الفهرس 
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Abstract
Autism spectrum disorder (ASD) is a syndrome that involves abnormal communication, repetitive and restrictive interests, and impaired social functioning. Given the nature of this disorder, parents felt overwhelmed as caregivers, and this had a negative impact on their wellbeing. Parents felt stressed, exhausted, drained from the care they provided to their child with ASD, and frustrated by the lack of time they had for themselves and their family. Moreover, parenting stress may be associated with less positive parenting behaviors and worse children’s adaptation outcomes.
Parent family life as a whole is often organized around the autistic child and his or her future. Given that parents of autistic children have to give up many of their dreams to care for their child, the ability to find new, more realistic goals can offer an important sense of purpose. Researches proved that parents who take care of their selves, remembering that suffering is part of the shared human experience which is inherent on self-compassionate personality, have more emotional resources available to successfully meet life challenges associated with raising an autistic child. Emotional Freedom Technique (EFT) is described as a clinical procedure for the relief of psychological and physical distress, and frequently referred to as “tapping”. This technique combines the cognitive reprocessing benefits of exposure and acceptance therapy along with the energetic disturbance releases associated with acupuncture and other energy therapies. Tapping is also combined with verbalizing the identified problem or target followed by a general affirmation phrase. Emotional Freedom Technique focuses on helping people become aware of and express their emotions, learn to tolerate and regulate them.
The aim of this study
This study aimed to determine the effect of using Emotional Freedom Technique on Stress, Goal Reengagement, and Self-Compassion among parents of Children with Autism Spectrum Disorder.
Research hypothesis
Subjects who undergo Emotional Freedom Technique show less level of stress, higher degree of goal reengagement, and better self-compassion than those who are not exposed to the technique.
Research design:
Quasi-experimental research design was used.
Setting:
This study was conducted at four governmental centers, and four private centers that offer care for children with autism spectrum disorders in Alexandria.
Subjects:
- Subjects of the present study were composed of a convenient sample of 66 parents of children diagnosed with an Autism Spectrum Disorder from at least 6 months, and the children’s ages ranged from 3-12 years old. Thirty four of the study subjects were selected from the private centers and 32 from the governmental centers. Both were divided equally into a study and a control group. Matching between the two groups was considered as much as possible in relation to socio- demographic data such as age, sex, educational level, etc.
Tools: four tools were used for data collection.
Tool I: Socio-demographic characteristics of parents of children with ASD structured interview schedule.
This tool was developed by the researcher to elicit data about the parents of children suffering from autism spectrum disorder, as well as data about their children with ASD as age, sex, birth order, presence of an autistic sibling, etc.
Tool II: Parent Stress Index– Short Form (PSI-SF).
This questionnaire was developed by Abidin,(1995), to assess the level of relative stress in a parent-child relationship. It includes 36 items divided into three subscales namely: Parent Distress (PD); Parent–Child Dysfunctional Interaction (PCDI); and Difficult Child (DC).
Each of the previous three subscales comprises 12 items, scored on a five-point Likert scale. The Parent Stress Index-Short Form (PSI-SF) total score ranges from 36 to 180; in which the higher the score, the greater the level of parent stress. Score of 86, or more, indicates a clinically significant parenting stress.
Tool III: Goal Reengagement Scale.
Goal Reengagement scale is considered as a sub-scale of Goal Disengagement and Goal Reengagement Scale, which was developed by Wrosch et al. (2003) to assess the extent to which individuals can reengage themselves with new meaningful goals after failure in achieving previously intended goals.
Parents indicated their responses on a 5-point Likert scale. Total score ranges from 6-30; in which scores from 6 -13 indicate low reengagement ability, from 14- 21 reflect moderate reengagement capacities , and scores from 22- 30 indicate that participants had an easier time disengaging from unattainable goals and reengaging in new ones.
Tool IV: Self-Compassion Scale (SCS):
This scale was developed by Neff (2003), it measures the way that individuals are kind and understanding toward themselves in the presence of pain or failure rather than being harshly self-critical. Self-compassion scale is a self-reported measurement tool composed of 26 items, assessing the features related to six sub dimensions of self-compassion, namely self-kindness, self-judgment, common humanity, isolation, mindfulness, and over identification. Responses to self- compassion scale are rated on a 5 point likert scale. Items that represent the lack of self-compassion as Self-judgment, isolation, and over identification subscales of the SCS were coded reversely. Total score ranges from 26-130; in which scores from 26 -60 indicate low self -compassion, from 61- 95 reflect moderate self- compassion, and scores from 96 -130 indicate high self- compassion.
- Tool II, III and IV were tested for content validity by nine experts in the field of Psychiatric Nursing, Psychiatric Medicine, and psychology from Alexandria University.
- Tool II, III and IV were tested for internal consistency using Cronbach’s Alpha test. They were reliable and their coefficient values were 0.85, 0.92, and 0.81 respectively.
- A pilot study was carried out on 10 parents of children with autism spectrum disorder to check and ensure clarity of the tools and to identify obstacles and problems that may be encountered during data collection. Subjects of the pilot study were excluded from the study subjects.
- Data were collected during the period from the 1st of April, to the end of November 2018.
The study was conducted through the following phases:
Phase1: selection of the subjects:
- Centers were ranked by using simple random sampling technique, and the starting point was from the governmental centers.
- In each of the selected centers, a list of children diagnosed with autism was obtained, and then their parents were identified and constituted the study subjects, according to the inclusion criteria.
- After assessing the socio-demographic data of each child`s parents in each center, data were checked to determine the matching socio-demographic characteristics among these parents as much as possible, and then they were divided into a study and a control group by simple random sample method.
- Each recruited parent was interviewed individually by the researcher to establish rapport, explain the purpose of the study, and to obtain consent.
- The recruited parent, either in the study or the control group, was exposed to the pre-testing phase using tools 2, 3, and 4 by interviewing each parent on an individual basis.
Phase 2: Implementing the Emotional Freedom technique (EFT).
Emotional freedom technique was implemented by the researcher on the study subjects as following:
Six therapy sessions were conducted within 3 consecutive weeks, twice\week on an individual basis. Duration of each session ranged from 45-90 minutes.
Each session of the program was developed based on general and specific objectives based on the aims of the study, and the sequence of the Emotional Freedom Technique. The overall objectives for each session as well as the content of the session were presented in Arabic language.
A private, quiet room in the assigned center was used by the researcher to meet the study subjects, and to implement the sessions.
In each session, the researcher started by describing the objective of each session.
The researcher instructed the subjects that a successful session is a collaborative activity that requires being an active participant. Every subject applied EFT tapping on specific distressing emotional issue determined by him self. The researcher guided and directed their performance until they became able to perform it independently and correctly.
At the end of each session, summary of the important points discussed in the session was done by the researcher
Homework assignment was suggested for the participant to measure the effectiveness of Emotional Freedom Technique on daily life issues.
Reviewing homework assignments of the previous sessions were done, and corrective feedback was given by the researcher to the participant in order to master the technique efficiently
The teaching materials that have been used for this research were educational video, photo, handouts.
At the end of the training program, the researcher asks the participant about their feedback about the technique.
The control group followed the normal routine of the centers.
Phase 3: The reassessment phase.
Tools 2, 3, and 4 were reapplied on the subjects of the study group immediately after implementing EFT and then again one month later following the training program. The control group was also reassessed again at the same time.
Results
The following are the main results yielded by the present study:
- The largest percentage of subjects in both study and control groups were females (90.9% and 87.88% respectively).
- More than half of the subjects (56.06%) have a university degree.
- More than two thirds of the study subjects (68.18%) were not working, and these represent the housewives.
- Large percentage of both groups (87, 69%) reported that they don’t receive support of any kind.
- More than three quarters (75.76%) of the children suffering from autism were males.
- More than half of both the study, and control groups (51.5%) were the first ordered child, and almost all the study, and control groups (96.97%) did not have another autistic sibling
- The median score and inter-quartile range of parent stress index in the study, and control group was 119(111-129), and 117(104-129) respectively before applying EFT, which reflects high stress level among both groups, with no statistical significant difference between them before applying EFT (Zmw= 1.258, p=0.209), while a statistical significant difference was found between them immediately after, as well as at one month follow up period, after applying EFT (Zmw =5.615, p= 0.000, Zmw= 5.569, p=0.000 respectively).
- It was found that the median score and inter-quartile range of parent stress index in the study group dropped from 119(111-129) before applying EFT to 92(83-96) immediately after applying the technique, then became 94(86-98) at one month follow up period of applying EFT, with overall highly statistical significant difference (X2 (fr)(df=2)= 50.427, P= 0.000). On the other hand, the median score and inter-quartile range of parent stress index in the control group raised slightly from 117(104-129) at pre intervention to 120(105-127) immediately after, and 119(107-131) after one month follow up, with over all high statistical significant difference X2(Fr)(df=2)=6.832 p=0.033*
- Pair-wise comparison for parent stress index total score of the study group, revealed a statistical significant difference of the median score and inter-quartile range of parent stress index at pre implementation minus post implementation (p=0.000), and pre implementation minus follow up ( p=0.000). But there is no statistical significant difference of the median score and inter-quartile range of parent stress index at post implementation minus follow up (p=1.000). While in the control group, it reveals a statistical significant difference of the median score and inter-quartile range of parent stress index only at pre implementation minus one month follow up (p=0.041).
- Comparison between the study and control groups in relation to their median score of parent stress index subscales, pre, post, and at one month follow up after applying EFT, revealed no statistical significant difference of the median score and inter-quartile range between the study and control groups before applying EFT, while statistical significant differences were found between the study and control groups immediately after applying EFT and at one month follow up regarding the three parent stress index subscales.
- A statistical significant difference was found between the study and control groups regarding their median score of goal reengagement before, immediately after, and at one month follow up after applying EFT ( Zmw =2.15, p= 0.032, Zmw =2.10, p= 0.035, Zmw =2.79, p= 0.005 respectively).
- The median score and inter-quartile range of goal reengagement scale in the study group raised from 20 (14-23) before applying EFT, to be 25(21-27) after applying EFT, and didn’t change at one month follow up of applying EFT. Within the study group, a statistical significant difference was found between the median score and inter-quartile range of goal reengagement scale at pre implementation minus post intervention (p=0.000), and pre implementation minus follow up (p=0.000).
- It was found that the median score, and inter-quartile range of self-compassion in the study group increased from 82(71 -95) before applying EFT to 106(99 -113) immediately after, and it nearly stands still at the same value after one month follow up of applying Emotional Freedom Technique 106(99-115). While the median score, and inter-quartile range of self-compassion in the control group was 85(71 -95) before applying EFT, and becomes 87(71-94) immediately after, then decreased to 79(68-92) after one month follow up of applying Emotional Freedom Technique.
- No statistical significant difference between the study and control groups regarding the self-compassion was found before applying EFT (Zmw= 0.282, p=0.778), while statistical significant differences were found between them immediately after and at one month follow up after applying EFT (Zmw =5.030, p= 0.000, Zmw= 5.465, p=0.000 respectively).
- Regarding the self-compassion subscales, no statistical significant differences were found between the study and control groups before applying EFT. But, statistical significant differences were found between them immediately after applying EFT, except for ”isolation ”. No statistical significant difference was found between the study and control groups immediately after applying EFT in relation to ”solation”.
- In relation to the self-compassion subscales, statistical significant differences were found between the study and control groups, at one month follow up after applying EFT.
- The current study results revealed a negative correlation between self-compassion, and goal reengagement, while a positive correlation was found between self-compassion, and goal reengagement
Conclusion
Findings of the present study proved that Emotional Freedom Technique (EFT) is valuable and effective in reducing the intensity of
stresses associated with raising a child with ASD. Moreover, EFT as a self-care tool enhanced goal reengagement and self-compassion among the studied subjects, which in turn creates a healthier balance between their own needs and between fulfilling their child’s needs.
Based on the current results, the following recommendations are suggested:
1-Recommendations geared toward parents of child with ASD.
- Conduct psycho-educational workshops for parents of children with ASD, with the purpose of raising their awareness of different stress reduction techniques, to help them to overcome different stressors and manage the challenge of raising a child with ASD.
- Raising peoples` awareness about ASD,through public campaigns, to decrease parent’s feelings of isolation, and social stigmatization.
2-Recommendations geared toward psychiatric nursing.
- Complementary therapies approaches, like (EFT), should be incorporated into the curriculum of psychiatric, pediatric, and community nursing.
- Emotional Freedom Technique (EFT) should be incorporated in psychiatric hospitals’ protocol of care, as a tool for managing a wide variety of psychological and physical conditions.
- Applying EFT on themselves, could assist psychiatric nurses in reducing their own stress and anxiety associated with caring for psychiatric patients, increasing their self-compassion and enhancing their goal reengagement.
3- Recommendations for further nursing researches:
- Replication of the present study on other samples, to elicit its effect on different categories of people.
- Further researches are needed to examine the effect of Emotional Freedom Technique on other variables as marital problems, self-esteem, and family adjustment among parents of children with ASD.
- Study the effect of applying Emotional Freedom Technique on children suffering from ASD, to determine its effect on their symptoms, and behavioral problems.