Archives of

1. Introduction
erebral Palsy (CP) is the most common
chronic motor disability in children and
a global disability. CP is a neurological
disease that causes non-progressive disturbance
of the locomotor system due to
damage to the developing brain (fetus & infant) [1]. CP
is associated with sensory, perceptual, cognitive, communicative,
and behavioral disorders as well as epilepsy
and musculoskeletal problems. It can restrict the daily
and social activities of patients and may lead to increased
functional limitations as the patients’ age [2]. Children
with CP cannot manage their daily routines, such as eating,
dressing, bathing, and moving, because of the nonprogressive
motor syndrome. These disabilities require
long-term care beyond the needs of typically developing
children [3]. Studies indicated that numerous children
with CP have not had a difficult delivery, and prenatal
factors play a major role in the abnormal development of
the brain [4, 5]. Some of these children only present mobility
impairments, whereas others also manifest learning,
hearing, and vision impairments, and seizures. The
state of intelligence varies depending on the location of
the cerebral injury, as some of the children with CP may
be talented and clever [6]. The global prevalence of CP
is estimated to be 2-6 infants per thousand live births [7].
Under these circumstances, raising a child diagnosed
with CP is a major challenge for parents and may greatly
alter the family’s lifestyle. The mother is a child’s
greatest teacher and educator. Besides, motherhood is
generally one of the most complex experiences for any
woman. Thus, experiencing motherhood concerning a
disabled child would be far more difficult and associated
with multiple unpleasant feelings for the mother. In
general, the mothers of disabled children are more prone
to engaging in the child’s behavioral problems than
their fathers [8]. Being a mother to disabled children is
physically and emotionally frustrating and stressful. The
mothers who are unexpectedly informed of their child’s
affliction with CP may experience different and contradictory
feelings, such as shock, hope, worthlessness,
child acceptance, and difficulty in anxiety control [9].
Anxiety is a condition that affects every individual to
varying degrees throughout their lives, as everyone has
experienced it at least once in their lifetime [10, 11].
As one of the most common mental health disorders,
anxiety is a distressing condition that results from the
apprehension of an unknown threat and disrupts an individual’s
behavioral continuity [12]. Negative thoughts,
emotions, and feelings cause numerous biopsychological
illnesses and anxiety. Anxiety is expressed by repeated
experiences of one’s thoughts about potentially
negative events [13]. Anxiety is painful mental distress
caused by the prediction of a possible future threat or
illness. Anxiety is usually associated with fear, sadness,
helplessness, and difficulty with finding a solution to an
anticipated and seemingly unsolvable problem [14, 15].
Anxious individuals are often unaware of the cause of
anxiety and whether this feeling is caused by a sense of
internal insecurity or external sources of fear [16]. More
reasonable forms of anxiety may be characterized by
depression, extreme sensitivity and anger, restlessness,
insomnia, and sleep disorders, whereas its severe forms
are associated with guilt [17]. Various studies reported a
high level of anxiety in the mothers of children with CP
and other disabilities [18-21].
Anxiety could gradually lead to depression in these
women. Depression is the oldest known disorder, the
most common mental health condition, and a natural human
reaction to environmental pressures [22]. There is a
strong association between depression and suicide; depressive
disorders contribute to 0.80 out of 0.95 mental
health disorders detectable in individuals who commit
suicide or have attempted it [23]. Disappointment with
the child’s treatment is the main depression-related factor
found in mothers, and plays a major role in ideation,
attempting, and completing suicide [24]. Akil et al. [25]
suggested that frustration may be a predictor of depression.
In depression, the subject encounters symptoms,
such as low mood with loss of energy and interest, feeling
of guilt, poor concentration, anorexia, and ideation of
death and suicide [26].
Various theoretical models and interventions have been
developed based on the cognitive pattern for treating
anxiety, as the most prevalent mental health disorder.
Most cognitive therapy methods are relatively effective
in controlling or reducing anxiety; however, the disadvantages
of these methods have led to the development
of alternative theoretical models [27]. Studies also indicated
that Compassion-Focused Therapy (CFT) can be a
strong predictor of mental health. Other studies investigated
the beneficial effects of compassion cultivation, as
internal compassion cultivation has turned into a major
therapeutic focus and goal [28]. Additionally, self-compassion
has recently received great attention from researchers
as a strategy to reduce mental health disorders.
CFT is a multidimensional therapeutic intervention, i.e.,
that has been developed based on remarkable advances
in Acceptance and Commitment Therapy (ACT), Cognitive-
Behavioral Therapy (CBT), Dialectical Behavior
Therapy (DBT), Emotion-Focused Therapy (EFT), Ra-
C
Khoshvaght N, et al. Depression in Mothers of Children With Cerebral Palsy. Arch Hyg Sci. 2021; 10(3):225-234.
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tional Emotive Behavior Therapy (REBT), and multiple
other approaches [16]. CFT aims to reduce components,
such as shame, self-criticism, and self-compassion [29].
Any CFT intervention is based on approval, support,
and kindness. Moreover, self-compassion is negatively
associated with self-criticism, depression, anxiety, ruminating
thoughts, and thought suppression; however, it
is positively correlated with life satisfaction and social
skills [30]. Compassion is an essential human force that
includes kindness, fair judgment, and interconnected
emotions, as well as helping others to find hope and giving
meaning to life in the face of challenges. Compassion
also means to simply attract kindness towards oneself and
to be influenced by the suffering of others [31]. Numerous
studies highlighted the effectiveness of CFT in reducing
anxiety, depression, and suicidal ideation in women
with vitiligo [32]; the symptoms of depression, anxiety,
stress, and weight self-efficacy in female students [33];
stress, anxiety, depression, and the symptoms of patients
with irritable bowel syndrome [34]; depression, anxiety,
and emotion regulation in patients with coronary heart
disease [35]; anxiety in breadwinning women, as well as
anxiety and depression in patients [36, 37].
Considering the adverse effects of the presence of
a child with CP in a family on anxiety among family
members, especially mothers, and its consequences, it is
necessary to develop appropriate interventions to reduce
anxiety and depression levels in these mothers and improve
their families’ quality of life. No international or
domestic study has investigated all research variables in
the mothers of children with CP. Given the importance
and prevalence of depression among families and the
lack of research in this regard, it was sought to examine
it in the present study. The results of this study are
considered as a fundamental effort to improve the psychological
condition of these mothers. Accordingly, this
study aimed to investigate the effects of CFT on anxiety
and depression in the mothers of children with CP.
2. Materials and Methods
This was an experimental study with a pre-test, posttest
and follow-up and a control group design. The statistical
population included all mothers of children with
CP who were referred to Bahar Rehabilitation Center in
Shiraz City, Iran, in 2020. Using the convenience sampling
method, we selected 40 children with CP who
were willing to participate in the study. The research
participants were randomly assigned to the experimental
and control groups (n=20/group). The inclusion criteria
were voluntary attendance in the study, obtaining a score
above the mean value on the anxiety questionnaire, >5
years of experience of having a child with CP, having at
least a middle school educational level, no mental health
illnesses, not receiving simultaneous psychological or
pharmaceutical treatment, and no substance use disorder.
The exclusion criteria were absence from >2 treatment
sessions and reluctance to continue the treatment
process. The experimental group received eight 60-minute
weekly sessions of CFT; however, the control group
received no intervention. After the training sessions, a
post-test was performed in the experimental and control
groups. Additionally, the follow-up was conducted in the
study groups after 45 days. At the end of the study, to observe
ethical considerations, the control group received a
course of CFT. For ethical considerations, the researchers
received written informed consent forms from the
study participants for participation in the research. The
following instruments were employed in the present
study to collect the necessary data.
Beck Anxiety Inventory (BAI): The BAI, consists of
21 self-reported items, i.e., scored based on a four-point
Likert-type scale (0-3). The obtained scores range from 0
to 63. Beck et al. reported that the internal consistency of
this scale was equal to 0.93 and it’s test-retest reliability
coefficient after a one-week pilot study was obtained to
be 0.75. Kaviani and Mousavi [38] also reported that validity
(0.72), reliability (0.82), and internal consistency
(0.92) of this scale were acceptable. They also stated a
score of 0-11, 12-18, 19-26, 27-36, and 37-63 respectively
for the BAI indicates asymptomatic, mild, moderate,
severe, and very severe levels of anxiety. They validated
this questionnaire in Iran and reported its reliability to be
0.82 [38]. In the present study, Cronbach’s alpha coefficient
was calculated as 0.81 for the questionnaire.
Beck Depression Inventory (BDI): The BDI is the revised
form of the Beck Depression Inventory developed
in 1996 to measure the severity of depressive symptoms.
The Beck Depression Inventory is among the most widely
used psychiatric diagnostic tools for depressive disorders.
The study used the short form of the Beck Depression
Inventory with 13 items (BDI-13). The 4 answer
choices of each item are scored from 0 to 3 with the total
score ranging from 0 to 39. Hamidi et al. [39] reported an
alpha Cronbach coefficient of 0.92 for the questionnaire.
In the present study, Cronbach’s alpha coefficient was
computed as 0.82 for the questionnaire.
CFT sessions were planned based on Gilbert’s CFT
model [40]. This intervention was performed in the experimental
group in eight 60-minute weekly sessions.
Table 1 provides a summary of CFT sessions.
Khoshvaght N, et al. Depression in Mothers of Children With Cerebral Palsy. Arch Hyg Sci. 2021; 10(3):225-234.
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The obtained data were analyzed by descriptive and
inferential statistics, such as mean, standard deviation,
minimum and maximum scores, Analysis of Covariance
(ANCOVA), and Multivariate Analysis of Covariance
(MANCOVA) in SPSS v. 24.
3. Results
According to the descriptive statistics, the mean age of
the experimental and control groups was 34.74 and 34.07
years, in sequence. In the experimental group, 5(25%)
subjects had a middle school degree, 11(55%) individuals
had a high school education, and 4(20%) samples had
a college education. Additionally, in the control group,
7(35%) subjects had a middle school degree, 8(40%) individuals
had a high school education, and 5(25%) units
had a college education.
Table 2 presents the Mean±SD values of the studied
variable in the experimental and control groups at the
pre-test, post-test, and follow-up stages. The Mean±SD
post-test score of the anxiety in experimental and control
groups was equal to 28.80±9.24, and 38.80±10.27,
respectively. Furthermore, the Mean±SD post-test value
of depression in experimental and control groups was
computed as 16.25±7.40 and 28.00±5.01, respectively.
Before analyzing the data to test the research hypotheses,
the underlying assumptions of ANCOVA were
examined. To test the normality of the collected data
respecting the significance of the Z-value, the Kolmogorov-
Smirnov test was employed. The relevant data
revealed that anxiety (Z=0.141; P=0.200) and depression
(Z=0.163; P=0.171) had a normal distribution. To test the
homogeneity of variances (for the same variances of the
experimental & control groups), Levene’s test was used
(F=0.289; P=0.750). The ANOVA was also used to examine
the homogeneity of the regression line slope for
the anxiety (F=2.612; P=0.318). According to the test
results, ANCOVA could be used. MANCOVA was used
to compare the experimental and control groups concerning
post-test scores to determine the effect of CFT on
anxiety and depression in the study subjects. According
to Table 3, all 4 relevant multivariate statistics (Pillai’s
trace, Wilk’s lambda effect, Hotelling’s trace, and Roy’s
largest root) were significant for the study variables in the
post-test and follow-up phases. There was a significant
difference between the experimental and control groups
regarding at least one of the examined variables (P<0.01).
Table 4 presents the ANCOVA results of dependent
variables for post-test and follow-up scores. The Fstatistics
of the analysis of covariance of the dependent
variables indicated a significant difference between the
research groups group concerning anxiety and depression
in the post-test and follow-up phases.
4. Discussion
The present study investigated the effects of CFT on
anxiety and depression in the mothers of children with
CP. The obtained findings suggested that CFT effectively
reduced depression in the post-test and followup
phases among the study subjects. This finding was
consistent with those of Ahmadi et al. [32], Taherpour
et al. [33], Seyyedjafari et al. [34], Adibizadeh, and Sajjadian
[35], Takahashi et al. [36], as well as Steindl and
associates [37]. In other words, increased compassion
acts as a barrier against negative events. Individuals with
high compassion under assess themselves less, are less
hard on themselves, and cope with problems and negative
life events more easily. Their reactions to problems
are mainly based on reality because their judgments are
neither self-defensive nor self-critical and self-blaming.
Studies indicated that individuals with high self-compassion
are kinder to themselves and more responsible for
their problems, and cope with events more easily; consequently,
they experience lower anxiety levels [35, 36].
One of the hallmarks of human commonalities is to accept
that everyone has flaws and mistakes and sometimes
may engage in unhealthy behaviors. In contrast to the increasing
assimilation, consciousness leads to a balanced
and clear awareness of present experiences that prevents
the painful aspects of life from being overlooked without
constantly preoccupying the mind. When encountering
painful life events, individuals unconsciously and
negatively judge and evaluate themselves, instead of
coping with issues based on a more vigilant and realistic
approach. In general, CFT protects individuals against
negative states and strengthens positive emotional states
by motivating compassion through compassion techniques,
identifying self-compassionate thoughts, and
eliminating barriers to self-compassion. As compassion
improves, individuals are further motivated to cope with
and manipulate negative thoughts. Mediation exercises
decrease cortisol levels and increase heart rate variability
[33]. Subsequently, such exercises can be helpful to
maintain and increase calm when managing stressful
situations. The extensive negative effects of diseases on
social and family relationships as well as mental preoccupations
can make individuals anxious.
The present study data also suggested that CFT was
effective in reducing depression in the explored mothers
of children with CP in the post-test and follow-up
Khoshvaght N, et al. Depression in Mothers of Children With Cerebral Palsy. Arch Hyg Sci. 2021; 10(3):225-234.
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phases. This finding was consistent with those of Adibizadeh
and Sajjadian [35], Takahashi et al. [36], Steindl
et al. [37], as well as Farokhzadian and Mirderekvand
[41]. In other words, depression exacerbates mothers’ inability
to regulate their emotions. Following depression
and the lack of emotion regulation, mothers gradually
become frustrated and feel depressed. A combination of
these changes intensifies each other in a vicious circle
and creates problems for the mothers. Compassionate
subjects experience less depression and anxiety than others;
a supportive attitude reduces depression and increases
their satisfaction with life [41]. Therefore, the central
therapeutic technique of CFT is compassionate mind
training to develop compassion for self and others. In
this technique, compassion skills and characteristics are
taught to the clients. Compassionate mind training helps
clients to modify their problematic cognitive-emotional
patterns. With changes made in destructive mental patterns,
mothers become kinder to themselves and others
and feel less sensitive to shortcomings and adversities.
These alternations bring peace of mind and reduce anxiety
and worry in mothers. Furthermore, teaching therapeutic
compassion-focused skills to mothers leads to
kindness and compassion for past hardships, sufferings,
and unpleasant experiences. Accordingly, they become
kinder to themselves, less likely to blame themselves,
and have fewer negative thoughts, which in turn, reduces
depression in them.
Table 1. A summary of CFT sessions
Sessions Content
First The introduction of participants; the introduction of group rules and regulations; The explanation of research variables;
the introduction of CFT.
Second The explanation of compassion: what compassion is and how CFT can help us to overcome problems.
Third
Teaching compassion and empathy: training in how to create more diverse emotions concerning others’ issues to increase
care for and attention to health, reflecting on being compassionate to others, attention to and focus on compassion, compassionate
thinking, compassionate behaviors, and compassionate imagery.
Fourth
Forgiveness training, training in how to accept mistakes and forgive ourselves for mistakes to facilitate changes, increasing
warmth and energy, mindfulness, training in how to accept issues and problems to accept upcoming changes and then
gain the ability to withstand challenging conditions due to the changing nature of life and face different challenges, wisdom
and power, intimacy, and no judgment.
Fifth
Training in the development of valuable and sublime emotions: training individuals in how to create valuable emotions in
themselves to appropriately and effectively cope with the environment, practicing consciousness and mindfulness, as well
as the assessment of advantages and disadvantages of the beliefs associated with useless emotions.
Sixth
Training in responsibility as the main component of self-compassion: training the participants in how to think self-critically
to develop newer and more effective views and feelings, practicing the color of compassion task, the sound and image of
compassion, and compassion-based correspondence.
Seventh Compassionate correspondence, practicing anger and compassion, and fear of compassion, as well as preparation for
terminating the group.
Eighth Reviewing, summarization, group termination, and post-test conduction.
Table 2. Mean±SD of the research variables in the pre-test, post-test, and follow-up
Variables Phase
Mean±SD
CFT Control
Anxiety
Pre-test 46.95±5.53 44.70±6.12
Post-test 28.80±9.24 38.80±10.27
Follow-up 29.85±2.15 41.70±4.87
Depression
Pre-test 29.05±2.96 26.60±4.30
Post-test 16.25±7.40 28.00±5.01
Follow-up 13.30±2.07 30.35±3.73
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Depressive symptoms are associated with higher levels
of shame and self-criticism and lower levels of selfcompassion
[42]. CFT is developed to help those who
experience high levels of shame and self-criticism. Self-
Criticism involves self-condemning thoughts. Depressed
individuals experience high levels of self-criticism and
rumination; thus, this therapy is expected to work for
depressed and divorced women with self-critical and depressive
symptoms [43]. Besides, mindfulness is the major
factor and element in CFT. Compassionate thinking,
behavior, and imagery are produced and implemented
through mindfulness. Mindfulness teaches individuals
how to pay attention to their inner and outer worlds with
curiosity and kindness without judgment [44]. Besides,
mindfulness helps individuals become aware of their ruminative
thoughts and the damage they cause to better understand
and break down these cycles of rumination and
self-critical thoughts. Much of the negative emotions experienced
by individuals come from rumination following
negative experiences. The components of mindfulness reduce
negative emotions (anxiety & depression) in individuals
by reducing their rumination. Compassion acts as a
barrier against the negative consequences of divorce [45].
5. Conclusion
CFT teaches individuals to use mediation techniques;
establish a decentralized relationship with their thoughts
by coping with and accepting them as unreal ideas;
defuse negative thoughts and feelings; increase their
awareness of their thoughts and body senses by raising
their cognition and experience through focusing
on breathing; modify their relationship with negative
thoughts, and moderate their arousal symptoms. In these
interventions, individuals accept their emotions but fail
to seek immediate relief from or avoidance of negative
emotions. In other words, individuals cannot change the
conditions of their lives; however, they can modify the
intensity of their emotional reactions to stressful situations
and events of life. When facing their emotions,
individuals find out that emotions are tolerable and they
can cope with negative emotions and reduce anxiety
and depression. Based on the study findings, counseling
Table 3. MANCOVA data in the post-test and follow-up phases
Test Phases Value df Error df F P η2
Pillais trace
Post-test 0.497 2 35 17.290 0.0001 0.497
Follow-up 0.916 2 35 191.011 0.0001 0.916
Wilks lambda
Post-test 0.503 2 35 17.290 0.0001 0.497
Follow-up 0.084 2 35 191.011 0.0001 0.916
Hotelling’s trace
Post-test 0.988 2 35 17.290 0.0001 0.497
Follow-up 10.915 2 35 191.011 0.0001 0.916
Roy’s largest root
Post-test 0.988 2 35 17.290 0.0001 0.497
Follow-up 10.915 2 35 191.011 0.0001 0.916
df: Degrees of freedom; F: F-distribution; η2: Eta-squared.
Table 4. The results of univariate ANCOVA on the post-test and follow-up scores of the explored variables
Dependent Variables
Phases SS df MS F P ηp
2 Statistical Power
Anxiety
Post-test 1009.162 1 1009.162 17.424 0.0001 0.329 0.98
Followup
1005.508 1 1005.508 81.362 0.0001 0.693 1.00
Depression
Post-test 1367.004 1 1367.004 34.034 0.0001 0.486 1.00
Followup
2591.558 1 2591.558 292.390 0.0001 0.890 1.00
SS: Sum of squares; df: Degrees of freedom; MS: Mean square; F: F-distribution; η2: Eta-Squared.
Khoshvaght N, et al. Depression in Mothers of Children With Cerebral Palsy. Arch Hyg Sci. 2021; 10(3):225-234.
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centers are recommended to apply CFT for treating such
mothers. A main advantage of the present study was exploring
psychological characteristics in the mothers of
children with CP. The present study data indicated the
attention to psychotherapy and support of the mothers of
children with CP.
All studied samples were of the same gender and from
only one city, i.e., Shiraz; thus, the study findings should be
cautiously generalized to other populations. Similar studies
are recommended to be conducted on larger sample sizes
and in other cities or on the fathers of children with CP.
In future research, to evaluate the continuity of the treatment
effect, it is suggested that follow-up evaluation be
performed longer. Considering the significant effects of
CFT on anxiety and depression reduction, counselors, clinical
psychologists, and specialists are recommended to pay
closer attention to this intervention. By helping clients to
take advantage of these therapies, there is hope that they
can better control their stressful stimuli, i.e., mostly mental;
accordingly, they can reduce their anxiety and depression
level themselves.
Ethical Considerations
Compliance with ethical guidelines
The participants willingly completed the questionnaires
and signed written informed consent. The Ethics Review
Board of Islamic Azad University, Ahvaz Branch, approved
the present study (Code: 1064819893917).
Funding
This article was extracted from the PhD. dissertation
of first author in the Department of Psychology, Ahvaz
Branch, Islamic Azad University, Ahvaz, Iran.
Authors' contributions
Conceptualization, supervision: Negin Khoshvaght, Farah
Naderi; Methodology: Negin Khoshvaght, Farah Naderi,
Sahar Safarzadeh; Investigation, writing – review & editing:
All authors. Writing – original draft: Negin Khoshvaght,
Farah Naderi; Investigation, Marjan Alizadeh; Funding
acquisition, resources: Negin Khoshvaght.
Conflict of interest
The authors declared no conflicts of interest.
Acknowledgments
The researchers wish to thank all the individuals who participated
in the study and the staff of Bahar Rehabilitation
Center of Shiraz.
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