I ranian Rehabilitation Journal
December 2018, Volume 16, Number 4
Research Paper: The Effect of Family-Centered Nature
Therapy on Interactions Between Parent and Child With
Autism Spectrum Disorder
Maryam Ramshini1 , Saeid Hassanzadeh2* , Goholamali Afrooz2, Hadi Hashemi Razini3
1. Department of Psychology, Faculty of Literature Humanities and Social Sciences, Science and Research Branch, Islamic Azad University, Tehran, Iran.
2. Department of Psychology, Faculty of Psychology and Education, University of Tehran, Tehran, Iran.
3. Department of Psychology, Faculty of Psychology and Education, Kharazmi University, Tehran, Iran.
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Citation Ramshini M, Hassanzadeh S, Afrooz Gh, Hashemi Razini H. The Effect of Family-Centered Nature Therapy on
Interactions Between Parent and Child With Autism Spectrum Disorder. Iranian Rehabilitation Journal. 2018; 16(4):379-386.
http://dx.doi.org/10.32598/irj.16.4.379
http://dx.doi.org/10.32598/irj.16.4.379
:
Article info:
Received: 26 Apr 2018
Accepted: 15 Aug 2018
Available Online: 01 Dec 2018
Keywords:
Autism, Family-centered, Eco
therapy
ABSTRACT
Objectives: Parents of Autism Spectrum Disorder (ASD) children often have a negative attitude
towards themselves. They are often negatively affected by these challenges and the failure of their
children. Thus, their interaction with their children is negatively influenced. The present study
aimed to investigate the potential effect of family-centered nature therapy on the interaction of
parents with their children.
Methods: The present research was a quasi-experimental study with pre-test and post-test
design and a control group. Statistical population included all ASD children aged 3-7 years
in Tehran City, Iran. A sample of 14 children with ASD were selected through convenience
sampling method. The subjects were non-randomly assigned into either the experimental or
control groups. The necessary data were collected through Parent-Child Relationship Scale
(PCRS) and the program of nature therapy developed on the basis of the current theoretical
frameworks and research findings. The collected data were subjected to descriptive statistical
analyses and Analysis of Covariance (ANCOVA).
Results: The obtained results suggested that the Mean±SD score of experimental group on
PCRS after the treatment was 100.14±11.82. While the Mean±SD score of the control group was
84.14±3.93. Moreover, the results of the statistical tests revealed that the difference between the
experimental and control groups was statistically significant, indicating that the family-centered
nature therapy was effective in improving the parents’ interactions with their ASD children. In
addition, the ANCOVA results indicated that the estimated F (13.32) was statistically significant at
P=0.001, indicating that the treatment had a positive effect on the dependent variable.
Discussion: Family-centered nature therapy was effective in improving the parents’ relationship
with their children. The ASD children had fewer conflicts with their parents, enjoyed a positive
relationship with their parents, and showed lower dependence on their parents after receiving
the treatment. Therefore, this therapy can be a complementary method along with other standard
treatments received by ASD children. It is an effective, simple and readily accessible option to
improve the interaction of parents with their ASD children.
* Corresponding Author:
Saeid Hassanzadeh, PhD.
Address: Departmemt of Psychology, Faculty of Psychology and Education, University of Tehran, Tehran, Iran.
Tel: +98 (21) 88802214
E-mail: shasanz@ut.ac.ir
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Highlights
● Family-centered nature therapy is effective on children with autism.
● Nature therapy improves parent-child relationship for autism children.
● Nature therapy increases autism children’s interactions.
Plain Language Summary
Study population comprised all autism children aged 3-7 years living in Tehran City, Iran. According to the study
results, the difference between the experimental and the control groups was statistically significant, indicating that the
family-centered nature therapy was effective in improving the parents' interactions with their autistic children.
1. Introduction
A
ccording to the Fifth Edition of Diagnos-
tic and Statistical Manual for Mental
Disorders, the diagnostic criteria for Au-
tism Spectrum Disorder (ASD) include
persistent deficit in social interactions in
various contexts, along with the current or past restrict-
ed repetitive patterns of interests, behavior and activi-
ties observed in the early stages of development, which
cause clinically important problems in one’s current
functioning. The symptoms widely vary based on the se-
verity of ASD, developmental stage, and biological age
of the patient [1].
The primary cause of this disorder remains unclear.
However, genetic factors play a comparatively important
role in autism occurrence. ASD occurrence is critically
rising, as 1 in each 68 children is diagnosed with ASD
[2]. The frequency and type of interactions in ASD chil-
dren with their parents, negatively affect the relationship
between them [3]. Parents often report high degrees of
anxiety, depression, isolation, separation and aggression
in their ASD children. These behavioral problems lead to
personal distress in parents. The gradually exacerbating
temper of parents of ASD children, negatively impacts
parent-child interactions.
Investigating parent-child relationship in families with
an ASD member started in 1980s. The relevant results re-
vealed that the parents of ASD children were under stress
and faced with a variety of life challenges. Issues such as
socio-behavioral problems, bad-temperedness, self-injury,
other injury, and verbal problems that cause changes in the
interaction between ASD children with their parents and
even with other family members [4, 5]. Such problems
complicate child raising for the parents, thus negatively
influence the parent-child interactions [6, 7].
The developmental characteristics of child and parents’
characteristics are important and form the nature of par-
ent-child relationship. In the theory of systemic family
therapy, all family members are believed to be involved
in the parent-child relationship [8]. Thus, using parents
as therapists in the treatment of ASD children seems to
be a logical effective strategy. Such strategy provides the
parents with a chance to be more active in taking care of
their children and have a better understanding of their
children’s desires and real needs.
A variety of treatment methods have been implemented
by experts to improve the quality of the development of
ASD children through eliminating the problems. The use
of special treatment for ASD children initiated in 1960.
Psychoeducational, medical, complementary or alterna-
tive treatments are currently available. However, nature
therapy has been introduced since 1992, as a type of eco-
psychology approach [9].
Nature therapy refers to all treatments in which a variety
of activities are performed in nature, outdoors, and green
areas [10]. This treatment approach is followed in an ex-
perimentally creative manner in the nature. Nature therapy
extends our classic understanding of place as a static con-
cept into a dynamic one under the control of the therapist.
Such place is used to form the structure, conditions, and
process of treatment [11]. In nature therapy, a number of
interventions are made by the therapist, including animal
assisted intervention, horticultural therapy, farming, per-
forming art in or with nature, wilderness therapy, adven-
ture therapy, and green exercise therapy [12].
380
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Much research indicate that experiencing and inter-
acting with nature have positive effects on cognitive,
physical, social and emotional development of children.
However, the lack of relation with nature is associated
with adverse effects on the development and health of
children. For example, studies in the field of education
revealed that nature has positive effects on the cognitive,
emotional, and social development in children with at-
tention deficit disorder, as well as attention deficit hyper-
activity disorder [13].
Similarly, a study conducted by the Psychotherapy
Center [14] reported that exposing hospital patients to
beautiful natural sites have some positive benefits for
them like reduced stress, increased self-esteem, weight
loss, and reduced substance abuse. Moreover, Culture
and Wilkins (1992) applied nature therapy to cure ASD
children, abnormal growth, conduct disorder, disregard
disorder, severe emotional disorders, and learning dis-
orders. Their obtained results included a reduction in
aggressive and hostile behavior, developing cooperative
behavior with peers, as well as increase in social skills
and self-confidence [15, 16]. Moreover, being attracted
by the nature can be considered as a type of self-therapy.
Nature therapy increases sensory stimulation, attention,
care, a sense of security, happiness and well-being. It
also decreases stress level, and mental fatigue.
The integration of nature therapy and family-centered
approach could be applied in the treatment of children
with ASD. Such integration provides a chance to expe-
rience nature, and enables parents to improve the qual-
ity of their interaction with their ASD children in the
calmness of nature [17]. Thus, the present study aimed
to investigate the potential positive effect of family-
centered nature therapy on the parent interactions with
their children with ASD.
2. Methods
This quasi-experimental study was of pretest-posttest
control group design. The statistical population included
all ADS children aged 3-7 years referred to rehabilita-
tion centers and clinics in Tehran City, Iran. A sample
of 14 ASD children were selected from 3 health centers
(Health Center of Seda-o-Sima, Zafar, Padideh). Sam-
ples were non-randomly assigned to either the experi-
mental or the control groups, by convenience sampling
method. After the children were diagnosed with autism
by a psychiatrist in the relevant centers, the parents were
briefed on the purpose and conditions of the study. They
were explained that the presence of both parents or one
parent in all treatment sessions was necessary. Finally,
the parents of 14 ASD children (12 males and 2 females)
without any mental disorders, attention deficit disorder,
and hyperactivity disorder agreed to participate in the
study. There were 6 males and 1 female in each group.
The exclusion criteria were any mental disorder identi-
fied as the primary diagnosis, absence from 2 or more
sessions, and any physical illness. The study participants
had received psychological therapies at the clinics be-
fore and during the course of the present study. The par-
ticipants attended ten 3-hour long treatment sessions in 3
months at Savan Nature School in Tehran. The introduc-
tory session for the parents of the experimental group
was held at TV Health Center building in June 2017 in
the presence of the specialist and all staff of the center.
The written informed consent was obtained from all par-
ents of the subjects after being informed about the pur-
pose of the study and confidentiality of their information.
Then, 10 treatment sessions were held in the nature. In
each session, some predetermined tasks and activities as
introduced in Table 1 were performed.
Before conducting the study, the parents of both groups
were required to complete the Child-Parent Relationship
Scale (CPRS) (Pianta, 1994) as the pretest. Because in
every session, the parents and children were present in
the nature, the researcher requested the staff of the center
to cooperate with the parents as facilitators, to provide
more safety for the parents and children. At the begin-
ning of every treatment session, the researcher explained
the relevant tasks and activities in details for the parents
and facilitators. The parents were required to cooperate
with the facilitator and their children to complete the as-
signed activities.
In some activities, the parents had to work alone with
their children to complete the assigned activities. Ten
days after the last treatment session, the CPRS was com-
pleted by the parents of both groups as the posttest. The
same scale was again completed by the parents after 3
months as the follow-up test. The present study was con-
firmed by the Ethics Committee of Islamic Azad Uni-
versity, Science and Research Branch, Tehran and the
Health Center of Seda-o-Sima in Tehran.
Study tools
Child-Parent Relationship Scale (CPRS) developed by
Pianta (1994), was translated into Persian by Abareshi,
Tahmasian, Mazaheri, and Panahi (2007). The validity
and reliability of the translated version of the scale was
confirmed by specialists. This scale is among the most
powerful measures of parent-child relationship, and es-
Ramshini M, et al. Family-Centered Nature Therapy in Interactions Between Parent and Child With ASD. IRJ. 2018; 16(4):379-386.
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Table 1. Tasks assigned in the treatment sessions
Session
Completed Tasks
First
Being in the nature (getting interested and mentally involved in the nature without the direct guidance of the trainer)
Performing a variety of tasks, including sitting on lawn, lying on lawn
Second
Repeating previous session tasks and performing special activities with a focus on visual, tactile, and vestibular
stimulation. Walking along an imaginary path and collecting stones along the road and putting them into a bag,
covering the body with soil and mud, performing balance activities
Third
Repeating previous session tasks and performing activities focused on auditory, taste, tactile, and olfactory stimulation.
Collecting wood to start a fire, roasting potatoes on fire, peeling and eating potatoes, smelling the bread heated
on fire, walking on dried tree leaves
Fourth
Fifth
Sixth
Seventh
Eighth
Ninth
Tenth
Repeating previous session tasks and performing activities focused on vestibular stimulation.
Keeping the body in different positions in the air, touching animals, hugging animals, making mud and putting
mud on hand, trunk and the leg
Repeating previous session tasks and performing activities focused on sight and tactile stimulation.
Playing Haft Sang (Persian game), playing bowling using wood pieces, hiding the body under the sand and gravels
Repeating previous session tasks and performing activities focused on vestibular stimulation.
Touching dried tree leaves with the body, performing activities like jumping, running, etc. Collecting small and big
stones, picking up dried leaves from the lawn, feeding animals, cooking Mirzaghasemi (a Persian dish) with the
help of parents
Repeating previous session tasks and performing activities focused on auditory, sight, and tactile stimulation.
Leaning against a tree and scratching the back with the tree, sitting by a stream and listening to the sound of run-
ning water
Repeating previous session tasks and performing activities focused on olfactory, vestibular, and sight stimulation.
Collecting vegetables, smelling vegetables, climbing a spider web while maintaining balance
Repeating previous session tasks and performing activities focused on sight and olfactory stimulation.
Walking on the edge of stones around raised garden beds, watering tomato plants using a glass
Repeating previous session tasks and performing activities focused on taste, tactile, and olfactory stimulation.
Going into the birds and rabbits cage, hugging them, and feeding them, smelling burned wood, making bread
(mixing flour with water)
pecially mother-child relationship. It consists of 30 items
organized in 3 different subparts of conflict (items 6, 28,
27, 26, 25, 24, 23, 21, 19, 17, 14, 12, 7, 4, 2), positive
relationship (items 8, 5, 3, 1, 30, 29, 22, 16, 13, 10), and
dependence (items 20, 18, 15, 11, 9), with the Cronbach
alpha of 0.84, 0.69, 0.46, respectively. This scale mea-
sures parents’ understanding of their relationship with
their children. This scale can be self-administered to
measure parent-child relationship, based on a 5-point
Likert-type scale, with 1 indicating “definitely apply”
and 5 indicating “definitely does not apply” [18, 19].
Family-centered Nature Therapy Program consists of
2 different stages; 1. Making children interested and
mentally involved in nature; 2. being present in nature
and performing certain predetermined activities and
tasks. The first stage contains free activities which are
not under the direct control of researcher. However, the
second stage consists of 3 parts, as follows: completing
horticultural therapy activities, establishing relationship
with animals in the natural environment, and perform-
ing physical activities in the nature. In each part, certain
activities are performed.
The physical activities consisted of 6 groups of activi-
ties, each focuses on 1 of the 5 senses of sight, hearing,
olfactory, taste, and the vestibular sense. The activities
performed in each stage are confirmed by 5 different
specialists. All of the aforementioned activities and tasks
were based on the documentation mentioned in other
research studies. The validity of the program was con-
firmed by relevant professors and specialists and occu-
pational therapists, and their content was content.
3. Results
The collected data were analyzed by descriptive in-
ferential statistics including Analysis of Covariance
(ANCOVA). Tables 2 and 3 summarize the measures of
central tendency and dispersion for the PCRS obtained
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scores. Those tables also present the follow-up test re-
sults for the experimental and control groups.
As per Table 2, the Mean±SD scores for the 3 subparts
of the scale are presented separately. The scores of the ex-
perimental group on the PCRS yielded Mean±SD score
of 83.14±8.13. However, after the treatment, the experi-
mental group obtained Mean±SD score of 100.14±11.82
on PCRS. The control group demonstrated Mean±SD
score of 88.71±7.83 on the scale before conducting the
study. In addition, the Mean±SD score of PCRS was
87.14±3.93, after the treatment. Also, the Mean±SD
score of the follow-up test for the experimental group re-
vealed a negligible difference with those obtained in the
post-test. Before running the parametric ANCOVA, the
normality of dispersion and the assumption of homoge-
neity of variance were confirmed through Kolmogorov-
Smirnov Test and the Levene’s Test.
According to Table 3, the obtained F-value of 13.32,
was statistically significant at P=0.001. Given the fact
that the significance level selected for the present study
was P=0.05, the obtained F-value was definitely signifi-
cant. Such finding indicates that the treatment provided
(independent variable) for the experimental group was ef-
fective in modifying parent-child interaction (dependent
variable). Thus, the obtained results suggested that fam-
ily-centered nature therapy improved the parent-child
interaction in the experimental group. In other words,
the provided treatment (independent variable) explained
Table 2. The Mean±SD of the pre-test and post-test scores of the experimental and control groups based on PCRS and follow-up data
Subparts
Conflict
Follow-up
Positive relationship
Follow-up
Dependence
Follow-up
Parent-child relation
Follow-up
Group
Test
No.
Pre-test
7
Experimental
Post-test
7
Pre-test
7
Control
Post-test
7
Pre-test
7
Experimental
Post-test
7
Pre-test
7
Control
Post-test
7
Pre-test
7
Experimental
Post-test
7
Pre-test
7
Control
Post-test
7
Pre-test
7
Experimental
Post-test
7
Pre-test
7
Control
Post-test
7
Mean±SD
30.57±9.3
41.29±7.25
40.41±6.59
25.71±6.63
22.00±5.39
24.86±6.23
33.300±5.13
34.00±5.65
22.00±2.77
21.71±4.11
10.29±3.40
13.00±2.24
12.00±2.51
7.14±2.54
6.29±2.87
83.14±8.13
100.14±11.82
97.00±11.59
88.71±7.83
78.14±3.93
Min
31
16
15.00
14.00
16.00
25.00
18.00
14.00
5.00
9.00
4.00
4.00
70.00
82.00
77.00
81.00
Max
52
40
37.00
29.00
32.00
39.00
26.00
26.00
16.00
15.00
12.00
12.00
94.00
116.00
99.00
92.00
Ramshini M, et al. Family-Centered Nature Therapy in Interactions Between Parent and Child With ASD. IRJ. 2018; 16(4):379-386.
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Table 3. The results of the ANCOVA (the effect of nature therapy program on parent-child relationship)
Source of Variance
SSE
df
Experiment
430.61
1
Error
355.51
11
Total
872.93
13
MSE
430.61
32.32
F
13.32
Significance Level
Eta-Squared
0.55
0.001
55% of the observed variance of the scores related to the
dependent variable.
4. Discussion
The present study mainly aimed to investigate the po-
tential effect of family-centered nature therapy on parent-
child interaction patterns among families with ASD chil-
dren. The results revealed that the posttest mean score
of experimental group was significantly higher than that
of the control group. These data suggest that the treat-
ment provided to the experimental group was effective
in modifying the interactions between parents and their
ASD children. In other words, the family-centered nature
therapy significantly improved the parent-child interac-
tion pattern. However, the improvement in parent-child
interaction takes place when there is a mutual emotional
expression and interaction between them.
There are a number of factors which facilitate the mu-
tual emotional child-parent interactions. Perhaps the
most important factor is their well-being. Firstly, the
children feel well when the parents are actively present
and involved in training them. in that the parents’ pres-
ence fosters close emotional relationships between the
parents and the kid, thus helping the child to feel safe and
secure [20, 21]. Secondly, as the results of the present
study indicate, the presence of parents and children in
the nature improves the social, communicative and other
skills in the children.
The ASD children’s parents are under extreme amount
of stress due to the specific challenges and problems as-
sociated with ASD children, including social, and unpre-
dictable behavioral problems. However, when they are
actively engaged in the treatment process, they can have
more interaction with the specialists. Thus, they can be
better informed about the real needs, desires, strengths
and weaknesses of their child. The ASD children’s par-
ents are supposed to have constant relationship with their
children throughout their lives. Therefore, it is important
for them to be actively engaged in the process of train-
ing their children and supporting them. In this way, they
feel in control of the situation, have more self-confidence
in establishing and adjusting their interactions with their
ASD children. As a result, they feel less stressed due to
feeling more intimate emotional bond with their chil-
dren, and an improved interaction with their children
[22]. Moreover, when children with ASD perform differ-
ent activities in the nature in the presence of their par-
ents (e.g. climbing a tree), they ask for their parents help.
Thus they have a chance to improve their relationship
with their parents [23].
Studies focusing specifically on the effect of family-
centered nature therapy on the parent-child interaction
are scarce. The majority of studies available have fo-
cused on the participation of parents in other training
programs, with few studies investigating the nature ther-
apy. However, the results obtained in the present study
are in line with those by Selinger and Elder [24], Par,
Grey, Wigham et al. [25], Fiona, Lacroix and Luis [26],
and Lunsky and Weiss [27].
In their study on ASD children, Selinger and Elder [24]
reported that the participation of parents in training in-
terventions decreased the undesirable behavior in ASD
children, thus improved the parent-child interaction. The
study by Par et al. [25] revealed that a family-centered
approach for the treatment of ASD children had a posi-
tive effect on the parent-child interaction and improved
the self-confidence in parents.
Fiona, Lacroix and Luis found that playing with sand
considerably improved interactions between ASD chil-
dren and their parents and others [26]. Lunsky and Weiss
investigated parent-child interaction among children
with ASD and reported a high level of stress in the moth-
ers of ASD children due to the challenging behavior of
their children [27]. They reported a positive correlation
between the psychological problems of ASD children
and the stress level their parents undergo. This issue has
direct negative influence on the interaction of these par-
ents with their autistic children.
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5. Conclusion
The results suggest that the provision of family-cen-
tered nature therapy for ASD children results in a con-
siderable improvement in the parent-child interaction.
There are however some limitations to the present study.
Because the presence of parents were necessary, the
number of treatment sessions was limited, and the par-
ents could not attend more sessions due to their employ-
ment conditions.
It is suggested that the family-centered nature therapy
be used as a complementary treatment along with other
treatment strategies for children with ASD of all ages,
and even for children with other special needs, to im-
prove the growth of these children, and improve the
mental health of their families.
Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of Is-
lamic Azad University of Science and Research Branch.
Funding
This research did not receive any specific grant from
funding agencies in the public, commercial, or not-for-
profit sectors.
Authors contributions
All authors had contribution in writing this paper, and
for it was prepared and analyzed according to the opin-
ion of all authors.
Conflict of interest
The authors declared no conflict of interest.
Acknowledgements
I would like to express my special gratitude to Dr. Hos-
seini (the head of the Health Center of Seda-o-Sima), Dr.
Karimi (the specialist at Health Center) and the parents
of children participating in this study, for their kind co-
operation with the researcher.
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