Introduction
Autism spectrum disorder (ASD) is one the most common neurodevelopmental disorders in child psychiatry which is defined by major deficits in interactions and social communication, along with repetitive behaviors and limited tendencies (Minaabad et al., 2020). ASD is a complex developmental condition that is associated with persistent challenges in a child’s social interaction, speech, and non-verbal communication and affects mother-child interaction (Liu et al., 2021). Having an autistic child in a family often causes irreparable damage to the family and severely affects the parents’ mental health (Oti-Boadi et al., 2020). Parents of children with autism experience higher levels of anxiety and stress. Parental anxiety and stress are associated with harmful consequences for the mental and physical health of the parents and the child’s performance (Neece et al., 2024).
ASD as an early-onset and most common neurodevelopmental disorder causes lifelong problems (Dollion et al., 2024; Amireh & Omer, 2018). The latest Centers for Disease Control and Prevention (CDC) survey estimates that approximately 1 in 36 children in the United States are diagnosed with ASD and that the condition affects all racial, ethnic and socioeconomic groups. ASD is almost 4 times more common among boys than among girls (Maenner et al., 2023). In Iran, the prevalence of ASD in the total sample is equal to 0.1% (10 per 10000), with a 2:1 male-to-female ratio (Mohammadi et al., 2019).
About one-third of parents of children with autism report high levels of stress clinically, which indicates their need for therapeutic interventions (Davis & Carter, 2008). Mothers with autistic children have a high level of psychological problems and their psychological health varies depending on the severity of ASD of the child (Benson, 2010). Anxiety is defined as a mental state characterized by preoccupation, feelings of stress, physical changes, intrusive thoughts, or frequent worries (APA, 2013). Issues related to the care of an autistic child are possible predictors of parental stress, anxiety, and depression (Yassin, 2023). These underlying issues include the severity of autism symptoms (Rivard et al., 2014), child problematic behavior (Estes et al., 2013), financial concerns caused by therapeutic and educational expenses (Thomas et al., 2016), exposure to social stigma (Weiss et al., 2014), and the onset of marital problems (Hartley et al., 2010). However, most studies in this field have suggested that the primary predictors of parental stress, anxiety and depression are the severity of symptoms, challenging child behavior, and lack of social support (Yassin, 2023). Mothers show a wide range of emotions such as anger, sadness, crying, and grief. Besides, they are worried about the reactions of the public, relatives, and close ones to their child’s autism, and sometimes they think that there is probably a solution that will end all their problems (Sotgiu et al., 2020). Stress, depression, and psychological distress adversely affect mothers’ performance in life. Increasing levels of anxiety, depression, and stress of the mother reduce her parenting abilities, which in turn can have negative effects on the psychological and physical health of the child (Alibekova et al., 2022; Rafii, et al., 2024). However, relaxation strategies can help reduce overall levels of anxiety and tension over time (Hamdani et al., 2022).
Different relaxation techniques are used for different mental disorders, such as diaphragmatic breathing which is used for panic attacks, autogenic exercise for stress, and progressive muscle relaxation, and the Benson relaxation response which is used for anxiety (Lindquist et al., 2018). There are various pathways to yield the Benson relaxation response (e.g. meditation, muscle relaxation, different breathing techniques and yoga) (Benson, 1983; Ibrahim et al., 2019). The relaxation response is associated with reducing the autonomic nervous system’s activity and reduced oxygen utilization (Benson et al., 1975). The main goal of Benson relaxation response is to strengthen self-confidence and self-respect (Benson, 1983). Otherwise, Benson relaxation response is one of the most common and simplest relaxation methods (Ebrahimi & Adib-Hajbaghery, 2022). It is a non-pharmacological, behavioral method, and the easiest to learn to handle stress and anxiety (Ibrahim et al., 2019; Walsh et al., 2007). 
There is a greater tendency to use complementary medicine to treat maternal anxiety compared to chemical treatments due to its low cost, ease of use, and no complications. Benson relaxation response as a key element for the effects of meditation, is one of the complementary medicine methods to relieve stress. By focusing on four basic elements (i.e. a calm environment, a comfortable position, a mental device such as a word to focus, and a passive attitude), this method reduces an individual’s stress (Anisah & Maliya, 2021). Benson relaxation response, in addition to its many benefits and easy administration, is uncomplicated and a person can use it independently (Najafi Ghezeljeh et al., 2016). When relaxation is performed, the parasympathetic system becomes dominant and patients become calmer and thus can overcome psychological symptoms, such as anxiety, depression, and fatigue (Abu Maloh et al., 2021). Parents of children with autism, especially their mothers, endure severe psychological distress and have special needs at every stage. 
Given the research gap concerning the effectiveness of Benson relaxation response in reducing the anxiety of parents of children with autism, the present study attempted to find out if Benson relaxation response is effective on the anxiety of mothers of children with autism. The insights from this study can also contribute to developing training programs for parents of children with autism and counselors in autism support centers. Moreover, the findings of this study can have some implications for taking measures to reduce the problems faced by parents and their autistic children. To this end, this study investigates the effect of Benson relaxation response on the anxiety of mothers of children with autism.

Materials and Methods 
This quasi-experimental study was conducted using an equivalent group, pre-test-post-test design. The subjects were selected voluntarily using convenience sampling from mothers with autistic children admitted to Shahid Zolfaghari Autism Support Center in Tehran City, Iran. A total of 100 subjects were selected based on the inclusion criteria and were randomly assigned into two intervention and control groups using permuted block randomization (each with 50 subjects [Figure 1]). The sample size was estimated using the Fleiss sample size estimation equation (Fleiss et al., 1980), where β=0.51, P0=0.91.5, P1=0.98, r=0.90, and α=0.05. Accordingly, considering 20% sample attrition, the sample size in each group was estimated to be 54 people. Based on this formula, the effect size for this sample is at a medium level. The criteria for enrollment in the study were as follows: 1) Having at least a diploma; 2) Being in the age range of 30 to 50 years; 3) Not suffering from psychological disorders according to the structured clinical interview for The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and based on psychiatrist’s diagnosis; 4) Willingness to attend group meetings; 5) Being married; and 6) Expressing willingness to participate in the study. Meanwhile, the exclusion criteria were not doing exercises during treatment sessions, failing to continue the exercises provided in training sessions at home, and, attending other psychological intervention sessions during the study. 



Study instruments 

Demographic information questionnaire 
Demographic data included mothers’ age, education, and occupation and also the number of children and their age.

Beck anxiety inventory
In 1988, Aaron Beck introduced this inventory to measure the severity of clinical symptoms of anxiety. This 21-item self-assessment tool measures anxiety symptoms on a 4-point Likert scale (0=not at all, 1=mildly, 2=moderately, and 3=severely). The scores of the inventory range from 0 to 63. In this scale, 0-7 indicates minimal anxiety, 8-15 shows mild anxiety, 16-25 reflects moderate anxiety, and 26-63 shows severe anxiety (Beck et al., 1988). Its internal consistency (α coefficient) was equal to 0.92 and its reliability was assessed as equal to 0.75 using the test re-test method within a one-week interval, and the correlation between the items varied from 0.30 to 0.76 (Beck et al., 1988). Toledano-Toledano et al., (2020) also estimated the reliability of this tool equal to 0.90 (Toledano-Toledano et al., 2020). This questionnaire was translated into Persian in 2005 and its reliability was reported as 0.74 (Ghassemzadeh et al., 2005). In this study, the internal consistency (Cronbach α) of the scale was estimated at 0.90.

Study procedure 
The BAI was first administered as the pre-test to the participants in both groups. Then, instructions on how to implement Benson’s relaxation were taught to the participants of the intervention group. They received the training in groups of 5-6. The relaxation response training was performed based on the procedure proposed by Benson and Klipper (1975) in 8-step (Table 1). The steps were repeated until all groups acquired the required skill. The duration of each session was between 20 and 25 min. The training was given by a psychologist at the Shahid Zolfaghari Autism Support Center. The subjects were asked to repeat this procedure twice a day for 30 days. The researcher encouraged the participants to continue their home exercises through phone calls and made sure that the exercises continued according to the program. The post-test was done after 30 days of relaxation sessions at home in both groups. To comply with ethical guidelines, the procedure was also implemented for the control group after the post-test. 



Data analysis
The collected data were summarized using descriptive statistics, such as frequency, percentage, Mean±SD. Moreover, the analysis of covariance (ANCOVA) was used to determine the effectiveness of Benson relation response on anxiety (ANCOVA is employed to identify differences between the means of two or more independent groups while accounting for scale covariates; a covariate may affect the dependent variable and thus requires control). Also, the paired difference t-test and chi-square test were used to measure the difference between the mean of the two groups. Before the ANCOVA test, the assumptions of this test were first checked using Levene’s and Box’s M tests. The data were analyzed using the SPSS software, version 26. The significance level was set at P<0.05. 

Results 
Table 2 shows the participants’ demographic characteristics. In all cases, the first child was diagnosed with autism. Accordingly, there was no significant difference between the two groups in terms of the demographic variables.



Table 3 shows the descriptive statistics for anxiety levels in the two groups before and after the intervention.



According to Table 3, there is no statistically significant difference between the two groups in terms of the mean anxiety scores before the intervention (P=0.63). However, there was a significant difference between the mean anxiety scores of the two groups after the intervention (P≤0.001). Furthermore, a statistically significant difference was observed between the mean anxiety scores before and after the intervention in the intervention group (P≤0.001). ANCOVA was run to detect the effectiveness of Benson relaxation response and to control the effects of covariates (Table 4). 



According to Table 4, after eliminating the covariate effect and considering the (F=10.69), there was a significant difference between the adjusted mean anxiety scores of the participants in terms of their group membership (control or intervention) in the post-intervention stage (P<0.001). These data imply that the Benson relaxation response had a significant effect on the anxiety levels of the participants in the intervention group compared to the control group.

Discussion 
This study investigated the effect of the BRM on the anxiety of mothers of children with autism. The findings indicated that after eliminating the covariate effect, there was a significant difference between the adjusted mean anxiety scores of the participants in terms of their group membership (control or intervention) in the post-intervention stage, implying that Benson relaxation response has led to a significant difference in the anxiety of mothers of children with autism before and after the intervention. Some studies have also shown the beneficial effects of BRM on different groups of healthy people (Mohammadi & Parandin, 2019). Moreover, Gika et al. (2012) reported that a six-week relaxation program was effective in reducing the level of stress experienced by the mothers of children with autism. In addition, Ibrahim et al. (2019) examined the effectiveness of BRM on the anxiety of adult patients. The results showed that the participants in the intervention group had significantly lower levels of anxiety compared to those in the control group. In their systematic review of randomized controlled trials, Abu Maloh et al. (2021) assessed the effectiveness of Benson relaxation responses on the anxiety and depression of patients under hemodialysis. The findings showed a statistically significant decrease in the patient’s anxiety scores in all five included studies. 
Pardede and Tarigan (2020) studied the effectiveness of the Benson relaxation technique on the anxiety levels of mothers in the pre-cesarean section stage. The results showed that Benson relaxation response is effective in reducing the anxiety induced by cesarean section (Pardede and Tarigan, 2020). Herbert Benson et al. (1975) observed that immediately after the onset of relaxation, slow waves of α appeared in the curves measuring brain activity, which increased in proportion and number as the state of relaxation progressed. For most people in society, the appearance of α waves is associated with arousing feelings of happiness and well-being. Benson believed that the relaxation method also reduces tension in muscles and increases muscular relaxation (Darmawati et al., 2021). In addition to arousing feelings of happiness, fun, and excitement, and promoting self-confidence, it can also suppress the release of cortisol, epinephrine, and norepinephrine hormones, which are strong vasoconstrictors in blood vessels (Sutrisno, 2023). Suppression of these hormones can cause dilation of blood vessels, leading to decreased vascular resistance and pressure (Price & Wilson, 2012).
Benson relaxation response intervention can block sympathetic nerve activation, which can reduce oxygen consumption in the body. It also relaxes the muscles and thus creates a feeling of relaxation and comfort. Relaxation reduces anxiety and increases the stability of the autonomic nervous system by increasing the hypothalamus nucleus that controls the activity of the parasympathetic nervous system (Anisah & Maliya, 2021). 
Given the adverse effects of anxiety on all body systems and many side effects of anti-anxiety drugs including drug resistance and the reduction of the effect of these drugs after a short period, as well as the high rate of autism in Iran (Mohammadi et al., 2019), Benson relaxation response can be used as an easy, inexpensive and non-invasive method to reduce anxiety and stress, reduce the frequency of using anti-anxiety and sedative drugs, reduce stress, and depression levels and improve the satisfaction of mothers of children with autism. Benson relaxation response is simple and does not require specialized personnel, and trained psychotherapists can use it to take a step towards calming clients and increasing their satisfaction. In this study, to reduce the possibility of communication between the participants in the two groups, the intervention sessions were carried out on days when the participants in the control group did not visit the center.

Conclusion 
The findings of the present study showed that Benson relaxation response helps the mothers of children with autism to decrease their anxiety levels. Benson relaxation response can be instructed in the form of a self-learning and self-help program. These relaxation exercises can be used by healthcare providers, including psychologists family counselors, and psychiatric nurses in autism centers as an effective, accessible, and inexpensive approach to maintaining the mental health and psychological well-being of the mothers of these children. Community health administrators and mental health managers can apply and implement BRM as a useful and therapeutic approach for mothers of children with autism in therapeutic centers.

Ethical Considerations

Compliance with ethical guidelines
The protocol of this study was approved by Qazvin University of Medical Sciences (Code: IR.QUMS.REC.1402.399). To comply with the ethical principles of voluntary participation, written informed consent was obtained from all the participants. The subjects were also reassured of the confidentiality of their information.

Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Authors' contributions
Conducting research, data gathering and analysis: Ali Jalilvandi; Supervisor, study design and data analysis: Mohammad Reza Sheikhi; Conceptualization and writing the original draft: Anahita Khodabakhshi-Koolaee; Final approval: All authors.

Conflict of interest
The authors declared no conflict of interest.




References 

Abu Maloh, H. I. A.,  et al., 2021. Efficacy of Benson’s relaxation response on anxiety and depression among patients undergoing hemodialysis: A systematic review. Clinical Nursing Research, 31(1), pp. 122–35. ‏ [DOI:10.1177/10547738211024797] [PMID]

Alibekova, R., et al., 2022. Stress, anxiety and depression in parents of children with autism spectrum disorders in Kazakhstan: Prevalence and associated factors. Global Mental Health (Cambridge, England), 9, pp. 472–82. [DOI:10.1017%2Fgmh.2022.51] [PMID] 

American Psychiatric Association.,  2013. Diagnostic and statistical manual of mental disorders, Fifth Edition. Washington, DC: American Psychiatric Association. [DOI:10.1176/appi.books.9780890425596]

Amireh, M. M. H. & Omer, F. E. Z. A. M., 2018. Caregivers’ perspective about the levels of sensory processing problems in children with Autism. Journal of Client-Centered Nursing Care, 4(3), pp. 131-8. [DOI:10.32598/jccnc.4.3.131]

Anisah, I. N. & Maliya, A., 2021. [Efektivitas relaksasi benson terhadap kecemasan pasien yang menjalani hemodialisa (Indonesian)]. Jurnal Berita Ilmu Keperawatan, 14(1), pp.  57-64.  [DOI:10.23917/bik.v14i1.12226]

Beck, A. T., et al., 1988. Beck anxiety inventory [Database record]. APA PsycTests. [DOI:10.1037/t02025-000]

Benson, H. Beary, J. F. & Carol, M. P., 1974. The relaxation response. Psychiatry, 37(1), pp. 37–46. [DOI:10.1080/00332747.1974.11023785] 

Benson, H., Greenwood, M. M. & Klemchuk, H., 1975. The relaxation response: Psychophysiologic aspects and clinical applications. International Journal of Psychiatry in Medicine, 6(1-2), pp. 87–98. [DOI:10.2190/376W-E4MT-QM6Q-H0UM] [PMID]

Benson, H., 1983. The relaxation response: Its subjective and objective historical precedents and physiology. Trends in Neurosciences, 6, pp. 281-4. [DOI:10.1016/0166-2236(83)90120-0]

Benson, P. R., 2010. Coping, distress, and well-being in mothers of autistic children. Research in Autism Spectrum Disorders, 4(2), pp. 217-28. [DOI:10.1016/j.rasd.2009.09.008]

Darmawati, I., et al., 2021. Implementing Benson’s relaxation therapy to decrease depression in the elderly. Malaysian Journal of Medicine and Health Sciences, 17(SUPP14), pp. 161-5. [Link]

Davis N. O. & Carter A. S., 2008. Parenting stress in mothers and fathers of toddlers with autism spectrum disorders: Associations with child characteristics. Journal of Autism and Developmental Disorders, 38(7), pp. 1278-91. [DOI:10.1007/s10803-007-0512-z] [PMID]

Dollion, N., et al., 2024. Effects of service dogs on children with ASD’s symptoms and parents’ well-being: On the importance of considering those effects with a more systemic perspective. Plos One, 19(1), pp. e0295702. ‏ [DOI:10.1371/journal.pone.0295702] [PMID] 

Ebrahimi, B. & Adib-Hajbaghery, M., 2022. Effect of Benson’s relaxation response on anxiety in family caregivers of patients with cancer: A randomized controlled trial. Nursing and Midwifery Studies, 11, pp. 37-43.  [Link] 

Estes, A., et al., 2013. Parenting stress and psychological functioning among mothers of preschool autistic children and developmental delay. Autism, 13(4), pp. 375-87. [DOI:10.1177/1362361309105658] [PMID]  

Fleiss, J. L., Tytun, A. & Ury, H. K.,  1980. A simple approximation for calculating sample sizes for comparing independent proportions.  Biometrics, 36(2), pp. 343–6. [DOI:10.2307/2529990] [PMID]

Ghassemzadeh, H., et al., 2005. Psychometric properties of a Persian‐language version of the Beck Depression Inventory‐Second edition: BDI‐II‐PERSIAN. Depression and Anxiety, 21(4), pp. 185-92. [DOI:10.1002/da.20070] [PMID]

Gika, D. M., et al., 2012. Use of a relaxation response by mothers of autistic children: A case-series study. Psychological Reports, 111(3), pp. 797-804. [DOI:10.2466/20.15.21.PR0.111.6.797-804] [PMID] 

Hamdani, S. U., et al., 2022. Effectiveness of relaxation techniques ‘as an active ingredient of psychological interventions’ to reduce distress, anxiety and depression in adolescents: A systematic review and meta-analysis. International Journal of Mental Health Systems, 16(1), pp. 31. [DOI:10.1186/s13033-022-00541-y] [PMID] 

Hartley, S. L. & Schultz, H. M., 2015. Support needs of fathers and mothers of children and adolescents with autism spectrum disorder. Journal of Autism and Developmental Disorders, 45(6), pp. 1636-48. [DOI:10.1007/s10803-014-2318-0] [PMID] 

Ibrahim, A., et al., 2019. The effect of Benson relaxation method on anxiety in emergency care. Medicine, 98(21), pp. e15452. [DOI:10.1097%2FMD.0000000000015452] [PMID]

Lindquist, R., et al., 2018. Complementary and alternative therapies in nursing. New York: Springer Publishing Company. ‏ [DOI:10.1891/9780826144348]

Liu, G., et al., 2021. The efficacy of wechat-based parenting training on the psychological well-being of mothers with autistic children during the covid-19 pandemic: Quasi-experimental study. JMIR Mental Health, 8(2), pp. e23917.  [DOI:10.2196/23917] [PMID] 

Maenner, M. J., et al., 2023. Prevalence and characteristics of autism spectrum disorder among children aged 8 years-Autism and Developmental Disabilities Monitoring Network, 11 sites, United States, 2020. Morbidity and Mortality Weekly Report. Surveillance Summaries (Washington, D.C. : 2002), 72(2), pp. 1–14. [DOI:10.15585%2Fmmwr.ss7202a1] [PMID]

Minaabad M. S. & Dorani Lomar S., 2020. The effects of children’s pedagogical songs on social, linguistic, and written skills development in children with autism spectrumdisorders. Journal of Client-Centered Nursing Care, 6(3), pp. 175-86. [DOI:10.32598/JCCNC.6.3.322.1]

Mohammadi, M. M. & Parandin, S., 2019. Effect of the combination of Benson’s relaxation response and brief psychoeducational intervention on multidimensional pain and negative psychological symptoms of pregnant women: A randomized controlled trial. Journal of Education and Health Promotion, 8(1), pp. 91. [DOI:10.4103%2Fjehp.jehp_286_18]

Mohammadi, M. R., et al., 2019. Prevalence of autism and its comorbidities and the relationship with maternal psychopathology: A national population-based study. Archives of Iranian Medicine, 22(10), pp. 546-53. [Link]

Najafi Ghezeljeh, T., Sedghian, H. & Mohades Ardabili, F., 2016. [Effect of Benson relaxation response on anxiety in critical care nurses (Persian)]. Iranian Journal of Cardiovascular Nursing, 5(3), pp. 26-33. [Link]

Neece, C. L., Fenning, R. M., Morrell, H. E. & Benjamin, L. R., 2024. Comparative effects of mindfulness-based stress reduction and psychoeducational support on parenting stress in families of autistic preschoolers. Autism, 28(4), pp.  985-98. ‏ [DOI:10.1177/13623613231191558] [PMID]

Oti-Boadi, M., Dankyi, E. & Kwakye-Nuako, C. O., 2020. Stigma and forgiveness in Ghanaian mothers of autistic children spectrum disorders (ASD). Journal of Autism and Developmental Disorders, 50(4), pp. 1391–400. [DOI:10.1007/s10803-020-04366-x] [PMID]

Pardede, J. A. & Tarigan, I., 2020. The anxiety level of mother presectio caesar with benson’s relaxation therapy. Jendela Nursing Journal (JNJ), 4(1), pp. 20-8. [DOI:10.31983/jnj.v4i1.5801]

Price, S. A. & Wilson, L. M., 2012. [Patofisiologi: Konsep Klinis Proses proses penyakit, Vol. 1(Malay)]. [Link]

Rafii, F., Seyedfatemi, N. & Asgarabad, H. E., 2024. The life of mothers of children with Autism: A grounded theory study. Revista Latinoamericana de Hipertension, 19(4), pp.154-62. [Link] 

Rivard, M., et al., 2014. Determinants of stress in parents of autistic children spectrum disorders. Journal of Autism and Developmental Disorders, 44(7), pp. 1609-20. [DOI:10.1007/s10803-013-2028-z] [PMID]

Sotgiu, S., et al., 2020. Immune regulation of neurodevelopment at the mother-fetus interface: The case of autism. Clinical & Translational Immunology, 9(11), pp. e1211. [DOI:10.1002/cti2.1211] [PMID] 

Sutrisno, S. & Nursalam., 2023. The effect of benson and autogenic relaxation therapy on sleep quality, blood pressure and anxiety of hypertension patients. Journal of Nursing Practice, 6(2), pp. 214-20. [Link]

Thomas, M. S., et al., 2015. The over-pruning hypothesis of autism. Developmental Science, 19(2), pp. 284-305. [DOI:10.1111/desc.12303] [PMID]

Toledano-Toledano, F., et al., 2020. Validity and reliability of the Beck Anxiety Inventory (BAI) for family caregivers of children with cancer. International Journal of Environmental Research and Public Health, 17(21), pp. 7765. [DOI:10.3390%2Fijerph17217765] [PMID] 

Walsh, K., et al., 2007. Reducing emotional distress in people caring for patients receiving specialist palliative care: Randomized trial. The British Journal of Psychiatry, 190, pp. 142-7. ‏ [DOI:10.1192/bjp.bp.106.023960] [PMID]

Weiss, J., Thomson, K. & Chan, L., 2014. A systematic literature review of emotion regulation measurement in individuals with autism spectrum disorder. Autism Research, 7(6), pp. 629-48. [DOI:10.1002/aur.1426] [PMID]

Yassin, R., 2023. Stress, anxiety, and depression in parents of autistic children in Saudi Arabia [PhD dissertation]. Lincoln: University of Lincoln. ‏ [Link]