Skip to main content
NCBI home page
Wiley Open Access Collection logoLink to Wiley Open Access Collection
. 2025 Sep 25;38(5):e70131. doi: 10.1111/jar.70131

Psychological Intervention in Parents of Children With Neurodevelopmental Disorders Using a Brief Protocol Based on Acceptance and Commitment Therapy

David Lobato 1,✉, Francisco Montesinos 1, Eduardo Polín 1, Juan Miguel Flujas‐Contreras 2, Inmaculada Gómez‐Becerra 3, Lidia Budziszewska 1
PMCID: PMC12462824  PMID: 40996691

ABSTRACT

Background

Parenting children with neurodevelopmental disorders and intellectual disabilities is associated with psychological and health problems in parents. It is also related to authoritarian and inflexible parenting, hindering the psychological adjustment of diagnosed children. Contextual therapies are developing a promising line of intervention for parents of children with intellectual disabilities.

Aim

To present a protocol for psychological flexibility in parents and its effect, aimed at reducing the impact of raising a child with a disability.

Methods

Standardised questionnaires and self‐monitoring at pre, post, and at follow‐up were administered to assess psychological changes after the intervention.

Results and Conclusions

Intervention was followed by an increase in general health and a decrease in psychological inflexibility, private eventsuppression, and parental stress at follow‐up. An increase in supportive interactions and a decrease in punitive interactions were observed. Training parents in psychological flexibility may improve the adjustment of parents and children with intellectual disabilities.

Keywords: acceptance and commitment therapy (ACT), intellectual disability, neurodevelopmental disorders, parental stress, psychological inflexibility

Summary.

  • Parenting children with neurodevelopmental disorders (NDDs) is associated with higher stress. The emotional coping of parents affects the psychological health of the whole family. Forty‐three parents with children with NDDs and intellectual disabilities participated in two successive studies.

  • A brief psychological group intervention based on Acceptance and Commitment Therapy (ACT) aimed at promoting psychological flexibility was administered.

  • The intervention protocol is described in detail so that other therapists can use it. Standardised questionnaires were used to assess parental psychological flexibility, parental stress, thought suppression, and general health status, as well as behavioural self‐monitoring of interactions with children to analyse family dynamics.

  • The intervention was followed by sustained decreases in both psychological inflexibility and private events suppression and increases in general health.

  • Parental stress was reduced at follow‐up. There was a sustained increase in supportive interactions and a decrease in punitive interactions.

  • A significant relationship was found between the level of previous psychological inflexibility and the magnitude of clinical change.

  • The study provides evidence that ACT is particularly useful in coping with stress for parents with higher psychological inflexibility.

  • A shift towards a focus on the family system would result in an improvement of the person with a disability, with the result that emotional relationships might be strengthened and help children to achieve higher levels of personal development and integration into the community.

1. Introduction

Neurodevelopmental disorders (NDDs) are a group of disorders that appear in childhood and are of a chronic nature, according to the DSM‐5 Manual (American Psychiatric Association 2013). Both general disorders (such as intellectual disability or autism spectrum disorder) and specific ones (such as attention deficit hyperactivity disorder) are encompassed under the general term of NDDs. The collective difficulties faced by people with NDDs, and especially autism and intellectual disability, have a significant impact on the quality of life of the family system, showing a greater propensity for psychological difficulties and adverse life events (Byrne et al. 2021).

Parenting a child with NDDs (especially one with an intellectual disability) can be a difficult and stressful experience that requires complex psychological skills. Psychological stress is more prevalent among parents of children with NDDs than among parents of children without such a diagnosis (Vernhet et al. 2019). This issue is also usually associated with a lower quality of life (Vasilopoulou and Nisbet 2016), emotional difficulties such as anxiety and/or depression (Scherer et al. 2019), lower effectiveness of interventions and therapeutic adherence (Gur and Reich 2023; Osborne et al. 2008), medical problems (Cohn et al. 2020), or with the worst psychological well‐being of the family as a unit (e.g., physical health, relationship, and marital satisfaction) (Weitlauf et al. 2014).

The way in which parents cope with these private aversive events (stress, discomfort, or reflections on the future of their children or on the degree of autonomy they can achieve) indirectly affects the family climate, which can become aversive and hostile by translating into authoritarian, hostile, and intrusive parenting (Brown et al. 2011), becoming less reactive to the needs of the child (Mash and Johnston 1990), and contributing to the worsening of the psychological health of family members and children. These individuals could, therefore, present a more unfavourable prognosis in terms of their development, social integration in their community, and general functioning (Scherer et al. 2019). In addition, children and youth with a diagnosis of NDDs experienced psychological problems as a consequence of COVID‐19 restrictions, in particular the alteration of routines and family structures; to the extent that 75% of these children manifested increased feelings of anxiety and their behaviour changed, with an increase in hypersensitivity, aggressiveness, appetite changes, lack of sleep, and tics. Due to this contextual change, the need for better psychosocial support for these children has increased (Shah and Absoud 2021).

There is a growing and promising scientific literature surrounding the effectiveness of Acceptance and commitment therapy (ACT) for parents of children facing chronic illnesses or difficulties (Gur and Reich 2023) such as NDDs (Byrne and O'Mahony 2020), or cerebral palsy (Whittingham et al. 2016). ACT uses six core processes (acceptance, mindfulness, cognitive defusion, self‐as‐context, values, and committed action) to promote psychological flexibility (PF), understood as a set of behavioural skills that allow one to be in contact with aversive private events in a full and mindful way while guiding behaviour in a valued direction (Hayes et al. 2012). Intervention that promotes family PF in the context of neurodevelopmental problems is associated with more adaptive parenting practices, fewer behavioural problems in children, a significant reduction in family stress, improved general health, and the promotion of less aversive family interactions (Cachia et al. 2016; Ridderinkhof et al. 2017). In previous studies by our team, it was found that PF mediates the impact of stress derived from raising children with chronic conditions (Lobato et al. 2021), and a group intervention programme based on ACT was designed for parents of children with NDDs. The programme has shown efficacy in reducing the psychological discomfort of these families and in the parent–child interaction styles, making them less aversive, through a pilot study, a pre‐experimental study, and a randomised clinical trial (Lobato et al. 2021, 2022, and 2023). In a review by Garcia et al. (2022) on ACT in individuals with NDD and their caregivers, it is noted that interventions with parents have focused on ASD diagnoses, finding a lower frequency in intellectual disability, despite the consequences noted above in this population. On the other hand, the authors point out that the ACT intervention obtains favourable results in improving stress, discomfort, anxiety and depression symptoms, and psychological adjustment of the children. However, it is still necessary to continue research in this field to obtain greater consistency in the results, achieve brief interventions, or investigate moderating variables in interventions with this population (Garcia et al. 2022).

The aim of this paper is to analyse the effect of an ACT‐based intervention to improve psychological flexibility of the parents with children diagnosed with intellectual disabilities and explore levels of parental psychological flexibility as a moderating variable of effectiveness. Furthermore, a detailed description of the intervention protocol is also included, which is expected to be useful for therapists.

2. Method

2.1. Participants

Convenience sampling was used. Recruitment was carried out among parents who participated in NGOs that served people with NDDs, intellectual disabilities, and their families. The sample consisted of 43 parents residing in the Community of Madrid who received the intervention programme. This study is a secondary analysis of variables measured in families with children with intellectual disabilities from a larger randomised clinical trial. All participants completed the pre‐, post‐, and follow‐up evaluation. The inclusion criteria were being over 18 years of age in the absence of current psychological and/or psychiatric treatment, having a good level of comprehension of Spanish, and having children diagnosed with NDDs with intellectual disabilities. Most of the parents were female (81.4%) with a mean age of 53.2 years (SD = 8.3); they had a mean of 1.7 children (SD = 0.8) aged 20.5 (SD = 5.7) years, and the majority were girls (69.8%). All children had a diagnosis of intellectual disability. In addition, comorbid conditions were present, including autism (20.9%), ADHD (11.6%), and other neurological problems (16.2%). The children had a mean degree of disability of 47.8 (SD = 15.3). The degree of disability is obtained through the assessment performed by orientation teams from each Spanish autonomous community. It is calculated according to the limitations of each person, in their specific context, as well as the required support they might need to develop a life that favours social integration, community participation, and equality of people with disabilities, in line with the convention approved by the United Nations on the Rights of Persons with Disabilities (UNCRPD 2006). A score of 47.8 corresponds to a moderate degree of disability, as defined in the Royal Decree 888/2022, which indicates that participants face difficulties in daily activities but maintain adequate levels of self‐care. Based on this score, the support is offered (psychological, economic, social, etc.).

2.2. Instruments

Parental Acceptance Questionnaire (6‐PAQ) (Flujas‐Contreras et al. 2020). This questionnaire evaluates parental psychological flexibility. The Spanish version of the questionnaire consists of 16 items on a 4‐point Likert scale (1 = strongly agree and 4 = strongly disagree), and its validation showed adequate internal consistency with a Cronbach's alpha of 0.81. Scores range from 16 to 64, with higher values indicating higher levels of psychological inflexibility. An example of an item from the 6‐PAQ is “it is difficult to initiate/maintain routines because I don't want to deal with my child's reactions”.

Perceived Stress Scale (PSS) (Cohen et al. 1983). The Spanish adaptation was used (Trujillo and González‐Cabrera 2007). This is a measure used to assess the degree of perceived control over life circumstances. In the study of the psychometric properties, Cronbach's alpha values of 0.72, 0.82, and 0.86 were obtained. It is a unidimensional scale with 14 items that are answered on a Likert‐type scale ranging from 0 (never) to 5 (very often). Direct scores range from 0 to 56. Higher scores indicate greater perceived stress. An example of an item from the PSS is “In the last month, how often have you been able to control irritations in your life”.

General Health Questionnaire (GHQ‐12) (Goldberg and Bridges 1987). Used to assess general health. It contains 12 items, and the Cronbach's alpha score for its consistency is 0.85. Higher scores indicate lower levels of general well‐being. Validation in Spanish was used, reporting a Cronbach's alpha of 0.76 (Sánchez‐López and Dresch 2008). An example of an item from the GHQ‐12 is “Feeling unhappy and depressed”.

White Bear Suppression Inventory (WBSI) (Wegner and Zanakos 1994). The Spanish validation was used (Rodríguez et al. 2008). This inventory evaluates the tendency to suppress unwanted private events. It is a 15‐item Likert‐type scale with five response options ranging from 1 (completely disagree) to 5 (completely agree). Scores range from 15 to 75. Higher scores indicate a greater tendency to suppress private events. Regarding the internal consistency of the scale, Cronbach's alpha values of 0.89 were reported. An example of an item from the WBSI is “I always try to put problems out of mind”.

Behavioural self‐monitoring. Parents documented an estimate of the daily occurrence of two types of behaviours: punitive‐hostile actions of parents towards children with disabilities (e.g., yelling, punishing, threatening, insulting, or bullying) and supportive‐accompanying behaviours (e.g., helping, sharing leisure time, and accompanying). The occurrence of each type of behaviour was estimated using a single‐item Likert‐type scale, where 0 never indicated, 1 almost never, 2 sometimes, 3 often, and 4 always. Participants completed 28 daily measures over 4 weeks, beginning 1 week before the intervention to create a baseline (BL) and continuing until 1 week after the intervention. Each participant's weekly total score was calculated (one for each behaviour type), and the corresponding weekly mean scores were used for statistical analysis.

2.3. Procedure

The research was approved by the ethics committee of the European University of Madrid (CIPI/20/153). The intervention was implemented in two collaborating associations by a psychologist trained in third generation therapies with experience working with families (the first author of the manuscript) and supervised by another expert therapist (the second author of the manuscript). The application of the designed group intervention protocol was implemented over three sessions of 3 h each on a weekly basis. Participants were divided into 5 groups (group 1 = 10 parents; group 2 = 10 parents, group 3 = 10 parents, group 4 = 6 parents, and group 5 = 7 parents). All dependent variables were recorded before the beginning of the intervention (pre), at the end of the intervention (post), and 3 months after the intervention (follow‐up). Access to the scales developed by the authors can be requested upon reasonable request to the first author of the manuscript. There were no incentives for participation.

2.4. Protocol Description

The intervention follows a similar structure to the program developed by Whittingham et al. (2014) and focuses on fostering psychological flexibility through (a) values clarification, (b) defusion strategies, (c) mindfulness training, (d) committed action, and (e) psychological acceptance. The therapeutic methods were adapted from manuals published by Harris (2019), Salas and Blarrina (2019), and Hayes et al. (2014). For the review of the therapeutic skills necessary for the application of the program, the publication by Páez and Montesinos (2016) was consulted. Transversally to the sessions and used in all experiential exercises, perspective taking of the “I as context” was trained through the “I as observer” exercise (Salas and Blarrina 2019) to train the self‐discrimination of private events through hierarchical and deictic cues.

The protocol was applied flexibly over three 3‐h sessions on a weekly basis, focusing more on the objectives of the techniques (modifying the functional relationships between psychological events and the relational contexts of the relatives) than on applying them in a rigid manner and/or as a prescription. To this end, the verbal repertoire, experiential exercises, metaphors, and examples were adapted to the everyday situations presented by the participants. The participants received a workbook that they completed throughout the sessions, with the aim of supporting the practice of the skills trained in the workshop and keeping track of the proposed tasks. The content of each session is described below.

2.5. Session 1

This session aimed at clarifying the functional relationships between the behavioural repertoires of family members and their effectiveness in managing parenting stress, promoting creative hopelessness, introducing the issue of control of private events, and clarifying values by which to orient parenting a child with a neurodevelopmental disorder and intellectual disability. After the presentation, the metaphor of the battlefield (Hayes and Smith 2005) was introduced, which helped to discriminate the parent who “fights” against an enemy that can be “won for a day, but always comes back”. In this struggle, he uses many personal and emotional resources (which he does not use to live the life he wishes to live), favouring the creation of relationships of coordination and equivalence with respect to the stress, discomfort, and personal costs derived from raising a child with neurodevelopmental problems. Secondly, the therapists created reflection groups about parental resources in the face of a child with a disability, again using the metaphor that refers to the “weapons” that they use in the battle against stress, making it easier for parents to derive that the battle never ends and that it necessarily entails many personal costs. This was consistent with the experience of creative hopelessness that is usually included in ACT and provided meaning to the workshop, creating a facilitating context for new strategies not aimed at suppression of discomfort but at acceptance. Subsequently, the therapist, in order to make the participants aware of their relational behaviour and the usefulness of the implementation of these strategies, created an interactive dynamic where complex situations in the relationship with their children were described, the private unpleasant events that triggered them, and the strategies deployed for their resolution. The usefulness of these strategies and the associated personal costs were analysed. This was done with the aim of favouring the perspective of the long‐term functionality and the avoidance cost of these repertoires in an experiential way. After that, to introduce the problem of control, the Quicksand metaphor was presented (Luciano and Wilson 2002). In this metaphor, the establishment of the equivalence relationship “fighting thoughts, feelings, or memories in interaction with a child with chronic conditions is like fighting quicksand” is sought, so that the patient derives for himself rules of the type “if fighting your way out of quicksand only makes you sink deeper, then yelling at my child when I feel anxious and worried only succeeds in increasing my anxiety and worry in the long run”. Finally, the therapist introduced the concept of values and distinguished values from goals using metaphors from the parents' stimulating universe or that they themselves had evoked in the previous exercises. The parents' values were clarified through different experiential exercises (such as the Parenting Compass: which north do I want to follow as a parent, or the Prime‐Time News Story (Stoddard and Afari 2014)) and ad hoc questionnaires designed to clarify values around parenting and assess to what degree they are important and whether they are living by them. The workshop closed by asking parents to formulate examples of valuable behaviours in their own parenting context and explaining the tasks to be done at home. The tasks were related to the implementation of the committed actions, the recording of difficult situations (struggle), and the daily mindfulness breathing exercise (Harris 2019) with the help of an audio recording provided by the therapist.

2.6. Session 2

This session aimed to train in mindfulness skills, learning to discriminate between private events and I by framing it with the deictic self (cognitive defusion and psychological acceptance), and continuing with behavioural commitment to values and management of difficult situations in the interaction with the diagnosed child.

First, the therapist began the session by retrieving the learning carried out during the previous session, as well as working on the proposed tasks through positive shaping and reinforcement by the therapist: The therapist is shaping the targeted behaviour. When a parent verbalises value‐oriented parenting behaviour in the presence of unpleasant emotions or thoughts, the therapist publicly acknowledges the behaviour (e.g., by smiling). Second, the therapist continued with the mindfulness breathing exercise (Harris 2019), emphasising that the goal was to contact with private events, in the absence of avoidant and/or escape strategies (congruent with the epistemological framework of ACT). Third, cognitive defusion skills were trained with the aim of reducing problematic verbal control of behaviour, facilitating not getting “entangled” with private content, and while orienting behaviour towards the valuable parenting that had been clarified in the previous session.

For this purpose, the bus passenger metaphor (Hayes et al. 2014) was used, “acting it out” first by the therapist to model parent learning, showing how the driver can choose to carry annoying passengers (equivalent to aversive private events) while staying on his route (a valuable direction). It was practised in dyads, in an experiential way, exchanging roles (passenger and driver), seeking to facilitate the discrimination of the ineffectiveness of strategies based on the control, suppression, or elimination of private events with aversive functions. The aim of this exercise is to exemplify an alternative way of coping with thoughts, memories, or emotions. The exercise was reinforced with an individual experiential exercise (to practise taking their own passengers, for example, their own mind messages, and to evoke them to establish a different relationship with those messages).

Subsequently, psychological acceptance was trained through a mindfulness exercise on parents' emotions (Whittingham et al. 2014), in which painful emotions were evoked in the context of parenting (fear, shame, or pain in interactions with their children) and, through reification, externalisation, and breathing, sought to “make a room for the emotion” (Harris 2019), with the aim of making contact with private events with aversive functions without responding by acting in the direction that verbal derivations indicate.

As a closure, the therapist first proceeded to facilitate the connection of the concepts and exercises learned in Session 2 with the values worked on in Session 1, modelling the implementation of PF skills through examples from his daily clinical practice with patients with children with neurodevelopmental disorders. In these situations, the therapist helps them to orient their lives to values through defusion exercises (bus passengers) and mindfulness (breathing mindfulness). Finally, the implementation of specific actions that connect with previously defined parental values was proposed as a task, and they were asked to continue filling in the register of complicated situations throughout the training programme in order to record and be aware of the possible change in the way of responding to unpleasant private events, as well as to continue working on mindfulness of breathing.

2.7. Session 3

This session aimed to detect possible private events with the discriminative function of neutralising, controlling, or suppressing behaviours and to reinforce the mindfulness and defusion skills learned to facilitate the emission of committed actions consistent with valuable parenting.

The therapist began the session by rescuing the learning that the participants built on the previous session, as well as working through shaping and positive reinforcement on the proposed tasks: those related to the practice of defusion and mindfulness with respect to the commitment they adopted, and the practice of mindfulness guided through the audio (recording made by the first author of the manuscript), reinforcing the behavioural changes in connection with the values. Secondly, he rescued the defusion exercise trained in the previous session and introduced its practice as a way of consolidating learning.

Thirdly, the actions committed to the already clarified values (Sessions 1 and 2) were developed in a more systematic and structured way through a hierarchy of actions according to the temporality incorporated in the workbook (What can I do today, this week, and in a month?). In this context and through an interactive experiential exercise, it is possible to evoke possible barriers that emerge from one's actions as well as possible solutions with the practiced skills. The activity is enriched by the “Choice point” (Harris 2019). Finally, the workshop ended, and Supporting Information was given to the families, consisting of a summary of the concepts and practiced exercises in a paper workbook (The Parental Psychological Flexibility Workbook).

2.8. Summary Table of the Intervention Protocol

In order to facilitate the reader's synthesis of the contents worked on throughout the intervention sessions, a summary table is presented with their corresponding methods and therapeutic processes (Table 1). The protocol can be obtained from the first author of the manuscript upon request.

TABLE 1.

Summary of the intervention protocol.

Session Therapeutic method Therapeutic process
Acceptance Defusion Values Commitment Present moment Self as context
1 Promoting creative hopelessness: an experiential exercise to assess the effectiveness of stress coping repertoires. X — — — — —
Battlefield Metaphor (Hayes and Smith 2005) X — — — — —
Quicksand Metaphor (Luciano and Wilson 2002) X — — — — —
History of prime‐time news (Stoddard and Afari 2014). — — X X — —
Parenting compass: what direction do I want to take as a parent? — — X — — —
Implementation of committed actions: What can I do this week to get closer to the kind of parent I want to be? — — X X — —
I‐observer exercise (Salas and Blarrina 2019). — — — — — X
Mindfulness of Breathing (Harris 2019). — — — — X —
Homework: implementing committed actions and self‐reporting — — X — —
2 Implementation of committed actions: What can I do this week to get closer to the kind of parent I want to be? — — X X — —
I‐observer exercise (Salas and Blarrina 2019). — — — — — X
Mindfulness on parental emotions (Whittingham et al. 2014). — X — — X —
“Passengers on the Bus” metaphor (Hayes et al. 2014). — X — — — —
Mindfulness of Breathing (Harris 2019). — — — — X —
Homework: implementing committed actions and self‐reporting. — — — X — —
3 Implementation of committed actions: What can I do this week to get closer to the kind of parent I want to be? — — X X — —
I‐observer exercise (Salas and Blarrina 2019). — — — — — X
“Passengers on the Bus” metaphor (Hayes et al. 2014). — X — — — —
Mindfulness of Breathing (Harris 2019). — — — — X —
Homework: implementing committed actions and self‐reporting. — — — X — —
Our values as parents. Sharing the values on which to orient/guide my actions. — — X X — —
Identify valuable actions in the presence of internal and external barriers. “When … then” — — X X — —
Choice point (Harris 2019). — — X X — —
Open in a new tab

2.9. Statistical Analysis

A descriptive analysis of the variables evaluated in each of the three defined moments: pre‐treatment, post‐treatment, and follow‐up (3 months) was performed. To evaluate the effectiveness of the intervention protocol, the participants' scores in each of the instruments before the intervention programme were compared with the scores obtained after the programme (e.g., pre‐post) and three months later (e.g., pre‐follow‐up). For this purpose, a paired sample t test was applied to each of the comparisons made. The effect size was also estimated using Cohen's d (Cohen et al. 1983). In addition, the clinical significance of the changes obtained as a result of the application of the protocol was contrasted using the method proposed by Jacobson and Truax (1991), which allows us to observe whether the change in the variables collected is clinically significant (the scores after the intervention should be two standard deviations (SD) outside the dysfunctional amplitude) and reliable. The latter was done through the Reliable Change Index (RCI, established in number of standard deviations). Jacobson and Truax's method classifies a patient as recovered if the RCI value is greater than 1.96 and the cut‐off point is exceeded, improved if the RCI value is greater than 1.96 but the cut‐off point is not exceeded, unchanged if the RCI value is not greater than 1.96, and worsened if the score involves a change that exceeds the RCI value of 1.96 but inversely, in the direction of worsening (Sanz and García‐Vera 2015). Likewise, to see if the psychological flexibility programme modified the family interaction repertoires of the parents towards their children, a repeated‐measures analysis of variance (ANOVA) was performed using the time factors (BL, W1, W2, and W3) as the repeated measure for supportive/accompanying and punitive/hostile behaviours variables throughout the application of the programme, but without a between‐subject factor. Post hoc subgroup analyses were conducted to assess changes between BL, W1, W2, and W3. In addition, to find out whether the effectiveness of the intervention programme was related to the levels of the participants' previous psychological flexibility‐inflexibility continuum, Pearson correlations were calculated between the pre‐intervention 6‐PAQ scores and the reliable change index obtained both at post‐intervention and follow‐up.

3. Results

A statistically significant change in the expected direction was observed for psychological inflexibility, general health, and private event suppression before and after the application of the protocol, as well as during the follow‐up phase. Perceived stress showed a statistically significant change during the follow‐up phase (e.g., at 3 months). In all cases, medium‐large effect sizes were observed. Table 2 showed the means and standard deviations obtained for each of the applied scales recorded at the three mentioned moments. The table also showed the results of the comparisons made using the t test and the effect size.

TABLE 2.

Questionnaires scores and comparisons of the effect of the intervention programme.

Pre Post Follow‐up Pre–Post Pre‐follow up
M (SD) M (SD) M (SD) t P d t p d
Variables
6‐PAQ 41.2 (7) 35.1 (4.7) 34.1 (4.5) 7.92 < 0.001 1.2 7.52 < 0.001 1.14
PSS‐14 31.3 (5.4) 30.7 (4.7) 27.5 (4.1) 1.63 0.110 0.24 3.42 0.001 0.52
GHQ‐12 27.4 (3.7) 24.5 (5.4) 23.3 (5.6) 3.29 0.002 0.5 4.03 < 0.001 0.61
WBSI 44.8 (8.6) 39.7 (7.8) 36.6 (6.1) 6.94 < 0.001 1.05 7.62 < 0.001 1.16
Open in a new tab

Regarding the analysis of clinical significance, Table 3 presents the clinical significance data obtained from the participants before and immediately after the application of the intervention protocol (pre‐post) and before and 3 months after it (pre‐follow‐up), for each of the questionnaires applied. The percentages represent the total number of participants for each of the conditions established by Jacobson and Truax (1991).

TABLE 3.

Clinical significance of the changes observed because of the application of the intervention programme.

Pre‐post Pre‐follow‐up
Wor Unc Imp Rec Wor Unc Imp Rec
PAQ 0 (0%) 16 (37.2%) 13 (30.2%) 14 (32.5%) 0 (0%) 16 (37.2%) 7 (16.2%) 20 (46.5%)
PSS 0 (0%) 31 (72%) 10 (23.2%) 2 (4.7%) 0 (0%) 19 (44.2%) 14 (32.5%) 10 (23.2%)
GHQ 0 (0%) 35 (81.3%) 8 (18.6%) 0 (0%) 0 (0%) 22 (51.2%) 18 (41.8%) 3 (6.9%)
WBSI 0 (0%) 23 (53.4%) 16 (37.2%) 4 (9.3%) 0 (0%) 20 (46.5%) 14 (32.5%) 9 (20.9%)
Open in a new tab

Abbreviations: Imp, improved; Rec, recovered; Unc, unchanged; Wor, worsened.

The intervention program for parental psychological flexibility training was followed by a change in the expected direction (improved or recovered) in the following variables: in the 6‐PAQ (psychological flexibility) 62.7% of parents both at post and at follow‐up; in the PSS (perceived stress), 27.9% of participants at post and 55.7% at follow‐up; in the GHQ (general health), 18.6% post and 48.7% at follow‐up; in the WBSI (suppression of unwanted private events), 46.5% of participants at post and 53.4% at follow‐up. The observed changes suggest that a high percentage of parents increased their psychological flexibility, reduced stress, increased their general health, and tended to respond by neutralising or suppressing less of their aversive private events. These changes were maintained, and parents continued to improve during the follow‐up phase, especially on the variables of perceived stress and general health.

Finally, to test whether the psychological flexibility programme modified interactions with diagnosed children (regarding the emission of supportive/accompanying and punitive/hostile behaviours), a repeated measures ANOVA was performed across the four time points (BL, W1, W2, and W3) in which this variable was measured. Table 4 shows the obtained means and standard deviations.

TABLE 4.

Descriptive statistics of support/accompanying behaviours and punitive/hostile behaviours.

Supportive/accompanying behaviour Punitive/hostile behaviour
Moments M SD Moments M SD
BL 13.3 1.9 BL 16.3 2.3
W1 14.7 1.5 W1 15 1.6
W2 15.7 2.1 W2 13.4 1.5
W3 16.8 2 W3 12.6 1.6
Open in a new tab

Abbreviations: BL, baseline; M, mean; SD, standard deviation; W, week.

Regarding the results obtained for the supportive/accompanying behaviours emitted by the parents, an increase was observed from BL to the end of S3, while for the punitive/aversive behaviours, a decrease was observed from BL to the end of S3. Figure 1 shows the changes in the response trend, representing the mean weekly scores of the participants on the y‐axis. All points shown in the graph are statistically significant with respect to BL.

FIGURE 1.

FIGURE 1

Open in a new tab

Changes in parents' interactions with their children over the 3 weeks of intervention implementation. BL, baseline; W, week evolution of parent–child interactions. Error bars show standard error of the mean (SEM). *p < 0.05; **p < 0.01; ***p < 0.001.

Parents who received the intervention programme showed a statistically significant change in their behavioural repertoires for both supportive/accompanying behaviours (F(3,126) = 32.886; p < 0.001) and punitive/hostile behaviours (F(3,126) = 27.555; p < 0.001).

As seen in Table 5, the increase in supportive/accompanying behaviours is statistically significant from week to week and the effect size is medium‐large. The most notable changes occurred between BL and the last week of the intervention. With respect to punitive/hostile behaviours, the decrease is statistically significant week to week, the effect size is medium‐large, and as with supportive/accompanying behaviours, the most notable change occurs between the BL and the last week of the intervention.

TABLE 5.

Magnitude of programme effect on supportive/accompanying behaviours and punitive/hostile behaviours.

Supportive/accompanying behaviours Punitive/hostile behaviour
Moments Mean difference t d p holm Moments Mean difference t d p holm
BL W1 −1.442 −3.951 −0.603 < 0.001 BS W1 1.372 3.739 0.570 < 0.001
W2 −2.395 −6.564 −1.001 < 0.001 W2 2.977 8.112 1.237 < 0.001
W3 −3.488 −9.559 −1.458 < 0.001 W3 3.744 10.203 1.556 < 0.001
W1 W2 −0.953 −2.613 −0.398 0.010 W1 W2 1.605 4.373 0.667 < 0.001
W3 −2.047 −5.608 −0.855 < 0.001 W3 2.372 6.464 0.986 < 0.001
W2 W3 −1.093 −2.995 −0.457 0.007 W2 W3 0.767 2.091 0.319 0.039
Open in a new tab

Strong and statistically significant negative correlations were found between baseline scores on the 6‐PAQ, and the magnitude of clinical change as assessed by the Reliable Change Index (RCI) (Jacobson and Truax 1991), obtained at both post‐intervention (r = −0.709, p < 0.001, R 2 = 0.502) and follow‐up (r = −0.773, p < 0.001, R 2 = 0.598). The correlations reflect the relationship between the degree of parental psychological inflexibility and the magnitude of clinical change. These data indicate that the greater the psychological inflexibility, the lower the RCI value (e.g., negative values indicate changes in the direction of functionality in the studied variable) after the intervention and at follow‐up.

4. Discussion

The results suggest that the application of the program was followed by a significant decrease in psychological inflexibility and the tendency to suppress thoughts with aversive functions, as well as a significant increase in general health at post‐intervention and, especially, during the three‐month follow‐up. During the latter phase, a significant reduction in perceived stress is also achieved. The results are similar to those found in ACT programs applied with parents of children with chronic conditions (Byrne et al. 2021), autism and neurodevelopmental disorders (Hahs et al. 2019), intellectual disabilities in different degrees (Lloyd and Hastings 2008), and caregivers of people with intellectual disabilities (Wong et al. 2016).

Parents of children with neurodevelopmental disorders and intellectual disabilities live with psychosocial stressors that often cannot be eliminated (e.g., the chronic nature of their children's difficulties, the difficulties of adapting to the community, or the constant search for support), so psychotherapeutic interventions for this population require a different technological approach to mediational strategies, which usually focus on the elimination or control of psychological distress associated with parenting. Thus, ACT promotes psychological flexibility, which implies active acceptance of the discomfort associated with parenting. Thus, to respond to these demands in the caregiver's career (Raina et al. 2004), exercises in ACT are designed to train people to relate more functionally and flexibly to their daily stressors (Wallace et al. 2016), which allows for greater effectiveness in the medium to long term, in line with the scientific literature in the context of parenting children with chronic conditions (Byrne et al. 2021).

The analysis of the clinical significance evaluated through the RCI made it possible to carry out an individualised analysis of the behavioural changes of the parents. A greater effect of the intervention was observed in the variables psychological inflexibility and suppression of private events than in the variables related to stress and general health, which improved during the follow‐up phase, in line with ACT goals (Hayes et al. 2014). The strategies derived from contextual‐functional science focus specifically on values, which favour behaviour change in the medium to long term, as this is guided by valued actions rather than avoidance or escape from unpleasant events (Coyne et al. 2011). Thus, it seeks to reduce the control of problematic private events and the evocation of those unpleasant emotions or thoughts when necessary to emit behaviours that guide valuable parenting.

Most behaviour modification programmes for parents focus on teaching more functional ways of managing children with neurodevelopmental disorders; however, ACT interventions incorporate parents, providing them with strategies to relate in a more flexible way to their painful private events and guiding them towards valuable parenting. The scientific literature shows results that guide us to think that this training improves the externalising (Backen Jones et al. 2016; Whittingham and Coyne 2019) or internalising (McCurry 2015) behaviour of the children with whom they live by translating into more adaptive parenting practices (Brassell et al. 2016). In this line, the data from the intervention protocol on the psychological flexibility of parents show an increase in support/accompanying behavioural repertoires and a decrease in punitive/hostile behaviours. These results are similar to those found in the scientific literature in the context of raising children with neurodevelopmental disorders (e.g., Lewallen and Neece 2015). Therefore, a parenting style based on psychological flexibility has been related to better emotional regulation (Moreira and Cristina Canavarro 2020), as it translates into parenting practices that are more responsive to children's needs in high‐stress contexts (Carreras et al. 2019).

On the other hand, the results obtained after the application of the protocol reveal the advantages of implementing parental training in a group format since it favours the modelling present in some families and allows the creation of a support network among relatives of children with chronic conditions (Santelli et al. 2001), especially among mothers (Hastings and Beck 2004). It also improves the efficiency and ecological validity of the interventions when applied in the usual parental care.

Regarding the relationship between parental psychological inflexibility and the magnitude of clinical change, the data suggest that there is a relationship between the previous level of parental inflexibility and the magnitude of clinical change, such that more inflexible parents would benefit more from the training protocol. The literature has linked psychological inflexibility with punitive, hostile, and unsystematic parenting practices (Brown et al. 2014) to avoid aversive private events (e.g., stress) rather than directing their interactions by orienting them to parenting‐related values (Burke and Moore 2015). Due to the mediating relationship between psychological inflexibility and stress derived from parenting, parental practices, and their impact on children's development, the target group for psychosocial interventions should be those with higher levels of inflexibility (Fonseca et al. 2020).

On the other hand, the results obtained with this intervention protocol have some limitations. Firstly, those derived from the small sample size of the participants. The vital context of the parents, the psychosocial support required by their children, and the stress derived from the parenting process favour the low adherence of the participants. The incorporation of an even larger number of participants would make the results more generalisable. Secondly, the results obtained correspond to all the parents who underwent the experimental condition from two different investigations (a pre‐experimental study in which there was no randomisation and a randomised clinical trial in which there was randomisation), which may have influenced the validity of the results. Thirdly, the degree of interference of the neurodevelopmental disorder with intellectual disability in the behavioural functioning of the child (e.g., levels of externalising behavioural problems, need for psychosocial supports, etc.), or the socioeconomic conditions of families was not controlled, and these variables could interfere with the effectiveness of the intervention (Singh et al. 2006), so that future studies could control for the degree of disability associated with the diagnosis, the behavioural problems manifested, or the need for support. Fourth, the change in interaction repertoires was assessed through self‐reports without prior training in behavioural observation, which could have affected the reliability of the results. For this, a before self‐report measure session could be introduced to improve self‐discriminative skills in parents, and/or standardised interaction questionnaires could be used (e.g., CBCL: Child Behaviour Checklist). Fifth, we did not assess whether these behavioural changes in family dynamics were maintained in the medium to long term, since one of the usual effects of parent training is a decrease in the effectiveness of the training, which could be assessed in a follow‐up phase (e.g., at 3, 6, and 12 months) as was done with the measures collected through questionnaires. Due to the conditions of the NGO, the burden faced by the families themselves and the daily stressors they must cope with, a short protocol (three sessions of 3 h) was used, as has been done in other studies of children with chronic conditions (Whittingham et al. 2014). However, in future research, it would be interesting to study the effect of a longer protocol over time. Finally, the participants were mostly women, for whom training seems likely to be effective. However, future research should evaluate whether this same program works in a sample composed mainly of fathers.

In short, this study aims to continue providing scientific evidence from the ACT framework (as a contextual‐functional therapy) on the importance of psychological flexibility and its relationship with stress, quality of life, and family dynamics in the context of parenting children with chronic conditions, such as NDDs, favouring valuable parenting even in such conditions.

Author Contributions

David Lobato and Francisco Montesinos: conceptualization. David Lobato, Francisco Montesinos, and Eduardo Polín: methodology. David Lobato and Francisco Montesinos: software. David Lobato and Francisco Montesinos: validation. David Lobato, Juan Miguel Flujas‐Contreras, and Eduardo Polín: formal analysis. David Lobato, Juan Miguel Flujas‐Contreras, and Francisco Montesinos: investigation. David Lobato, Francisco Montesinos, and Eduardo Polín: resources. David Lobato and Francisco Montesinos: data curation. David Lobato and Francisco Montesinos: writing – original draft preparation. Inmaculada Gómez‐Becerra, Lidia Budziszewska, and Juan Miguel Flujas‐Contreras: writing – review and editing. David Lobato and Inmaculada Gómez‐Becerra: visualisation. Francisco Montesinos and Lidia Budziszewska: supervision. Francisco Montesinos: project administration. Francisco Montesinos and David Lobato: funding acquisition. All authors have read and agreed to the published version of the manuscript.

Ethics Statement

The studies involving human participants were reviewed and approved by the European University of Madrid (CIPI/20/153) and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Consent

Written informed consent was obtained from the participants.

Conflicts of Interest

The authors declare no conflicts of interest.

Acknowledgements

The authors would like to thank all parents of children with neurodevelopmental disorders and disabilities who participated in the study, as well as to the intellectual disabilities associations ADISLI Madrid and CentroConmigo. The authors would like to thank all who participated in the study.

Lobato, D. , Montesinos F., Polín E., Flujas‐Contreras J. M., Gómez‐Becerra I., and Budziszewska L.. 2025. “Psychological Intervention in Parents of Children With Neurodevelopmental Disorders Using a Brief Protocol Based on Acceptance and Commitment Therapy.” Journal of Applied Research in Intellectual Disabilities 38, no. 5: e70131. 10.1111/jar.70131.

Funding: This work was supported by Universidad Europea de Madrid (2021/UEM07).

Data Availability Statement

The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.

References

  1. American Psychiatric Association . 2013. Diagnostic and Statistical Manual of Mental Disorders: DSM‐5. Vol. 5. American Psychiatric Association. [Google Scholar]
  2. Backen Jones, L. , Wittingham C., Coyne L., and Lightcap L.. 2016. “A Contextual Behavioral Science Approach to Parenting Intervention and Research.” In The Wiley Handbook of Contextual Behavoral Science, edited by Zettle D., Hayes S., Barnett‐Holmes D., and Beglin A.. John Wiley and Sons. [Google Scholar]
  3. Brassell, A. A. , Rosenberg E., Parent J., Rough J. N., Fondacaro K., and Seehuus M.. 2016. “Parent's Psychological Flexibility: Associations With Parenting and Child Psychosocial Well‐Being.” Journal of Contextual Behavioral Science 5, no. 2: 111–120. 10.1016/j.jcbs.2016.03.001. [DOI] [Google Scholar]
  4. Brown, F. L. , Whittingham K., Boyd R. N., McKinlay L., and Sofronoff K.. 2014. “Improving Child and Parenting Outcomes Following Paediatric Acquired Brain Injury: A Randomised Controlled Trial of Stepping Stones Triple P Plus Acceptance and Commitment Therapy.” Journal of Child Psychology and Psychiatry 55, no. 10: 1172–1183. 10.1111/jcpp.12227. [DOI] [PubMed] [Google Scholar]
  5. Brown, M. A. , McIntyre L. L., Crnic K. A., Baker B. L., and Blacher J.. 2011. “Preschool Children With and Without Developmental Delay: Risk, Parenting, and Child Demandingness.” Journal of Mental Health Research in Intellectual Disabilities 4, no. 3: 206–226. 10.1080/19315864.2011.596990. [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Burke, K. , and Moore S.. 2015. “Development of the Parental Psychological Flexibility Questionnaire.” Child Psychiatry & Human Development 46: 548–557. 10.1007/s10578-014-0495-x. [DOI] [PubMed] [Google Scholar]
  7. Byrne, G. , Ghráda Á. N., O’Mahony T., and Brennan E.. 2021. “A Systematic Review of the Use of Acceptance and Commitment Therapy in Supporting Parents.” Psychology and Psychotherapy: Theory, Research and Practice 94: 378–407. 10.1111/papt.12282. [DOI] [PubMed] [Google Scholar]
  8. Byrne, G. , and O'Mahony T.. 2020. “Acceptance and Commitment Therapy (ACT) for Adults With Intellectual Disabilities and/or Autism Spectrum Conditions (ASC): A Systematic Review.” Journal of Contextual Behavioral Science 18: 247–255. 10.1016/j.jcbs.2020.10.001. [DOI] [Google Scholar]
  9. Cachia, R. L. , Anderson A., and Moore D. W.. 2016. “Mindfulness, Stress and Well‐Being in Parents of Children With Autism Spectrum Disorder: A Systematic Review.” Journal of Child and Family Studies 25: 1–14. 10.1007/s10826-015-0193-8. [DOI] [Google Scholar]
  10. Carreras, J. , Carter A. S., Heberle A., Forbes D., and Gray S. A.. 2019. “Emotion Regulation and Parent Distress: Getting at the Heart of Sensitive Parenting Among Parents of Preschool Children Experiencing High Sociodemographic Risk.” Journal of Child and Family Studies 28: 2953–2962. 10.1007/s10826-019-01471-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Cohen, S. , Kamarck T., and Mermelstein R.. 1983. “A Global Measure of Perceived Stress.” Journal of Health and Social Behavior 24, no. 4: 385–396. 10.2307/2136404. [DOI] [PubMed] [Google Scholar]
  12. Cohn, L. N. , Pechlivanoglou P., Lee Y., et al. 2020. “Health Outcomes of Parents of Children With Chronic Illness: A Systematic Review and Meta‐Analysis.” Journal of Pediatrics 218: 166–177. 10.1016/j.jpeds.2019.10.068. [DOI] [PubMed] [Google Scholar]
  13. Coyne, L. W. , McHugh L., and Martinez E. R.. 2011. “Acceptance and Commitment Therapy (ACT): Advances and Applications With Children, Adolescents, and Families.” Child and Adolescent Psychiatric Clinics of North America 20, no. 2: 379–399. 10.1016/j.chc.2011.01.010. [DOI] [PubMed] [Google Scholar]
  14. Flujas‐Contreras, J. M. , García‐Palacios A., and Gómez I.. 2020. “Spanish Validation of the Parental Acceptance Questionnaire (6‐PAQ).” International Journal of Clinical and Health Psychology 20, no. 2: 163–172. 10.1016/j.ijchp.2020.03.002. [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Fonseca, A. , Moreira H., and Canavarro M. C.. 2020. “Uncovering the Links Between Parenting Stress and Parenting Styles: The Role of Psychological Flexibility Within Parenting and Global Psychological Flexibility.” Journal of Contextual Behavioral Science 18: 59–67. 10.1016/j.jcbs.2020.08.004. [DOI] [Google Scholar]
  16. Garcia, Y. , Keller‐Collins A., Andrews M., et al. 2022. “Systematic Review of Acceptance and Commitment Therapy in Individuals With Neurodevelopmental Disorders, Caregivers, and Staff.” Behavior Modification 46, no. 5: 1236–1274. 10.1177/01454455211027301. [DOI] [PubMed] [Google Scholar]
  17. Goldberg, D. , and Bridges K.. 1987. “Screening for Psychiatric Illness in General Practice: The General Practitioner Versus the Screening Questionnaire.” Journal of the Royal College of General Practitioners 37, no. 294: 15–18. [PMC free article] [PubMed] [Google Scholar]
  18. Gur, A. , and Reich A.. 2023. “Psychological Flexibility of Parents of Children With Disabilities: A Systematic Literature Review.” Research in Developmental Disabilities 136: 104490. 10.1016/j.ridd.2023.104490. [DOI] [PubMed] [Google Scholar]
  19. Hahs, A. D. , Dixon M. R., and Paliliunas D.. 2019. “Randomized Controlled Trial of a Brief Acceptance and Commitment Training for Parents of Individuals Diagnosed With Autism Spectrum Disorders.” Journal of Contextual Behavioral Science 12: 154–159. 10.1016/j.jcbs.2018.03.002. [DOI] [Google Scholar]
  20. Harris, R. 2019. ACT Made Simple: An Easy‐To‐Read Primer on Acceptance and Commitment Therapy. New Harbinger Publications. [Google Scholar]
  21. Hastings, R. P. , and Beck A.. 2004. “Practitioner Review: Stress Intervention for Parents of Children With Intellectual Disabilities.” Journal of Child Psychology and Psychiatry 45, no. 8: 1338–1349. 10.1111/j.1469-7610.2004.00357.x. [DOI] [PubMed] [Google Scholar]
  22. Hayes, S. C. , Pistorello J., and Levin M. E.. 2012. “Acceptance and Commitment Therapy as a Unified Model of Behavior Change.” Counseling Psychologist 40, no. 7: 976–1002. 10.1177/0011000012460836. [DOI] [Google Scholar]
  23. Hayes, S. C. , and Smith S.. 2005. Get out of Your Mind and Into Your Life: The New Acceptance and Commitment Therapy. New Harbinger Publications. [Google Scholar]
  24. Hayes, S. C. , Strosahl K. D., and Wilson K. G.. 2014. Terapia de Aceptación y Compromiso: Proceso y Práctica del Cambio Consciente (Mindfulness). Desclee de Brouwer. [Google Scholar]
  25. Jacobson, N. S. , and Truax P.. 1991. “Clinical Significance: A Statistical Approach to Defining Meaningful Change in Psychotherapy Research.” Journal of Consulting and Clinical Psychology 59: 12–19. 10.1037/0022-006X.59.1.12. [DOI] [PubMed] [Google Scholar]
  26. Lewallen, A. C. , and Neece C. L.. 2015. “Improved Social Skills in Children With Developmental Delays After Parent Participation in MBSR: The Role of Parent–Child Relational Factors.” Journal of Child and Family Studies 24: 3117–3129. 10.1007/s10826-015-0116-8. [DOI] [Google Scholar]
  27. Lloyd, T. , and Hastings R. P.. 2008. “Psychological Variables as Correlates of Adjustment in Mothers of Children With Intellectual Disabilities: Cross‐Sectional and Longitudinal Relationships.” Journal of Intellectual Disability Research 52, no. 1: 37–48. 10.1111/j.1365-2788.2007.00974.x. [DOI] [PubMed] [Google Scholar]
  28. Lobato, D. , Montesinos F., García‐Leal Ó., and Cebrián J.. 2021. “Teràpia d'Acceptació i Compromís amb Familiars de Fills/es Amb Discapacitat Intelectual: un Estudi Pilot.” ÀÁF Àmbits de Psicopedagogia i Orientació 55: 67–81. 10.32093/ambits.vi55.5030. [DOI] [Google Scholar]
  29. Lobato, D. , Montesinos F., Polín E., and Cáliz S.. 2023. “Third‐Generation Behavioural Therapies in the Context of Neurodevelopmental Problems and Intellectual Disabilities: A Randomised Clinical Trial With Parents.” International Journal of Environmental Research and Public Health 20, no. 5: 4406. 10.3390/ijerph20054406. [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Luciano, M. C. , and Wilson K. G.. 2002. Terapia de aceptación y compromiso: Un tratamiento conductual orientado a los valores. Pirámide. [Google Scholar]
  31. Mash, J. , and Johnston C.. 1990. “Determinants of Parenting Stress: Illustrations From Families of Hyperactive Children and Families of Physically Abused Children.” Journal of Clinical Child Psychology 19: 313–338. 10.1207/s15374424jccp1904_3. [DOI] [Google Scholar]
  32. McCurry, C. 2015. Working With Parents of Anxious Children: Therapeutic Strategies for Encouraging Communication, Coping & Change. WW Norton & Company. [Google Scholar]
  33. Moreira, H. , and Cristina Canavarro M.. 2020. “Mindful Parenting is Associated With Adolescents' Difficulties in Emotion Regulation Through Adolescents' Psychological Inflexibility and Self‐Compassion.” Journal of Youth and Adolescence 49, no. 1: 192–211. 10.1007/s10964-019-01133-9. [DOI] [PubMed] [Google Scholar]
  34. Osborne, L. A. , McHugh L., Saunders J., and Reed P.. 2008. “Parenting Stress Reduces the Effectiveness of Early Teaching Interventions for Autistic Spectrum Disorders.” Journal of Autism and Developmental Disorders 38, no. 6: 1092–1103. 10.1007/s10803-007-0497-7. [DOI] [PubMed] [Google Scholar]
  35. Páez, M. , and Montesinos F.. 2016. Tratando Con … Terapia de Aceptación y Compromiso. Habilidades Terapéuticas Centrales para la Aplicación Eficaz. Pirámide. [Google Scholar]
  36. Raina, P. , O'Donnell M., Schwellnus H., et al. 2004. “Caregiving Process and Caregiver Burden: Conceptual Models to Guide Research and Practice.” BMC Pediatrics 4, no. 1: 1–13. 10.1186/1471-2431-4-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
  37. Ridderinkhof, A. , de Bruin E. I., Blom R., and Bögels S. M.. 2017. “Mindfulness‐Based Program for Children With Autism Spectrum Disorder and Their Parents: Direct and Long‐Term Improvements.” Mindfulness 9, no. 3: 773–791. 10.1007/s12671-017-0815-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. Rodríguez, M. G. , Delgado P. A., Rovella A. T., and León R. C.. 2008. “Structural Validity and Reliability of the Spanish Version of the White Bear Suppression Inventory (WBSI) in a Sample of the General Spanish Population.” Spanish Journal of Psychology 11, no. 2: 650–659. 10.1017/S1138741600004650. [DOI] [PubMed] [Google Scholar]
  39. Salas, S. V. , and Blarrina M. P.. 2019. Aceptación psicológica: Qué es y por qué se fomenta en terapia. Ediciones Pirámide. [Google Scholar]
  40. Sánchez‐López, M. P. , and Dresch V.. 2008. “The 12‐Item Psychological Health Questionnaire (GHQ‐12): Reliability, External Validity and Factor Structure in the Spanish Population.” Psicothema 20, no. 4: 839–843. [PubMed] [Google Scholar]
  41. Santelli, B. , Poyadue F. S., and Young J. L.. 2001. The Parent to Parent Handbook: Connecting Families of Children With Special Needs. Paul H Brookes Publishing Company. [Google Scholar]
  42. Sanz, J. , and García‐Vera M. P.. 2015. “Técnicas Para el Análisis de Diseños de Caso Único en la Práctica Clínica: Ejemplos de Aplicación en el Tratamiento de Víctimas de Atentados Terroristas.” Clínica y Salud 26, no. 3: 167–180. 10.1016/j.clysa.2015.09.004. [DOI] [Google Scholar]
  43. Scherer, N. , Verhey I., and Kuper H.. 2019. “Depression and Anxiety in Parents of Children With Intellectual and Developmental Disabilities: A Systematic Review and Meta‐Analysis.” PLoS One 14: e0219888. 10.1371/journal.pone.0219888. [DOI] [PMC free article] [PubMed] [Google Scholar]
  44. Shah, R. , and Absoud M.. 2021. “The Failure of Provision for Neurodiverse Children During the Covid‐19 Pandemic.” BMJ (Clinical Research Edition) 375: n2711. 10.1136/bmj.n2711. [DOI] [PubMed] [Google Scholar]
  45. Singh, N. N. , Winton A. S. W., Singh J., et al. 2006. “Mindfulness‐Based Caregiving and Support.” In Antecedent Assessment and Intervention: Supporting Children and Adults With Developmental Disabilities in Community Settings, edited by Luiselli J. K., 269–290. Paul H. Brookes Publishing. [Google Scholar]
  46. Stoddard, J. A. , and Afari N.. 2014. The Big Book of ACT Metaphors: A Practitioner's Guide to Experiential Exercises and Metaphors in Acceptance and Commitment Therapy. New Harbinger Publications. [Google Scholar]
  47. Trujillo, H. M. , and González‐Cabrera J.. 2007. “Propiedades Psicométricas de la Versión Española de la “Escala de Estrés Percibido” (EEP).” Psicología Conductual 15, no. 3: 457–477. [Google Scholar]
  48. UNCRPD . 2006. Convention on the Rights of Persons With Disabilities and Optional Protocol. United Nations Convention on the Rights of Persons with Disabilities. [Google Scholar]
  49. Vasilopoulou, E. , and Nisbet J.. 2016. “The Quality of Life of Parents of Children With Autism Spectrum Disorder: A Systematic Review.” Research in Autism Spectrum Disorders 23: 36–49. 10.1016/j.rasd.2015.11.008. [DOI] [Google Scholar]
  50. Vernhet, C. , Dellapiazza F., Blanc N., et al. 2019. “Coping Strategies of Parents of Children With Autism Spectrum Disorder: A Systematic Review.” European Child & Adolescent Psychiatry 28, no. 6: 747–758. 10.1007/s00787-018-1183-3. [DOI] [PubMed] [Google Scholar]
  51. Wallace, D. P. , Woodford B., and Connelly M.. 2016. “Promoting Psychological Flexibility in Parents of Adolescents With Chronic Pain: Pilot Study of an 8‐Week Group Intervention.” Clinical Practice in Pediatric Psychology 4, no. 4: 405. 10.1037/cpp000016. [DOI] [Google Scholar]
  52. Wegner, D. M. , and Zanakos S.. 1994. “Chronic Thought Suppression.” Journal of Personality 62, no. 4: 615–640. 10.1111/j.1467-6494.1994.tb00311.x. [DOI] [PubMed] [Google Scholar]
  53. Weitlauf, A. S. , Vehorn A. C., Taylor J. L., and Warren Z. E.. 2014. “Relationship Satisfaction, Parenting Stress, and Depression in Mothers of Children With Autism.” Autism 18, no. 2: 194–198. 10.1177/1362361312458039. [DOI] [PMC free article] [PubMed] [Google Scholar]
  54. Whittingham, K. , and Coyne L.. 2019. Acceptance and Commitment Therapy: The Clinician's Guide for Supporting Parents. Academic Press. [Google Scholar]
  55. Whittingham, K. , Sanders M., McKinlay L., and Boyd R. N.. 2014. “Interventions to Reduce Behavioral Problems in Children With Cerebral Palsy: An RCT.” Pediatrics 133: 1–9. 10.1542/peds.2013-3620. [DOI] [PubMed] [Google Scholar]
  56. Whittingham, K. , Sanders M. R., McKinlay L., and Boyd R. N.. 2016. “Parenting Intervention Combined With Acceptance and Commitment Therapy: A Trial With Families of Children With Cerebral Palsy.” Journal of Pediatric Psychology 41, no. 5: 531–542. 10.1093/jpepsy/jsv118. [DOI] [PMC free article] [PubMed] [Google Scholar]
  57. Wong, C. C. , Mak W. W., and Liao K. Y. H.. 2016. “Self‐Compassion: A Potential Buffer Against Affiliate Stigma Experienced by Parents of Children With Autism Spectrum Disorders.” Mindfulness 7: 1385–1395. 10.1007/s12671-016-0580-2. [DOI] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.

Articles from Journal of Applied Research in Intellectual Disabilities are provided here courtesy of Wiley

RESOURCES