Sociology Mind
2013. Vol.3, No.1, 62-66
Published Online January 2013 in SciRes (
Copyright © 2013 SciRes.
Effects of Stress Management Training by Using
Cognitive-Behavioral Method on Reducing
Anxiety and Depression among Parents of
Children with Mental Retardation
Abbas Ali Hosseinkhanzadeh1, Taiebeh Yeganeh2, Nouradin Rashidi3,
Ghasem Zareimanesh3, Nouradin Fayeghi4
1University of Guilan, Rasht, Iran
2Young Researchers Club, Tonekabon Branch, Islamic Azad University, Tonekabon, Iran
3M.A. in Counseling, Kermanshah, Iran
4M.A. in Psychology, Kermanshah, Iran
Received September 28th, 2012; revised November 3rd, 2012; accepted November 18th, 2012
Present study is designed to investigate the effects of stress management training by using cognitive be-
havioral method on anxiety and depression among parents of children with mental retardation. This study
is a quasi-experiment that designed as pretest and post-test with control group. The statistical population
of study included all parents with mental retarded children from city of Babol in 2011-2012. Sample
population was including 40 parents that were selected cluster sampling and allocated in experimental and
control groups (20 parents for experimental group and 20 for control group). The experimental group
trained during 10 sessions of stress management with method of cognitive-behavioral, whereas during this
period the control group did not received any intervention. Both groups in pre-test and post-test assessed
by using anxiety and depression scale and results were analyzed by using independent t-test. The results
of t-test showed that there were no significant differences between two groups in pre-test, but stress man-
agement training with method of cognitive-behavioral in experimental group were significantly reduced
scores of anxiety and depression. The results of this study showed that stress management by using cogni-
tive-behavioral method decreases depression and anxiety scores compared with the control group. Due to
psychological problems of parents with mental retarded children, cognitive-behavioral stress management
training program can be used as intervention method to reduce anxiety and depression in order to decrease
Keywords: Stress Management; Cognitive-Behavioral Method; Anxiety; Depression
During the last two decades movements of institutions has
been changed focusing of primary care from psychiatry hospi-
tals into community mental health centers, and because of bu-
dget, resources and facility limitations, families of patients had
to take responsibilities such as being practical assistance or
emotional supports (Gutierrez-Maldonado et al., 2005). In the
past, children who were in institutions, but now they are living
in family environment which is better for their development but
on the other hand these changes have great pressures on fami-
lies (Pelchat & Lefebvre, 2004). Generally interesting to the
issue of psychological needs of caregivers goes back to 1950
(Honea et al., 2008). Some experts underline that role of care-
givers often accompanied by set of rewards and positive rein-
forcement (Picot, 1996).
The birth of a child with a disability affects the dynamic and
interaction among family members which could leads to crisis
within family. Specially issue of mental retardation in children
is very serious because family with mental retarded children
have problems in parental system, marital relationships, sibling
relationships, even it affects their external system such as friend,
family, neighbors, school and will cause more pressure within
the system, at this point emotional state and physiological
thoughts become abnormal then leads to vulnerability in cogni-
tive activities which outcome of these behavioral problems will
bring out depression and anxiety (Hernandez, 2005). Regarding
to this issue, Goffman (1963) believes that experiences of stig-
ma not only affect people who carrying stigmatized traits, but
also will expand to those have directly relationship with people
who carry negative attributions. Affiliates could internalize their
stigma and affect their life, so they might face with contagious
stigma which is complex phenomenon (Gray, 1993; Green,
The birth of a child with mental retardation could lead to
deep impact on families, thus parents of children with special
needs are facing more problems than parents of normal children
which affect their psychological well-being (Rohini, 2012).
This kind of birth is one of the most stressful events among
individual’s life (Mc Conkey et al., 2008). Some factors such as
advances in medicine and technology, effect mental retarded
children to live longer and healthier (Saloviita, Itallina, & Lei-
nonen, 2003). The continuing care of children with mental re-
tardation is often stressful for parents (Esdaile & Greenwood,
2003). The effects on family unit can be economic, social, and
emotional in nature. Researchers have indicated that parents of
children with mental retardation are generally at risk for a vari-
ety of emotional difficulties (Beckman, 1991; Khamis, 2007).
The cumulative impact of daily hassles and difficulties in deal-
ing with disabled children represent significant stressors that
may subsequently affect parents and family functioning. In par-
ticular, a great deal of evidence points to associations between
the severity and frequency of behavior problems of children
with intellectual disabilities and parental stress and psychiatric
problems such as depression and anxiety (Baker, Blacher, Crnic, &
Edelbrock, 2002).
Severe and long term stresses can affect adaptation ability,
and reduce pleasure which results with depression (Kiecolt-
Glaser, 2002). According to the studies, adapting to mental re-
tarded children has some stages, in the first stage family en-
counters with crisis such as anger and denial. Then family will
experience emotional turmoil, anger, guilt, depression and shame
that can reduce their self esteem, at this point child will be un-
der excessive care or ostracized by family and finally child will
be accepted by family (Heyward, 2000).
Varies studies have confirmed that parents of mentally re-
tarded children showed higher levels of stress than children
with normal status. The results of Shieve and colleagues re-
search in 2007 showed that the presence of stresses among
parents of children with special needs are 44% which this amount
among parents with normal children are 11%. Also research of
Cushner-Weinstein and colleagues in 2008 have been reported
amount of stresses among parents with epilepsy children is
around 45%.
The most important problems of these parents are: 1) Diffi-
culty in accepting mental retarded children; 2) Fatigue of care-
giver; 3) Issued that related to leisure time; 4) Financial prob-
lems of family; 5) Medical things (Khamis, 2007). All those
cases make stresses on families, especially on mothers, because
mothers are spending more time to care their children due to the
traditional role of “care”, also they are more under risk of de-
pression compared with men (McConkey et al., 2007; Pin-
quart & Sorensen, 2006). Also they might abandoned by their
spouse for reasons such as lack of willingness to accept addi-
tional responsibilities or stigma (Rohini, 2012).
Some features such as the nature of disabilities, behavioral
problems of children, emotional status, lack of social support,
presence of additional disabilities in children, stressful resources
associated with the inability of children can lead to increasing
anxiety even depression among parents (Kaplan, 2010; Zaid-
man-Zait, 2007), that in turn, existence of these psychological
abnormalities significantly contribute to reducing quality of life
(Sakakura et al., 2007).
One of the variables that directly correlated with parental
stress is severity of disability. Children who are born with se-
vere injuries are more likely to make the family anxious be-
cause their family has more responsibility toward their children
(Dabrowska & Pisula, 2010). According to the extent of the
severity, their needs will increase so then they need more ser-
vices from their family. Additional role is imposed on parents
in the birth of children with disabilities especially on mothers
make lots of stress. In addition mothers also have responsibility
such as educating their children (Parrette & Brotherson, 1996).
Parette & Brotherson discuss reasons that underline need of
providing educational services to parents. From their view point
parents with mental retardation experience high level of anxiety
and stress thus this requires specialized and training to identify
them. These children often need special cares because of de-
laying or failure to obtain customs such as toilet training, dres-
sing, eating, clothing, and problems such as bed-wetting and
seizures. In order to achieve diagnosis and treatment, parents
become strict and this might result with financial loss, energy
and time in order to take care of themselves or other members
of family.
The subject of stress management by using cognitive-be-
havioral method tends to be very important issue now a day, be-
cause it particularly affects function of family and relationship
within the family members which might results to caught vi-
cious cycle. Family experiences anxiety and then causes vari-
ous psychological problems among members of family, thus
this gradually will lead to negative effect on family function. A
child that develops in dysfunctional family that faces with many
conflicts is more likely to have emotional, behaveioral and
educational problems. These problems have a negative impact
on family members and this cycle continues and becomes more
complex every day. For breaking this cycle stress management
training by using cognitive-behavioral method is important
because this method focuses on cognitive-behavioral approach.
Stress management increases the ability of individual in or-
der to coping with stressful situation to reduce the level of
stress. This method of intervention consist of elements such as
raising awareness about stress, relaxation training, identifying
inefficient thoughts, cognitive restructuring, problem solving,
anger management, self management and planning activities
(Linden, 2005; Anderson, 2006; Antoni et al., 2009). Such in-
terventions are necessary because the level of psychological
well-being of parents directly associated with positive and ef-
fective interaction between them (Ruhuny, 2012). Considering
the fact that there exists a significant hiatus in the examination
of parental stress and psychological distress among parents of
children with mental retardation in Iran, present study investi-
gates whether stress management training by using cognitive-
behavioral method reduces the anxiety and depression among
parents of children with mental retardation or not?
The Sample and Sampling
Present study is quasi-experiment designed as pre-test and
post-test with control group. Samples consist of all parents with
mental retarded children from city of Babul in 2011-2012.
Sample population was including 40 parents that were selected
by cluster sampling and allocated randomly in experimental and
control groups (20 parents for experimental group and 20 for
control group).
Research Tools
In this study to gather data from pre-test and post-test, scale
of anxiety and depression of SCL-90-R questionnaire is used.
This scale in addition to psychiatric patients, are useful and
appropriate in the case of alcohol and drug addicts, patients
with cancers, patients with heart failure and those who are under
stressful situation. This scale chosen from authors, because it
has short, simple and brief buoy of anxiety and depression, also
with respecting to the low educated patients was the best scale
Copyright © 2013 SciRes. 63
in comparing with other scales in order to measure depression
and anxiety. It is based on Likert scale of five choices (Not at
all, Little, Partly, High, Very high) and scored as (0, 1, 2, 3, 4).
In an Iranian study on depression and anxiety, coefficient vali-
date scale is reported as 92% and 86% (Khorramabady et al.,
2009). In the study of Riahi and colleagues (2010) reliability
coefficient was calculated for the scale of mental health based
on its reliability is equal with 0.932 which shows extreme har-
mony between the items of this scale.
Introducing the Intervention Program
After running the pre-test on the both groups, experimental
group attended in stress management program by using cogni-
tive-behavioral method and after intervention, test scores were
collected. Program of stress management by using cognitive-
behavioral method (Antoni, Ironson, & Schneiderman, 2007)
includes 10 session of 90 minutes in experimental groups was
performed as follows: In general, each session consists of two
parts, first steps contains techniques of stress management and
second part includes relaxation exercises.
First Session: Describe the factors of causing stress, response
to factors of causing stress, awareness of the physical effects of
stress and its possible consequences on health-muscle relaxa-
tion for 16 groups of muscles.
Second Session: Stress and awareness (of automatic thoughts
and physical sensations)—muscles relaxation for 8 muscles.
Third Session: Describe the relationship between thoughts
and emotions-diaphragmatic breathing, muscle relaxation for 4
groups of muscles.
Fourth Session: Identification of negative thinking and cog-
nitive distortions-breathing, illustration and passive muscle re-
Fifth Session: Replacement of logical thoughts—Self-train-
ing for being heaviness and heat.
Sixth Session: Learn to deal effectively—Self-training for
heart rate, respiration, abdomen and forehead.
Seventh Session: Implementation of effective coping re-
sponse—Self-training with illustration and self-induction.
Eighth Session: Anger management training and mantra me-
Ninth Session: Gary expresses training—Counting breath
Tenth Session: Social Support—Overview of program and
personal stress management program.
The presentation of material in each session was first to re-
view the material of last meeting, then materials of that session
were presented, and at the end of that session the new materials
were reviewed and finally new task has been given to them.
After completing program, post-test were administrated to both
groups in order to determine degree of anxiety and depression.
In order to determine the effect of cognitive behavioral stress
management training in the both experimental and control
groups, first scores on the variable of depression and anxiety in
the pre-test and post-test was calculated. Table 1 shows profile
of the sample.
In order to compare experimental and control groups in terms
of effectiveness of stress management training on anxiety and
Table 1.
Means and standard deviation of experimental and control groups.
Experimental 20 41.07 4.35
Control 20 40.67 5.8
depression, the independent t-test was used where the total ave-
rage difference between pre-test scores—post-test (d score) has
been compared in two groups (One of the common statistical
methods in the design of pre-test and post-test is with control
group). The results are shown in Tables 2 and 3.
According to Table 2, there is no significant difference in
average of two groups of control and experimental, but after
stress management training and in comparison of averages in
post-test, test, results of t-test indicated that there are significant
differences between two groups in terms of anxiety variable.
Final amount of t is outcome of immunization effect on anxiety
4/1 which is on P 0.001 and is meaningful with 1% alpha, in
other words we can say that the effect of immunization training
in reducing anxiety is significant.
The data in Table 3 also shows that there is no significant
difference between two groups in pre-test in terms of depress-
sion variable, but after stress management training, results of
independent t-test indicates that there are significant differences
between two groups in terms of depression variables. The final
amount t outcome of immunization effect on depression is 3/4
which is on P 0.001 and is meaningful with 1% alpha. In
other words stress management training, significantly reduced
depression. Overall, there are significant differences between
scores of pre-test and post-test in control and experimental
groups on anxiety and depression. These findings indicate that
cognitive-behavioral stress management training is effective
and reduces anxiety and depression in parents of children with
mental retardation.
Discussion and Conclusion
Pressure of psychiatric care that is imposed on caregiver re-
duces the quality of care and can jeopardize their mental and
physical health and releasing these tensions and pressures
without treatment and intention can lead to reducing physical
and mental health of home caregivers as hidden patient (Goode
et al., 1998).Therefore, some strategies to reduce stress for the
parents seems to be necessary, such as family counseling, cop-
ing skills training, inadequate social support and providing pro-
fessional classes for the parents. Providing such interventions
defined as mental health professionals to reduce tensions from
home caregivers (Riebscheger et al., 2008; Gutierrez-maldo-
nado & Caqueo-Urizar, 2007).
Therefore, this study examines the impact of cognitive-be-
havioral stress management training in reducing anxiety and
depression among parents of children with mental retardation.
The results of this study has been proved that cognitive-be-
havioral stress management training reduce depression and an-
xiety scores in experimental group comparing with control
group, findings of this result are consistent with the results of
the research study Baron (1994), Keogh et al. (2005), Vivian
Khamis (2006), Sheehy & Horan (2004), Rohini (2012). Find-
ings of these researchers also indicated that stress management
by using cognitive-behavioral method help people to deal with
Copyright © 2013 SciRes.
Copyright © 2013 SciRes. 65
Table 2.
Results of independent t-test in order to compare experimental and control groups on anxiety.
Experiment 20 18.8 1.86
Control 20 18.6 1.18
0.35 0.73
Experiment 20 16.13 1.4
Control 20 18 1.25
3.84 0.001
Experiment 20 2.66 1.34
Test score difference
Control 20 0.6 1.35
4.1 0.001
Note: DF = 38.
Table 3.
Results of independent t-test in order to compare scores between control and experimental groups on depression.
Experiment 20 28.53 3.25
Control 20 27.73 3.01
0.69 0.49
Experiment 20 24.4 3.2
Control 20 27.4 2.85
2.7 0.012
Experiment 20 2.66 1.34
Test score difference
Control 20 0.6 1.35
0.4 0.002
Note: DF = 38.
particular pressures in order to improve quality of their life.
Husting & Beck (2004) investigated group intervention pro-
gram with the aim of reducing anxiety among parents of chil-
dren with mental retardation. They believe that parents of chil-
dren with mental retardation are increasingly vulnerable to
stress and other psychological problems such as depression and
anxiety thus, they need to interceptive programs in order to
decrease stress. Review of Husting & Beck has shown that
among intervention programs, the cognitive-behavioral method
have the greatest effective impact in reducing stress. The above
findings can be explained by cognitive-behavioral strategies.
By using cognitive stress management training try to identified
unreasonable thoughts, inefficient, and factors that arousing
anxiety and depression and try to help them to have insight in
order to replace rational thoughts. This will enhance their self-
esteem and psychological adequacy thus will lead them to achi-
eve more resources to help their disabled child. As Lazarus &
Folkman (1984) argue that when individual coping with stress,
if resources are available to help, will show less vulnerability to
The nature of this type training has been effective in reducing
the stress of people, because the parents all were well trained
group. Berg & colleagues (1998) underline nature of all prob-
lems based on social and interpersonal. Participation in those
kinds of trainings give them chance to share their problems,
understand problems of others, learn new ways to solve prob-
lems and learn constructive plans in order to cope with stress.
Actually, this is kind of social support, emotional and informa-
tional support (Thoits, 1986). Social support affect life satisfac-
tion in two ways: first way is direct effect or general effect of
social support on life satisfaction without considering the level
of distress experienced by individual, it effects the life satisfac-
tion, and second way consists of indirect effect or mediator
effect that protect people in facing with stressful conditions
(Van Leeuwen et al., 2010).
In order to provide another explanation, Lazarus and Folk-
man (1984) underline that major issue is how individual per-
ceive or deal with stress that might affect outcome, thus if peo-
ple find more ways to compromise to cope with environmental
stressors and reduce level of stress.
In the present study aim was to teaching various ways in or-
der to challenge with negative thoughts and attitudes associated
with having a mental retarded child, and to reduce symptoms of
anxiety and depression and as a result improve and resolve
impaired functions of activities, life satisfaction, self-esteem
and social relationships. Prevalence of anxiety and depression
among parents of children with mental retardation is in high
level, thus therapies such as cognitive-behavioral therapy be-
side other methods seems to be necessary, because those treat-
ments can teach parents to learn how deal with their children in
order to adapt their social situation. Thereby, improving com-
pliance, while reducing the harmful effects of these disabilities
will help to children and parents in order to comply with the
disease and also will help them find the best solutions (Wil-
liams et al., 2003). In sum, increasing the mental health leads to
physical health and finally to healthy society. The final point
that must be pay attention is that importance of continuing to
improve the level of psychiatric services for these individuals
and their families (Awad & Voruqanti, 2008). So, in further
studies suggested that to use other methods of therapy and com-
pare them with each other which have been proven that are ef-
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