT-
based treatments for nurses and other related specialists.
It was stated by Lunsky et al. (2018) that ACT interven-
tions implemented with mothers of children with ASD were
effective regarding levels of depression and anxiety. The
decrease occurring after the implementation also continued
in follow-up. In another study in which ACT was imple-
mented with parents of children with ASD, it was determined
that mean scores for symptoms of depression, anxiety and
stress decreased significantly between measures made before
and after the intervention (Poddar et al., 2015). Moreover,
Current Psychology
in similar studies that were carried out, implementation of
ACT resulted in reductions in levels of depression in parents
of children with ASD (Hahs et al., 2018; Joekar et al., 2016).
In a study conducted by Fung et al. (2018) with the same
group, it was emphasised that ACT enabled improvements
related to depressive symptoms and perceived stress, and
that it increased value-oriented activities in the short term.
In a study by Whittingham et al. (2016), it was reported that
an ACT intervention implemented with parents of children
with cerebral palsy resulted in a reduction in depression and
stress levels compared to the control group, although it did
not make a difference to anxiety levels. As a result of the
continuation study that was made, it was also revealed that
ACT made a unique contribution as a parenting intervention
(Whittingham et al., 2019).
In a study carried out by Blackledge and Hayes (2006),
in which the effectiveness of ACT on parents of children
with ASD was evaluated, it was reported that there was a
reduction in levels of depression and anxiety, although this
decrease was not statistically significant. The results show-
ing that depression and anxiety were reduced remained valid
for a period of three months (Blackledge & Hayes, 2006).
In a study by Montgomery (2015), it was stressed that ACT
implemented with parents of children with ASD resulted in
a decrease in rates of depression following the implementa-
tion, and that although not statistically significant, ACT was
an effective intervention.
The World Health Organization states that in many people
suffering from depression, numerous other problems occur
such as stress, anxiety, sleep disruption, loss of appetite,
feeling of guilt, low self-esteem, and loss of concentration,
as well as a number of issues that cannot be explained by
medical diagnosis (World Health Organization, 2020). Com-
pared with other parents, parents of CSN experience more
depression, anxiety, stress, psychiatric problems, and illness.
These parents have an extremely high burden of chronic
stress and illness, and this negatively affects their children
and family. Considering that levels of depression, anxiety
and stress experienced by parents were high, and the con-
sequences that this will have both for themselves and their
children, the importance of giving them support emerges
once again. According to the findings of the research, it is
considered that psychological and social interventions aimed
at strengthening parents of CSN through ACT will be able to
reduce depressive symptoms, anxiety and stress.
Effect of ACT‑based interventions implemented
with parents of CSN on parents’ levels of caregiver
burden
Caregivers within the family experience various problems
in psychological, physical, social and economic terms dur-
ing the course of caregiving and illness (Orak & Sezgin,
2015). Caregiver burden and the problems that occur are
experienced in different dimensions related to providing
care to individuals who are disabled or have special needs
(Karahan & İslam, 2013). Caring for CSN leads to serious
levels of caregiver burden in parents. Studies conducted in
this area reveal that caregiver burden in parents of CSN are
greater than in others (Karahan & İslam, 2013; Putra et al.,
2017; Sarpdağı, 2018). In the current study, it was seen that
at the beginning, parents’ levels of caregiver burden were
moderately severe. Following the ACT interventions that
were applied, the levels of caregiver burden in the interven-
tion group were reduced to little or no burden, in contrast
with the control group, and this situation continued in the
follow-up. This finding is valuable in terms of showing that
the ACT interventions were effective.
In the literature, no study could be found in which ACT
was used for reducing caregiver burden in parents of CSN.
Therefore, examples are given of the effect on caregiver bur-
den for similar groups in which ACT was used. In a study
in which an ACT intervention was used to reduce family
burden in parents providing care to children with mental dis-
ability, it was stressed that while no difference was found in
the control group that received only health education, there
was a significant difference in the group receiving ACT. It
was reported that the ACT intervention that was made had a
57% effect on family burden (Putra et al., 2017). In a study
of caregivers of patients with dementia, it was emphasised
that as a result of ACT training, there was a significant cor-
relation between certain components of ACT and caregiver
burden, and that it could be an effective intervention and
should be supported with clinical studies (Olzmann, 2017).
Considering the burden experienced by parents providing
care to CSN and the problems that accompany this, it can be
said that more extensive use should be made of ACT-based
interventions. Parents must be supported before caregiver
burden develops with the use of interventions with proven
efficacy such as ACT, and their caregiver burden must be
reduced. The present study is important due to the fact that
its results were found to be very effective, it draws attention
to this subject which had not been studied previously, and it
is a method which can be put into practice.
Strengths and limitations
Strengths of the study; the fact that the study was designed
with an experimental design offers those working in the field
the option of an intervention with valuable evidence that
supports parents of children with special needs. Although
the study demonstrates notable strengths, some limitations
also existing. The fact that among parents, only the mothers
participated in the research (since the fathers were work-
ing and were not willing to participate) was a limitation of
the study. The fact that due to the nature of the research,
13

blinding between the researcher and parents could not be
carried out can be evaluated as a limitation.
Conclusion
The fact that in parents of children with special needs, the
ACT-based interventions led to a decrease in their levels of
psychological inflexibility, depression, anxiety, stress, and
caregiver burden, reveals that the intervention was effective
on this group.
With this study, ACT-based interventions were imple-
mented for the first time for strengthening parents of children
with special needs by the public health nurse/nurse in Tur-
key. Different from the existing studies, the effect of ACT
on caregiver burden in parents of CSN was examined for
the first time. Moreover, the fact that the study was designed
with an experimental design offers those working in the field
the option of an intervention with valuable evidence that
supports parents of children with special needs. The impor-
tance of using randomized controlled studies with high evi-
dence levels and contributing to the literature is also appear-
ing. It is recommended that these interventions are used for
providing parents with strengthening and support.
Supplementary Information The online version contains supplemen-
tary material available at https://d​ oi.o​ rg/1​ 0.1​ 007/s​ 12144-0​ 22-0​ 3760-1.
Author contribution EÇG: Project administration- project apply,
Conceptualization, Methodology, Investigation, Implementation and
interventions, Writing—original draft, Writing—review & editing.
SÖ: Project administration, Conceptualization, Methodology, Review
& editing, Supervision, Funding acquisition. All authors read and
approved the final manuscript.
Funding The research was supported by the Akdeniz University
Scientific Research Projects Coordination Unit (Project ID number:
TDK-2019–4588).
Data availability statement The dataset generated and analyzed dur-
ing the current study is available from the corresponding author on
reasonable request.
Declarations
Conflict of interest No conflict of interest has been declared by the
authors.
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