diabetes mellitus ( dm ) is a common disease in iran and around the world .
it is a chronic , progressive and costly disease , and results in a number of complications . for individuals with dm , it is difficult to accept that they must change their lifestyle .
since these patients are unaware of short - term and long - term complications of the disease , it is not unusual for them to experience mood disorders such as depression , anxiety caused by negative thoughts about the illness and low self - efficacy in dealing with their disease ( 1 ) .
depression and anxiety disorders are characterized by symptoms of low mood , reduction of energy and interest , feelings of guilt , difficulty in concentrating , loss of appetite , thoughts of death and suicide , chronic daily stress , lower levels of psychological well - being and consequent low quality of life , insomnia or hypersomnia , significant loss of weight , and dysfunction ( 2 ) .
children with dm , because of the need for self - care , and in most cases , care by family members , may see themselves as a burden on their families , compared to healthy children of the same age .
the way these thoughts are interpreted is an important factor in determining the severity of the consequential discomfort , anxiety , and perceived negative stress ; such as believing themselves to be a financial burden on their family , and ascribing the difficulties of their family to themselves .
evidently , it should be noted that being seen as a burden by parents and friends is also influential in creating stress and decreasing self - efficacy in children .
therefore , misinterpretation of these negative thoughts leads to a set of symptoms such as negative perceived stress and low self - efficacy ( 4 ) .
perceived stress is derived from lazarus and folkman s concept of stress as an individual s cognitive appraisal of negative life events .
diabetic individuals may forget to care for themselves , in terms of using certain foods and consumption of medications , due to stress , and this in turn affects their blood sugar levels ( 5 ) .
due to frustration and perceived stress , diabetic children have a particular mental condition which causes feelings of helplessness , powerlessness , lack of self - efficacy , and apathy toward life ( 6 ) .
self - efficacy is an important and effective concept in bandura s social cognitive theory and is explained as confidence and belief in one s ability to control thoughts , feelings , activities , and function effectively in stressful situations .
therefore , efficacy is an individual s actual performance , emotions , and choices , as well as inhibition of negative influences , organization and execution of courses of action required to achieve goals and advancement , and ultimately the amount of effort spent on an activity ( 7 ) .
the aims of dm treatment are the prevention of its complications and maintaining optimal psychological well - being in patients . in the past
, it was thought that the doctor was able to provide favorable conditions for an individual through effective treatments and control of disease symptoms .
nevertheless , evidence suggests that psychological well - being , and in a wider context quality of life , in treating a chronic disease such as dm does not only influence the control of symptoms , but also the improvement of psychological well - being and quality of life ( 8) .
diabetic children do not show appropriate emotional responses and experience lower psychological well - being due to difficulties such as dietary and activity limitation , invasive monitoring of blood glucose , daily insulin injections , chronic physical complications , hospitalizations and shortened life expectancy ( 9 ) .
the treatment of chronic diseases such as dm , on the one hand , disrupts the psychological well - being and social function of the individual , and on the other hand , has a negative impact on family function .
the prevalence of negative psychological outcomes among people with dm , especially children and adolescents , and their frustration from the medical treatment process demonstrates the necessity of developing psychological interventions in the fields of clinical psychology , health psychology and pediatric psychology .
most studies performed on people with dm have often been based on self - care training , which has been performed publicly .
acceptance and commitment therapy ( act ) differs from traditional cognitive behavioral therapy ( cbt ) .
this form of therapy has two major goals : a ) fostering acceptance of problematic unhelpful thoughts and feelings that can not and perhaps need not be controlled , and b ) commitment and action toward living a life according to one s chosen values ( 10 ) .
this treatment method endeavors to increase individual psychological acceptance in the case of subjective experiences ( thoughts and emotions ) , reduces ineffective control measures , and increases psychological awareness ( 11 ) .
there are numerous psychological therapeutic interventions for stress , and depression and psychological consequences associated with it , such as inability and infirmity , for diabetic patients .
some researchers believe that act has high efficacy , due to its underlying mechanisms such as increasing acceptance and awareness , desensitization , living in the present moment , observing without judgment , confrontation and release ( 12 ) .
results of previous studies showed that the use of the mindfulness method will cause a decrease in depressive and anxiety attacks ( 13 , 14 ) .
the study by boey showed that acceptance of dm and its related cognitions is significantly associated with lower hba1c values and decreased stress in patients , simultaneously ( 15 ) .
the results of a research indicated that stress can lead to mental and physical diseases , impairment of function and adaptation , and ultimately lower self - efficacy in coping with the disease ( 7 ) .
another study revealed that stress can result in the patient not following the required diet , and therefore , indirectly affect blood sugar ( 16 ) .
there is a wide range of research on psychosocial and behavioral interventions for adolescents with dm , and current psychosocial interventions have demonstrated modest effects on glycemic control .
it may prove useful to identify underlying psychological processes that contribute to poor disease management .
however , very little research has been done on the mentioned psychological complications of dm ( perceived stress and special health self - efficacy ) with this treatment method . moreover , a few studies have been conducted on children and adolescents .
this paper aimed to illustrate how the psychological processes of cognitive fusion and experiential avoidance may contribute to dm management difficulties .
therapeutic strategies outlined in act might be a way to intervene in dm care and simultaneously target issues relating to regimen adherence , dm - related acceptance , and family management issues .
according to the above discussion , this study aimed to answer the question of whether act is effective in reducing perceived stress and increasing special health self - efficacy in seven to fifteen - year - old children with dm .
the present study was a clinical trial with a pretest - posttest control group design , and random assignment .
the study population included all seven to fifteen - year - old individuals who had referred to the dm association of tabriz , iran , of whom 40 participants were selected using convenient sampling .
the experimental group participated in therapy sessions and the control group did not receive any interventions .
inclusion criteria for this study included age of < 15 years , having dm ( type 1 and 2 ) for at least one year , and lack of any major psychiatric disorder .
exclusion criteria , determined by the diagnosis of a physician in most cases , included needing significant change in the dose of insulin administered during the research , suffering from an acute or chronic medical illness that causes problems in venesection or intolerance of long sessions , having severe medical complications of dm , receiving psychiatric treatments or using psychotropic drugs , and drug abuse during the study period . in order to obey research ethics , in addition to obtaining written consent from the children and their parents to participate in the research , pretests were also conducted .
evidently , two members of the experimental group and two patients of the control group were excluded for various reasons , including absenteeism from more than three sessions , lack of participation in pretest , disease , and relocation to another city .
finally , 18 patients in the experimental group and 18 patients in the control group remained in the study . for data collection , the special health self - efficacy scale was used .
this questionnaire included 14 items and three subscales of nutrition self - efficacy scale , physical exercise self - efficacy scale , and resist alcohol self - efficacy scale .
it was a likert - type scale with items answered on a four - point scale from one for very uncertain to four for very certain .
cronbach s alpha internal reliability was 0.87 for nutrition self - efficacy , 0.88 for physical exercise self - efficacy , and 0.79 for resist alcohol self - efficacy ( 17 ) .
validity evidence for this scale has been reported by narimani and ahadi ( 17 ) .
the reliability of this test was calculated at 0.76 using cronbach s alpha in this research .
furthermore , the perceived stress scale ( pss ) was also used for data collections .
the pss is a 14-item likert - type scale that offers a nonspecific measure of appraised stress .
the internal consistency reliabilities of the pss ranged from 0.84 to 0.86 across two groups of university students and one group of participants in a community smoking - cessation program .
the alpha coefficient for the mexican sample was 0.835 while for the individuals residing in the usa this was 0.885 ( 18 ) .
this instrument has been found to be significantly correlated with life events , depressive and physical symptoms , utilization of health services , social anxiety , maintenance of smoking reduction and lower life satisfaction ( 18 ) .
it is said to be an appropriate measure of global stress for all age groups ( 19 ) . in a study performed by ghorbani et al .
( 20 ) , cronbach s alpha was calculated as 0.86 for america and 0.81 for iran . in the present study ,
the topics for each session included : 1- building a therapeutic contract and functional analysis ; 2- creative hopelessness :  the man in the cave  and  the farmer and the donkey  metaphors ; 3- value clarification and building a commitment ,  the funeral  exercise metaphor :  eat the whole apple  ; 4- control as a problem :  the rule of 95 - 5%  and control as a problem :  pink elephants  and  what s the name of your mother ?
 exercises ; 5- the alternative to control , be willing as a possibility , and acceptance exercises : 
eyes on  exercise ; 6- cognitive diffusion :  the ride with posters  ,  milk , milk , milk  exercises and establishing language conventions :
 i m having the thought that i m a failure  instead of saying 
i m a failure  ; 7- self as context : metaphor :  chessboard  , and screening for barriers and strengthening values : metaphors :  the journey  and  welcome to all and the rude  ;
8- acceptance and commitment , and fear of commitment : metaphor :  now you know how to drive  ; 9- remember session , internal dialogue :  this is not working , it is always the same , and i thought it was ok , but it is not ...  metaphor :  the rider  ; 10- remember session and relapse prevention ( 21 ) .
after ten sessions of intervention for the experimental group , the posttest was performed on both groups .
we performed a descriptive study of the dependent variables of interest ( means and standard deviations ) .
data analysis was performed with the spss statistical package ( version 19.0 ; spss inc . ,
the participants in this research were in the age range of seven to fifteen years , and 69.44% were boys and 30.56% girls .
the mean (  sd ) age of the experimental group was 11.44 (  2.59 ) and the control group was 9.72 (  2.37 ) ( p < 0.05 ) .
in addition , twelve boys and four girls participated in the experimental group , and nine boys and seven girls participated in the control group .
table 1 shows mean and standard deviation of perceived stress and special health self - efficacy variables in the experimental and control groups . to measure the equality of variances ,
the results showed that variances of the experimental and control groups for total perceived stress ( f = 1.03 , p = 0.317 ) , negative perceived stress ( f = 1.50 , p = 0.22 ) , positive perceived stress ( f = 0.46 , p = 0.50 ) , and special health self - efficacy ( f = 1.45 , p = 0.23 ) were equal .
the results showed significant homogeneity using mancova tests including pillai s trace , wilks lambda , lawley - hotelling trace , and roy s largest root .
experimental and control groups differed from each other , in at least two dependent variables ; therefore , these variables could be used to analyze the data .
the mancova results on the variables of perceived stress and special health self - efficacy in both control and experimental groups after controlling the pretest are shown in table 2 .
this analysis showed that the two groups were different in three investigated variables according to the means presented in table 1 .
furthermore , an increase in positive perceived stress and special health self - efficacy variables and a decrease in total perceived stress and negative perceived stress scores were observed in the experimental group as compared with the control group .  
the results showed that act is effective on reducing perceived stress and increasing special health self - efficacy of children with dm .
they believed that the application can increases effectiveness of this method in addition to reducing the disease symptoms , due to its underlying mechanisms such as increasing acceptance and awareness , desensitization , living in the present moment , observing without judgment , confrontation , and release ( 24 ) .
it should be noted that this treatment modality is a short - term and structured intervention .
in addition , and like traditional cognitive therapy , the purpose of mental care education is not to change the content of thoughts , but rather to create a different attitude toward or relationship with thoughts , feelings , and emotions , which includes maintaining full and constant attention with an attitude of acceptance and without judgment ( 25 ) .
conceptually , children and adolescents with dm , who drown in their private issues and subsequently engage in experiential avoidance , may attempt to control their private affairs via behavioral strategies that may not be useful in the long - term .
for example , an adolescent with dm may have thoughts such as  people think i m different when they see me check my blood sugar  ,  my insulin makes me fat and unpopular 
 i ca nt do normal things like go out for ice - cream  , or 
 they may then engage in unhealthy eating ( e.g. unplanned snacking ) , or avoid insulin injections or blood - glucose checks , as an attempt to alleviate these painful thoughts .
these experiential avoidance behaviors may lead to greater long - term emotional distress and health problems . by not engaging in dm management behaviors ,
the focus of this act process is to develop and enhance clients willingness to accept their private experiences .
treatment involves exploring the futility of emotional control and avoidance , which can often paradoxically increase individuals levels of distress and deter them from engaging in purposeful and vital value - driven behavior .
instead , individuals are encouraged to accept their private experiences ; doing so will help them engage in valued behavior ( 3 ) . based on act ,
the concept of emotional interlinking or diffusion is defined as the rate of the impact of a thought on behavior ; such as the effects of subjective interpretation on children s perceived stress and special health self - efficacy ( 21 ) .
context - dependent behavior and thought - dependent behaviors are placed on the continuum between emotional interlinking and diffusion .
when an individual merges and becomes one with his thoughts , he does not distinguish subjective judgment from reality ( 23 , 26 ) .
thus , increasing psychological flexibility of pediatric patients in act and creating a thinking strategy based on mindfulness can increase the patient s ability to cope with symptoms of disease and family adversity , and follow the prescribed diet .
naturally , reduction of negative perception caused by stress and individual commitment caused by some behaviors will increase self - efficacy of the child in dealing with the illness in the long - term .
these findings indicate that increased cognitive fusion and experiential avoidance are related to decreased adherence and dm - related quality of life , and increased social anxiety and dm - related worry . in conclusion , these findings provide preliminary support for the adverse impact of cognitive fusion and experiential avoidance for children and adolescents with dm . limitations of this study were the small study population , inability to generalize the results and limited number of similar studies in iran and the world .
moreover , some of the obtained differences are related to possible differences in confounding variables due to lack of matching confounding variables ( such as age and gender ) .
 background : diabetes mellitus ( dm ) imposes restrictions on physical , emotional and social functioning of children and adolescents.objectives:the aim of this study was to determine the impact of acceptance and commitment therapy ( act ) on perceived stress and special health self - efficacy in seven to fifteen - year - old children with dm.patients and methods : the present study was a clinical trial with a pretest - posttest control group design . 
 the study population included all seven to fifteen - year - old patients who had referred to the diabetes mellitus association of tabriz , iran , of whom 40 participants were selected using convenient sampling . 
 they were randomly allocated to two matched groups ( experimental and control ) . 
 the experimental group participated in therapy sessions , while the control group did not receive any interventions . 
 the research instruments were perceived stress and special health self - efficacy scales.results:the multiple analysis of covariance ( mancova ) results showed that the treatment was effective on variables of perceived stress and special health self - efficacy ( p < 0.001).conclusions : the act is effective for reducing perceived stress and increasing special health self - efficacy in children with dm . 
1. Background
2. Objectives
3. Materials and Methods
4. Results
5. Discussion