Psychology and Psychiatry: Open access
Open Access

Attention-Deficit/Hyperactivity Disorder (ADHD) is one of the most common problems in children and the reason for referral to psychiatrists and psychologists [1]. This disorder, which has a profound effect on the lives of children and families, is associated with symptoms of hyperactivity, inattention and impulsivity. Several studies indicate a prevalence of 5 to 12% in the children's population and it constitutes about 50% of the clients to children's psychiatric clinics [2,3]. Children with ADHD are talkative, stubborn and self-willed children, they do not accompany their parents and do not obey them, they expect others to help them and they cannot play and do activities independently [4]. The mothers of children with ADHD have more stress than healthy mothers because they face more parenting challenges. Therefore, the presence of children with ADHD in the family causes fatigue and discouragement from family life for parents; because parents have to spend all their energy to control the child [5,6]. Therefore, the sensitivity of parents in interaction and communication with the child can help to improve the psychological conditions of the child [7]. The presence of a child with behavioral problems and disorders in a family affects the structure of that family and affects the mental health of family members, especially mothers [8]. Parents' behavior and psychological states, followed by family structure, can have different results against the child's developmental cycle or psychological problems. In this regard, research has shown that ADHD has an important impact on the child, family, and work at school, relationships with peers, and family relationships, and affects the mental and psychological conditions of parents, especially mothers of these children. Constantine and Jerman have also shown that the families of children with ADHD have more conflicts and ruptures than normal ones [9].

A significant number of families suffer from the effects of having a child with ADHD [10]. Parents of these children, especially mothers, suffer a lot of psychological pressure. Anxiety, worry, and mental disturbance are common reactions and disorders that occur in mothers following the knowledge of the child's illness [11]. According to studies, the mothers of children with ADHD suffer more stress and anxiety than other mothers and experience continuous psychological disturbances. Moreover, Schoenfelder et al., and DosReis et al., showed that mothers who have a child with ADHD suffer from psychological disturbances and experience more stress than other mothers [12,13]. Mental distress is a term used to describe acute and short-term episodes of a specific disturbance that first manifests with features of depression, anxiety, or stress. This situation occurs in certain cases after a person is unable to perform daily activities due to the problems that have occurred, and it is also sometimes described with the term collapse [14]. Another disorder that mothers of children with ADHD order suffer from is anxiety. Benson showed that mothers of children with ADHD suffer from a lack of control over the situation, which is one of the main symptoms of anxiety. Anxiety is also one of the basic human emotions that arises in response to a part of human emotions and physiological states and is responsible for informing the organism of an imminent danger [15].

Several studies have shown that mothers of children with ADHD experience psychological problems such as: Depression, anxiety, dissatisfaction with the role of mother, stress, decreased sense of competence and attachment to the child, and impaired communication with others and spouse [16]. This principle has prompted various researchers to search for a method to reduce the emotional and psychological problems of these mothers; because as a result of improving the psychological conditions of mothers, their behavior and care performance will be improved and children's problems will have less effect [17]. Therefore, in stressful and unfortunate situations where a person's mental health is endangered, one should seek effective treatment and provide conditions to avoid mental disorders and life problems. CBT is one of the treatments that mainly focus on identifying, evaluating and correcting different levels of the patient's damaged thoughts and beliefs that are related to his behavior and feelings [18]. Lau et al., showed that cognitive behavioral method used for families with disabled children is effective in treating the anxiety of these families [19]. Also, Carpenter et al., found that cognitive behavioral therapy is effective for treating children's anxiety [20].

It seems that this treatment is effective in increasing the distress tolerance and reducing the anxiety of mothers of children with ADHD. In therapeutic approach, cognitive definitions, incorrect attributions and low self-esteem are taken into consideration, and its goal is to reduce self-condemning attitudes, increase attributions Positive and improving coping skills. In other words, CBT is an intervention that brings about emotional and behavioral changes by learning new ways of coping and recognizing thoughts in a person [21]. In the CBT approach to improve child-parent relationships through mechanisms such as acceptance, not judging oneself and others based on awareness and thoughts, feelings occur, which requires learning new skills and doing exercises to reduce rumination in order to improve relationships. Studies have shown that parent education programs have been effective in reducing problems such as anxiety and depression in children with emotional-behavioral problems. Usually, the mothers of children with ADHD suffer from low distress tolerance and high anxiety, and these disorders, in addition to reducing the mental health of mothers, cause serious damage to the family foundation. Therefore, it is very important to conduct a study focusing on the treatment of agitation and anxiety disorders in the mothers of children with ADHD. The present study was conducted in line with the research gap with the aim of investigating the effectiveness of CBT based on mindfulness on the distress tolerance and anxiety in the mothers of children with ADHD.

This semi-experimental study was carried out as pre-test and post test design with a control group and follow-up. The statistical population included mothers of children with ADHD aged 7 to 12 in Kermanshah city, Iran, 2021. The convenience sampling method was from those who referred to the counseling and psychotherapy center in Kermanshah. In this study, 40 mothers of children with ADHD declared their readiness to participate in the research and were selected based on the study criteria.

Inclusion criteria were including not suffering from mental illness, at least first secondary education, not receiving psychological treatments before or during group therapy sessions. Mother's lack of consent to continue participating in the research, and absence from more than 2 training sessions were considered as the excluding criteria for people to be from the study.

In order to collect data from the research samples, first by referring to the Kermanshah Aramesh counseling and psychotherapy center, the necessary arrangements were made regarding the objectives of the research. Then, among the volunteers who were willing to participate in the research, 30 participants were selected as samples according the criteria and were randomly assigned to groups of experimental (15 people) and control (15 people). At the beginning of the research, the researcher gave the subjects the necessary information about the goals, duration of the research, and how to co-operate during the study, and informed written consent was obtained from them. Also, in line with ethical considerations, the research units were assured that the collected information will be considered confidential and the results will be reserved for each person. Before starting the training, the questionnaires of distress tolerance and anxiety were provided to the people and the pre-test was performed in two groups. Then, the experimental group underwent CBT intervention based on the protocol of Bgels and Restifo for 8 one-hour sessions and two sessions per week, and at the end, a post-test was performed on both experimental and control groups. Then after one month follow-up was also implemented. In addition, after the end of the test, the control group was also treated. The training content of CBT based on mindfulness is presented in Table 1.

Table 1: Cognitive behavioral therapy based on mindfulness, according to the approach of Bgels and Restifo, 2014.

Tools

Distress tolerance scale: This questionnaire is a self-measurement index of distress tolerance that was created by Simons and Gaher in 2005 [22]. This scale has 15 items and four subscales, namely emotional distress tolerance, being absorbed by negative emotions, mental estimation of disturbance and adjustment of efforts to relieve disturbance. The options of this scale are scored based on a five-point Likert scale from 1 (complete agreement) to 5 (complete disagreement). High scores in this scale indicate high distress tolerance. In the study of Hawkins, the internal consistency of the distress tolerance scale was reported as 0.91 [23]. The Persian version of the questionnaire was standardized by Azizi et al. [24]. Cronbach's alpha for the subscales of tolerance, absorption, evaluation, and adjustment were reported as 0.75, 0.77, 0.70, and 0.75, respectively. In the present study, Cronbach's alpha coefficient of the whole scale was 0.83.

Anxiety questionnaire: This questionnaire is a self-report questionnaire that was introduced by Beck and Steer and was prepared to measure the severity of clinical anxiety symptoms in people. Beck's anxiety questionnaire is a 21-item scale in which the subject chooses one of four options from 0 to 3 in each item, which indicates the intensity of anxiety, so that the total score is in the range of 0 to 63. This questionnaire has high reliability and validity. Its internal consistency coefficient is 0.92 through Cronbach's alpha, its reliability is 0.75 with a one-week interval, and the correlation of its items ranges from 0.30 to 0.76. This questionnaire was translated into Persian by Kaviani and Mousavi and is validated [25]. Its internal consistency coefficient was obtained as 0.92 using Cronbach's alpha, and its reliability was reported as 0.75 with a one-week interval. In the present study, Cronbach's alpha was reported as 0.78.

To analyze the data, indicators such as mean and standard deviation were used, and to test the research hypotheses, analysis of variance was used.

In the present study, the experimental group consisted of 60% aged 20-35 and 40% aged 35-45. Also, 26.4% had a diploma, 40% had a bachelor's degree, and 33.6% had a bachelor's degree. The control group had 66 6.6% were 20-35 years old and 33.4% were 35-45 years old. 33.3% had a diploma, 40% had a bachelor's degree, and 26.7% had a bachelor's degree. The mean and standard deviation of the distress tolerance and anxiety variables is shown in Table 2. The results showed that there is a significant difference between the pre test and the post-test in the average of distress tolerance and anxiety.

Table 2: Mean and standard deviation and Kolmogorov-Smirnov test for the normality of research variables (n=30).

The normality of the study variables is presented in Table 2. According to the results of the Kolmogorov-Smirnov test, the distribution of the research variables is normal. The results of box's M was checked, which indicates the homogeneity of covariance in the experimental and control groups (P=0.074, F=1.34, Box=61.22). In addition, the results of Levene's test also showed that there is homogeneity between the variances of the groups (P<0.05).

The results of the multivariate tests were investigated on the post test mean of the variables of the experimental and control groups (Tables 3 and 4). With the pre-test control, there is a significant difference between the test and control groups in one of the dependent variables (F=26.12, P<0.001). The effect size was equal to 0.53, which indicates that 53% of the individual differences in the post-test scores of mother's distress tolerance and anxiety are related to the effect of CBT.

Examining Pillai's trace, Hotelling's effect and Roy's largest root with the pre-test control of the significant levels of all tests, indicates that there is a significant difference between the test and control groups in terms of one of the dependent variables (53.0). (F=12.26 and P>0.001). The effect or difference is equal to 0.53. In other words, 53% of the individual difference in the post-test scores of mother's anxiety tolerance is related to the effect of cognitive behavioral therapy. The statistical power is equal to 1, so there is no possibility of second type error.

Table 3: The results analysis of distress tolerance and anxiety scores.

The results of analysis on distress tolerance are shown in Table 3. The results of one-way ANCOVA showed that by removing the effect of the pre-test scores, the effect of the independent variable on the post-test of distress tolerance scores is significant (Partial η2=0.87, P<0.05, F=181.34). Also, based on the results of the analysis of covariance on anxiety, by removing the effect of the pre-test scores, the independent variable had a significant effect on the post-test anxiety scores (Partial η2=0.641, P<0.05, F=48.324). It means that CBT has increased the distress tolerance and reduced anxiety in the mothers of children with ADHD.

Table 4: Changes scores of distress tolerance and anxiety in mothers in the follow-up phase.

As can be seen in Table 4, there is no significant difference between the post-test and follow-up scores of the experimental group (P>0.05), therefore it can be state that the intervention had a lasting effect on the distress tolerance and reducing the anxiety of the mothers.

In this study, the effectiveness of CBT on the distress tolerance and reducing the anxiety in the mothers of children with ADHD was investigated. The results showed that there is a difference between the experimental and control groups in the post-test in the distress tolerance. This means that CBT based on mindfulness was effective on the distress tolerance in the mothers of children with ADHD and increased the mothers' distress tolerance. The findings of the present research are aligned with the results of Nikyar et al., and Olsson et al. In explaining the obtained results, it can be stated that CBT based on mindfulness through managing negative emotions and controlling rumination in the mothers of children with ADHD can help control anger. This will improve the quality of psychological flexibility, increase social and individual adaptability, and also raise the mothers' distress tolerance. The mothers with children with ADHD can increase their social and individual adaptation through mindful parenting training and thus improve their distress tolerance. The mental health of the mothers of children with ADHD is at a low level due to stressful conditions and unfortunate situations. So that in dealing with the problems of life and the pressures of life without mastering their thoughts and emotions, they are not prepared to deal with these challenges and their distress tolerance is very low. CBT based on mindfulness through increasing the focus on individual skills makes mothers focus all their attention on the stressful conditions of their children and find a suitable solution to overcome the challenges. Therefore, with cognitive therapy based on mindfulness, the distress tolerance of mothers increases.

In this study, the results showed that there is a difference in the anxiety variable between two experimental and control groups in the post-test. This means that CBT based on mindfulness was effective on the anxiety in the mothers of children with ADHD and reduced their anxiety. The results of the research were consistent with the findings of Lau et al., and Carpenter et al. It can be stated that CBT based on mindfulness through emotion management and anger control, and rumination management reduces anxiety in the mothers with hyperactive children and it makes mothers feel less anxious.

Also, mindful parenting can often lead to desirable parenting styles. For example, the high correlation of mindful parenting with the authoritative style and the low correlation with the authoritarian style and the lower use of styles based on excessive protection and exclusion and the greater prevalence of encouraging styles will lead to parents, especially mothers, be less stressed and anxious with the help of this type of training. Adopting a mindful parenting approach due to its focus on the present, along with a compassionate and non judgmental view of the child, will help mothers better regulate the emotions that arise during interaction with the child and deal with parenting anxiety in a better way. Mindful parents are less reactive towards their children and use more effective parenting methods. This ability helps them to break the vicious cycles of parenting and adopt a warm attitude and higher levels of acceptance and compassion towards their children.

Participants in the research, with the help of cognitive-behavioral techniques based on parenting mindfulness and by emphasizing on behavior control training in the form of self-control skills training, increase the distress tolerance and reduce the anxiety of mothers. Also, it is tried to use the methods of classical and active conditioning, and mothers are taught to recognize the undesirable behavior of their child and then increase the positive behavior by giving rewards and attention. Participating in these educational programs increases the awareness level of mothers regarding their child's behavioral characteristics. In addition, mothers learn to identify their child's problematic behavior and use positive reinforcement. This behavior is eliminated by strengthening the opposite behavior. This method can reduce and replace the effects of past bitter experiences such as failures, rejections and punishments. The information presented about the cause of ADHD leads to the change of the wrong attitude of some parents about the cause of children's behavioral problems. Studies have shown that many mothers consider themselves to be the main responsible for children's misbehavior problems, which causes guilt and self-blame, anxiety and depression. Based on this, it can be claimed that the parent-centered mindfulness program has an effect on reducing the anxiety of mothers of children with hyperactivity. By participating in these classes, mothers can achieve a very good individual compatibility with their children. Undoubtedly, mothers who participated in CBT classes are more distress tolerance and less anxious than other mothers. During the treatment, the mothers were asked to pay attention to the child until he was active. This work provides an opportunity for mothers to learn how to perpend to their children without interfering and asking questions and how to make positive comments. Teaching positive attention helps mothers to pay attention to the desirable behaviors that they want their child to increase or continue. It is necessary to pay more attention to the child's desirable behaviors than his undesirable behaviors. Therefore, in the cognitive-behavioral education method, mothers have been tried to be aware of their child's attention and concentration capacity, and with a better knowledge of these children, the mother’s distress tolerance and anxiety will also decrease.

The impossibility of participation of all mothers with children with ADHD in the research, as well as the limited sample of the present study limited to a specific geographical region, has limited the generalizability of the research. Since this research was unique to the city of Kermanshah, it is suggested to the researchers to work on this concept in other societies as well.

In this study, CBT based on parent-centered mindfulness, focusing on the mind and reducing anger and rumination in mothers, was able to increase the distress tolerance in the mothers of children with ADHD. Providing the necessary training to deal with the disorders caused by the child with ADHD towards the mother will provide the mental health of the mothers. Mindful mothers are less reactive towards their children and use more effective parenting methods. This ability helps them to be less disturbed and their mental health is less compromised. With CBT, mothers' anxiety also decreases through mind management and personal and social adaptation. Therapists can use CBT based on mindfulness in order to increase the level of distress tolerance and reduce anxiety of mothers with children with ADHD and thereby increase the mental health of mothers and families. Moreover, In order to save time and money, medical centers can provide the necessary training to mothers with children with ADHD.

The authors sincerely thank all those who participated and assisted in this research.

The authors declare that they have no conflict of interest.

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