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Introduction
Down syndrome (DS) is considered the most common genetic disorder with unknown causes [1]. Research suggests that the prevalence of this syndrome is one in 800 to 1000 live births. In Iran, there are about 1.2 million people with DS [2]. In general, many children with DS have physical, developmental, cognitive, mental, and psychological problems [3]. Undoubtedly, the family and people around these children will be affected by these problems in different ways. The mental disability of the child, as a member of the family, prevents the family system from performing its functions and duties properly, and as a result, the family function is impaired [4]. Families who care for a child with DS at home face many psychological, social, and economic problems [5]. Children’s parents with DS experience more stress compared to normal children’s parents. Having an ill child in the family causes physical and psychological stress to family members, especially the mother as these children spend more time with their mothers than their fathers [6].
Stress is the biggest threat to health, and the strategy to cope with it is one of the structures in the quality of life [7]. Resilience builds an individual’s capacity to cope with stressors [8]. Families of children with DS can tolerate the challenges associated with child growth and development through resilience skills [9]. Resilience is one of the issues investigated by positive psychology [10]. Resilience is a phenomenon that arises from human adaptive responses. It is a kind of developable state in the person, through which he or she can face failures, disasters, and family and relationship problems. It can be viewed as a measure of stress-coping ability in response to adversity, improve social performance, and overcome problems [11].
Moreover, creating resilience through psychological acceptance reduces work stress and increases the mental health of those who interact with people with mental disabilities [12]. Therefore, as mothers are more engaged in their children’s illnesses among family members and are more responsible for taking care of children, they experience higher adverse events. Also, mothers are considered the heart of life in the family. Hence, resilience can be introduced as a relatively new perspective that can open a new horizon in the area of promoting the health of people with mental disabilities and their families. Thus, given what was mentioned and because there is no study on the effect of resilience on the stress of mothers of students with this syndrome, this study aimed to evaluate the influence of resilience skills training on the stress of these mothers.

Materials and Methods
Study design
This study is a non-randomized clinical trial. The statistical study population of the study consisted of all students’ mothers with DS at Shahid Rajaieh School in Tehran.

Sample size
The sample size was determined to be at least 18 people in each group considering similar studies, the formula of determining the sample size (n=(Z1-Z1-β)22×SD2/d2), the type 1 error (α=0.05), the probability of dropout, and test power of 80% [12]. Then, 46 people were selected based on the purpose, and assigned to two groups (23 in the intervention group and 23 in the control group) by convenience random sampling. 

Sampling method
After obtaining permission and a letter of introduction from the Ethics Committee University of Social Welfare and Rehabilitation Sciences, mothers aged 8-14 years and mothers who had information, addresses, and contact numbers based on the inclusion criteria were selected by the researchers in this school.
After introducing himself to the participants, he provided explanations about the research and its objectives. Then, written consent was obtained from mothers who were willing to participate in the study. After collecting data and matching two groups, the intervention and control groups were randomly assigned to the two groups based on the classification of participants (demographic and intervening variables). 

Intervention
The training was provided only to the intervention group. Then, all training was given to the control group and the school. Participants were first asked to complete a parenting stress index (PSI). Then, resilience skills training [13] was provided to the mother in ten sessions of 45 minutes, 2-3 times per week, by a researcher who participated in relevant courses and workshops under supervision. One month after the final session [14], the participants completed the questionnaires again, and the results were evaluated. In addition, to obtain the final approval of the educational content, an educational package was sent to some professors of University of Social Welfare and Rehabilitation Sciences, and their opinions were used to complete and improve it. 

Participants’ inclusion and exclusion criteria
Inclusion criteria included willingness to participate in research, living in Tehran, having a primary school student with DS, child and mother living together, no physical and mental illness (based on medical records, self-disclosure of mother, the physician, and the treatment team), lack of serious emotional problems and severe family crises (divorce, death of first-degree relatives, etc.) and not participating in similar training courses. Exclusion criteria also included incomplete questionnaires and not participating in training sessions. 

Assessment tool
A demographic information questionnaire and PSI were used for data collection. PSI consists of 120 five option questions designed by Abidin in 1983 [15], which was translated and validated in Iran in 2009 by Kaveh [16]. It assesses a child’s behavioral characteristics, parents’ personality traits, and family environment stressors. The total score was obtained by summing up the scores of the subscales. A score of more than 75 percentile reflects a higher level of stress [17]. 

Data analysis
The collected data was analyzed by SPSS software, version 18. The two groups (treatment and control) were compared before the treatment in terms of baseline characteristics (maternal age, maternal education, number of children, and income) using a chi-square test. The independent samples t-test was used to compare the mean stress scores before and after the intervention, and multivariate analysis of covariance (ANCOVA) was used to investigate the effect of the intervention on the stress scores.

Results 
The two groups were homogeneous in terms of demographic characteristics. Table 1 presents the demographic variables and compares them in the two groups.


Before the intervention, the mean stress scores in the intervention and control groups were not significantly different (P=0.89). After the intervention, the mean stress scores in the intervention group decreased and remained almost unchanged in the control group. The independent t-test showed that the mean scores of the two groups were significantly different (P=0.001) (Table 2).


In addition, the ANCOVA results showed a significant difference between the experimental and control groups in the mean stress scores in the post-test (F=192.908; P<0.001), and the effect of training was approximately 88% (Table 3).



Discussion 
The present study aimed to investigate the effect of resilience training on the stress of mothers of students with DS at Shahid Rajaieh School. Mothers experienced above-normal stress levels. Lee et al. reported that the younger age of individuals with DS was associated with increased unique needs of the children and stress levels in parents and caregivers [18]. However, O’Sullivan found that the parents of DS children perceived a higher-than-average stress level, which could be exacerbated by the child’s young age [19]. The findings of another study highlighted the higher psychological stress in families caring for a disabled child, which can affect their ability to meet their child’s needs. Thus, families need to maintain their resilience when facing considerable stress in their lives [20]. In addition to affecting their parenting roles, excessive parental stress can exert negative impacts on various aspects of parents’ lives and prevent them from meeting their needs in life [21]. Despite spending much time, energy, and money and paying great attention to their disabled children, the families of such children suffer from feeling inadequacy in meeting their child’s needs and are subject to more stress compared to other families [22]. Nevertheless, these families require more support, and by providing sufficient support, healthcare providers, including nurses, can help them better manage their children [23]. Among the interventions that could enhance the welfare of these individuals was promoting resilience. The results of the present study revealed that participation in resilience skills training sessions could help reduce stress in mothers of DS children. Consistent with this finding, Onyedibe et al. also suggested that highly resilient parents perceived less parenting stress and parental stress, and resilience-based treatment appears to be effective in managing the stress of the upbringing of such children [24]. Pastor-Cerezuela et al. also indicated an association between high resilience and mild stress in these families [25]. Families having DS children could live full, productive lives. They could successfully cope with their child’s diagnosis by early recognition of the problems that they are facing and providing interventions to enhance their resilience [26]. In a study on mothers of children with intellectual disabilities, Hosseini-Ghomi et al. concluded that training resilience skills in these mothers could mitigate their stress levels and improve their mental health [27]. Kaboudi et al. also showed that mothers who were trained in resilience skills could increase their style of coping and reduce parental stress significantly [28]. The results of the studies done by Rostami et al. [29] and Kaveh et al. [30] also comply with the present research.
In developing countries, due to a shortage of social services, the parents undertake the entire responsibility of raising a disabled child, which is highly stressful for them and adversely impacts their quality of life [30]. These parents need to strengthen their resilience to minimize the difficulties of raising a disabled child [32]. Resilience is associated with parental acceptance, cognitive adaptation, positive affect, and self-efficacy and can mark a starting point for their understanding and learning [33]. 
It is recommended that the results of this program be used in training other caregivers of these children as well as mentally retarded children and their teachers and in-service training for nursing staff and nursing students. The present study faced some limitations, including convenience sampling and no follow-up after the study due to the unavailability of mothers during school holidays. Thus, we suggest that future studies should be conducted on larger samples, preferably selected by random sampling and involving other age groups, such as young children and adolescents.

Conclusion
Strengthening the resilience skills of mothers with DS children reduces their stress, increases their quality of life, and ultimately increases the quality of life of other family members. Also, increasing resilience skills can empower parents in educating their children ultimately reduce the damage caused by mental disability and help parents accept the existing status. Thus, introducing resilience as a relatively new perspective can open a new horizon in promoting the health of people with mental disabilities and their families. 

Ethical Considerations
Compliance with ethical guidelines
All the ethical considerations based on the international ethical protocols were considered by the authors and the work was approved by the Ethics Committee of the University of Social Welfare and Rehabilitation Sciences (Code: IR.USWR.REC.1394-279). 

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors.

Authors' contributions
All authors equally contributed to preparing this article.

Conflict of interest
The authors declared no conflict of interests.

Acknowledgments
We thereby appreciated all of the professors of University of Social Welfare and Rehabilitation Sciences, the staff of Shahid Rajaieh School of Tehran, and the mothers who participated in the research.


References

1. Gharibpour S, Hojati H. [The effect of reality therapy on self-efficacy in mothers of children with Down syndrome (Persian)]. Iranian Journal of Nursing Research. 2019; 13(6):63-7. [DOI:10.21859/ijnr-130609]
2. Pereira K, Basso RP, Lindquist AR, da Silva LG, Tudella E. Infants with down syndrome: Percentage and age for acquisition of gross motor skills. Research in Developmental Disabilities. 2013; 34(3):894-901. [DOI:10.1016/j.ridd.2012.11.021] [PMID]
3. Baburamani AA, Patkee PA, Arichi T, Rutherford MA. New approaches to studying early brain development in Down syndrome. Developmental Medicine and Child Neurology. 2019; 61(8):867-79. [DOI:10.1111/dmcn.14260] [PMID]
4. Hardman MM. Human exceptionality: Society, school, and family. [H. Alizadeh, K. Ganji, M. Yousef Loyeh, F. Yadeghari, Persian trans]. Tehran: Danjeh Publiscations; 2009. [Link]
5. Naghdi N, Ghasemzadeh S, Ghobari Bonab B. [Phenomenology of lived experience of mothers of children with down syndrome (DS) (Persian)]. Journal of Applied Psychological Research. 2019; 10(2):105-18. [DOI:10.22059/japr.2019.72654]
6. Amiri Majd M, Hosseini S, Jafari A. [Comparing the quality of life and marital intimacy among parents of children with down syndrome, parents of children with learning disabilities, and parents of normal children (Persian)]. Journal of Learning Disabilities. 2014; 4(1):38-55. [Link]
7. Momeni K, Shahbazirad A. [Relationship of spirituality, resiliency, and coping strategies with quality of life in university students (Persian)]. International Journal of Behavioral Sciences. 2012; 6(2):97-103. [Link]
8. Groarke A, Curtis R, Skelton J, Groarke JM. Quality of life and adjustment in men with prostate cancer: Interplay of stress, threat and resilience. Plos One. 2020; 15(9):e0239469. [DOI:10.1371/journal.pone.0239469] [PMID]
9. Van Riper M. Families of children with Down syndrome: Responding to "a change in plans" with resilience. Journal of Pediatric Nursing. 2007; 22(2):116-28. [DOI:10.1016/j.pedn.2006.07.004] [PMID]
10. Khanjani M, Sohrabi F, Aazami Y. [The effectiveness of resilience and stress management training program on psychological well-being, meaning of life, optimism, and satisfaction of life in female-headed households (Persian)]. Iranian Journal of Psychiatric Nursing. 2018; 6(2):1-11. [DOI:10.21859/ijpn-06021]
11. Wu Y, Yu W, Wu X, Wan H, Wang Y, Lu G. Psychological resilience and positive coping styles among Chinese undergraduate students: A cross-sectional study. BMC Psychology. 2020; 8(1):79. [DOI:10.1186/s40359-020-00444-y] [PMID]
12. Kaveh M, Alizadeh H, Delavar A, Borjali A. [Development of a resilience fostering program against stress and its impact on quality of life components in parents of children with mild intellectual disability (Persian)]. Journal of Exceptional Children. 2011; 11(2):119-40. [Link]
13. Friborg O, Barlaug D, Martinussen M, Rosenvinge JH, Hjemdal O. Resilience in relation to personality and intelligence. International Journal of Methods in Psychiatric Research. 2005; 14(1):29-42. [DOI:10.1002/mpr.15] [PMID]
14. Hoseini Ghomi T, Salimi Bajestani H. [Effectiveness of resilience training on stress of mothers whose children, suffer from cancer in Imam Khomeini Hospital of Tehran T. Hosseini Ghomi*/ H. Salimi Bajestani**1 (Persian)]. Health Psychology. 2013; 1(4):97-109. [DOI:20.1001.1.23221283.1391.1.4.8.1]
15. Abidin RR. Parenting stress index: Manual, administration booklet, and research update. Charlottesville: Pediatric Psychology Press; 1983. [Link]
16. Kaveh M. Development of a resilience fostering program against stress and its impact on quality of life components in parents of children with mild intellectual disability [Persian] [PhD dissertation].Tehran: Allameh Tabatabaii University; 2009.
17. Babakri H, Tahmasebi S, Amani S. [Validation of the parenting stress index (PSI) among mothers of Preschool children in Tehran (Persian)]. Shenakht Journal of Psychology and Psychiatry. 2018; 5(4):29-39. [DOI:10.29252/shenakht.5.4.29]
18. Lee EY, Neil N, Friesen DC. Support needs, coping, and stress among parents and caregivers of people with Down syndrome. Research in Developmental Disabilities. 2021; 119:104113. [DOI:10.1016/j.ridd.2021.104113] [PMID]
19. O’Sullivan E. Physical and mental wellbeing of parents of children with Down syndrome in Ireland. Cork city: Community-Academic Research; 2022. [Link]
20. Sayed Mohamed H, Mohamed Elkhatib H, Mohamed Mohamed N. [Effect of psycho-educational program on psychological stress and resilience among families caring for children with intellectual disability (Persian)]. Egyptian Journal of Health Care. 2020; 11(4):1062-76. [DOI:10.21608/ejhc.2020.227162]
21. Darla S, Bhat D. Health-related quality of life and coping strategies among families with Down syndrome children in South India. Medical Journal, Armed Forces India. 2021; 77(2):187-93. [DOI:10.1016/j.mjafi.2020.07.010] [PMID]
22. Yarar F, Akdam M, Çarpan İ, Topal S, Şenol H, Tekin F. Impact of having a disabled child on mothers’ anxiety, depression and quality of life levels. Pamukkale Medical Journal. 2021; 14(1):223-32. [DOI:10.31362/patd.758161]
23. Gashmard R, Ahmadi F, Kermanshahi SMK. Coping strategies adopted by Iranian families of children with down syndrome: A qualitative study. Medicine. 2020; 99(28):e20753. [DOI:10.1097/MD.0000000000020753] [PMID]
24. Onyedibe MC, Ugwu LI, Mefoh PC, Onuiri C. Parents of children with Down Syndrome: Do resilience and social support matter to their experience of carer stress? Journal of Psychology in Africa. 2018; 28(2):94-9. [DOI:10.1080/14330237.2018.1455308]
25. Pastor-Cerezuela G, Fernández-Andrés MI, Pérez-Molina D, Tijeras-Iborra A. Parental stress and resilience in autism spectrum disorder and down syndrome. Journal of Family Issues. 2021; 42(1):3-26. [DOI:10.1177/0192513X20910192]
26. Caples M, Martin AM, Dalton C, Marsh L, Savage E, Knafl G, et al. Adaptation and resilience in families of individuals with down syndrome living in Ireland. British Journal of Learning Disabilities. 2018; 46(3):146-54. [DOI:10.1111/bld.12231]
27. Hosseini Ghomi T, Jahanbakhshi Z. [Effectiveness of resilience training on stress and mental health of mothers whose have children suffering mental retardation (Persian)]. Counseling Culture and Psycotherapy. 2021; 12(46):205-28. [DOI:10.22054/qccpc.2020.50262.2327]
28. Kaboudi M, Abbasi P, Heidarisharaf P, Dehghan F, Ziapour A. The effect of resilience training on the condition of style of coping and parental stress in mothers of children with leukemia (Persian)]. International Journal of Pediatrics. 2018; 6(3):7299-310. [DOI:10.22038/ijp.2018.29245.2559]
29. Rostami C, Ardalan A, Ahmadian H, Moradi M. [The effect of resilience skills on life expectancy and stress of mothers with mentally retarded children in Kamyaran (Persian)]. Zanko Journal of Medical Sciences. 2019; 20(66):35-45. [Link]
30. Kaveh M, Keramati H. [The impact of resilience fostering program on parenting stress, marital satisfaction and resiliency of children with learning disability (Persian)]. Journal of Learning Disabilities, 2017; 6(3): 69-91. [DOI:10.22098/jld.2017.520]
31. Mohan R, Kulkarni M. Resilience in parents of children with intellectual disabilities. Psychology and Developing Societies. 2018; 30(1):19-43. [DOI:10.1177/0971333617747321]
32. Savari K, Naseri M, Savari Y. Evaluating the role of perceived stress, social support, and resilience in predicting the quality of life among the parents of disabled children. International Journal of Disability, Development and Education. 2021; 1-15. [DOI:10.1080/1034912X.2021.1901862]
33. Zhao M, Fu W. The resilience of parents who have children with autism spectrum disorder in China: A social culture perspective. International Journal of Developmental Disabilities. 2020; 68(2):207-18. [DOI:10.1080/20473869.2020.1747761] [PMID]