Journal of Childhood

Introduction
Pediatric cancer is one of the most emotionally and physically distressing experiences for families, especially mothers who often serve as the child’s primary caregiver. The psychological burden stemming from the diagnosis, treatment, and uncertainty surrounding the illness may lead to anxiety, distress tolerance deficits, and death anxiety among mothers. Resilience, defined as a dynamic process of positive adaptation to challenging life experiences, has been identified as a key protective factor in such contexts. Moreover, distress tolerance (the ability to endure negative internal states) and death anxiety (the fear related to the loss of self or loved ones) are crucial components influencing the caregiver’s psychological stability. 
Recent psychological studies emphasize the role of therapeutic models such as acceptance and commitment therapy (ACT) in improving psychological flexibility, emotional regulation, and alignment with personal values, especially under chronic stress. On other hand, crisis intervention offers structured short-term support tailored to individuals facing emotional and cognitive problems due to unexpected traumatic events. Although both approaches have individually demonstrated efficacy, limited attention has been paid to their combination for supporting mothers of children with cancer. Therefore, the present study aims to evaluate the impact of a crisis intervention program combined with ACT on three key psychological constructs: resilience, distress tolerance, and death anxiety in mothers of children with cancer in Iran.

Research Methods
This is a quasi-experimental study with a pre-test/post-test design. The study population included all mothers children with cancer in Shahrekord, Iran, in 2024. Using G*Power software, the required sample size was calculated to be 30 (15 per group), considering α=0.05, test power=0.80, and effect size=0.25. Participants were selected via purposive and convenience sampling and randomly assigned to intervention and control groups. The intervention group received a ten-session structured crisis intervention (based on Roberts’ seven-stage model) plus ACT for six weeks. The used instruments included the Connor-Davidson Resilience Scal, Simons & Gaher’s Distress Tolerance Scale, and Templer’s Death Anxiety Scale. The data were analyzed using analysis of covariance (ANCOVA) in SPSS software, version 27. Assumptions including normality (Shapiro–Wilk), homogeneity of variance (Levene’s test), and regression slope consistency were verified prior to ANCOVA.

Results
Descriptive and inferential statistics indicated that the integrative intervention had a significant positive impact on the psychological indicators of mothers. In the post-test stage, the intervention group showed notable improvements in the mean scores of resilience (from 37.27 to 62.25) and distress tolerance (from 36.47 to 54.07), and a reduction in death anxiety score (from 12.73 to 6.56) compared to the control group. Multivariate ANCOVA results showed a significant group effect on the variables in overall (Wilks’ Lambda=0.528, P=0.009, η²=0.38). The univariate ANCOVA results confirmed group differences in all variables including resilience (F=27.26, P=0.001, η² =0.53), distress tolerance (F=37.12, P=0.001, η²=0.48), and death anxiety (F=9.25, P=0.001, η²=0.31). 

Conclusion
The present study confirmed the effectiveness of a combined crisis intervention-ACT program in enhancing resilience and distress tolerance, and reducing death anxiety among mothers of children with cancer in Iran. The intervention program worked by activating coping strategies, decreasing experiential avoidance, and fostering psychological flexibility, helping parents adapt to their child’s health crisis. These results align with ACT’s theory of value-based living and the core principles of crisis-focused therapy, suggesting the model’s potential for broader application in similar populations.
There were several limitations in the study including small sample size, the use of purposive sampling limited to mothers from specific treatment centers, lack of a follow-up phase, and not assessing the moderating variables such as personality traits or social support. These factors may restrict generalizability of the findings. 
Theoretically, this study supports the combination of ACT with crisis intervention for managing acute psychological distress among mothers of children with cancer. Practically, it highlights the potential for applying such approaches in family counseling centers, pediatric oncology units, and parent-support programs. Future research is encouraged to employ longitudinal designs with diverse groups, assess the intervention’s effects on psychological distress of fathers or other family members, and compare ACT-crisis intervention with alternative therapies such as CBT or mindfulness therapy. Implementing resilience training workshops, educating healthcare staff about parental death anxiety, and designing family-centered therapeutic programs can further increase the intervention’s practical impact.

Ethical Considerations

Compliance with ethical guidelines
This study was conducted in compliance with ethical standards approved by the Research Ethics Committee of Islamic Azad University, Isfahan (Khorasgan) Branch (Code: IR.IAU.KHUISF.REC.1403.121). All participants were informed about the study objectives and procedures, and their informed consent was obtained. Confidentiality of their data was also observed.

Funding
This article was extracted the master's thesis of Nazanin Jafarzadeh at the Faculty of Psychology, Islamic Azad University, Naein Branch. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for profit sectors.

Authors contributions
Design, investigation, and writing: Nazanin Jafarzadeh; supervision, editing & review: Shahnaz Khaleghipour

Conflicts of interest
The authors declare no conflict of interest.

Acknowledgments
The authors would like to thank all the mothers who participated in this study for their time and cooperation.