Examining the Influence of Self-compassion Education and Training Upon Parents and Families When Caring for their Children A Systematic Review

: Background: It is well-recognized that early parenting significantly influences the health and well-being of children. However, many parents struggle with the daily demands of being a parent and feel overwhelmed and exhausted psychologically and physically. Encouraging self-care practices is essential for parents, and self-compassion may be a potential strategy to utilize. Objectives: The review aims to assess the influence and impact of providing self-compassion education for parents and families when caring for their children. Methods: This systematic review utilized Joanna Briggs Institute (JBI) methodology. A three-stage search approach was undertaken that included seven electronic databases, registries and websites. These databases are Medline, Embase, PsycINFO, Emcare, Cochrane library, Scopus, and ProQuest. The included studies were appraised using the standardized critical appraisal instruments for evidence of effectiveness developed by JBI. Results: Ten studies met the inclusion criteria. Overall, the studies confirmed improved psychological well-being, and higher levels of self-compassion, kindness towards oneself and others, and mindfulness were reported. In addition, there were improvements in psychological well-being, decreased parental distress and perceived distress, lower levels of anxiety, and avoidance of negative experiences. Conclusion: The findings provide evidence to guide further research on developing, designing, facilitating, and evaluating self-compassion education programs and workshops for parents and families


INTRODUCTION
It is well-recognized that early parenting significantly influences the health and well-being of both children and their daily stressors associated with their children's disorders compared to parents without children with these disabilities [3,4].It has been proposed that self-compassion as a psychological intervention might support parents' mental wellbeing.
Self-compassion is not a new concept, having been embedded in Buddhist philosophy and practised for over 2500 years.Contemporary research on self-compassion has increased significantly due to its positive impact on mental well-being [5].Strauss and colleagues provide a comprehensive definition of self-compassion as; "a cognitive, affective, and behavioral process consisting of the following five elements that refer to both self and other-compassion: 1) Recognizing suffering; 2) Understanding the universality of suffering in human experience; 3) Feeling empathy for the person suffering and connecting with the distress (emotional resonance); 4) Tolerating uncomfortable feelings aroused in response to the suffering person (e.g., distress, anger, fear) so remaining open to and accepting of the person suffering; 5) Motivation to act/acting to alleviate suffering" [6].
Self-compassion has been described as having three components.Each of the three components has a constraining positive and negative aspect [7].The positive aspects are selfkindness, common humanity, and mindfulness.The negative components are self-judgment, isolation, and overidentification.Self-kindness relates to being supportive, gentle, and caring to oneself during a distressful life experience rather than self-judgment and criticism.Common humanity acknowledges and recognizes that everyone is suffering and experiences hardship during their lives rather than being the only one and isolating oneself from others.Mindfulness involves being aware of painful thoughts and negative emotions without avoiding or ignoring them and accepting them to help the healing process [4,7,8].Therefore, each of the three components of self-compassion constitutes sets of both positive and negative cognitions and behaviours.To develop self-compassion as a wellbeing strategy, the focus needs to be on the positive components (self-kindness, common humanity, and mindfulness) rather than the negative aspects (self-judgment, isolation, and over-identification) [4,7,8].
Research exploring self-compassion have reported that self-compassion acts as a buffer against negative emotions and feelings and helps maintain psychological well-being, and promotes resilience [9 -12].Studies have also discussed the importance of self-compassion in different populations in reducing levels of anxiety, stress, negative emotions, and more severe mental health conditions such as depression.For example, there was a relationship between the level of selfcompassion and emotional wellbeing and psychological distress in adolescents [13 -15].Furthermore, self-compassion reduced the strength of the relationship between maladaptive perfectionism and depression in adolescents and adults [10,16].Additionally, another study reported that having a high level of self-compassion was associated with improved sleeping patterns and resilience in health professionals such as nurses, dieticians, physicians, and social workers [14,17].Most commonly, self-compassion has been measured using the self-compassion scale (SCS), initially developed by Neff [18].However, there are different versions and adaptations of this scale [19].
More recently, self-compassion has been adopted as an intervention within parenting programs [1].It has been suggested that self-compassion may help parents develop acceptance and a more compassionate response to their children's behaviors and negative emotions [4].Additionally, self-compassion education has been shown to decrease parental distress and thus improve well-being [3].Previous studies have discussed the link between the level of self-compassion and mindful parenting [20 -22].These studies reported that a higher level of self-compassion was associated with a higher level of mindful parenting, lower level of parenting stress and lower levels of authoritarian and permissive parenting styles.Furthermore, self-compassion was positively correlated with different domains such as affective, cognitive patterns, achievement and social connections, and networking [5].Moreira et al. [22] highlighted the importance of developing and designing parenting education programs to reduce parenting stress and help parents become more compassionate toward themselves and others.It is recognized that peer support helps parents remain psychologically well and promotes positive parenting behaviors [23].Taylor et al. [23] reported that parents who received peer support demonstrated positive parenting skills and the ability to monitor their children and children's social competence.Therefore, it would be reasonable to suggest that parents may benefit from education and training on self-compassion to develop coping strategies to respond more positively to potential stressors and be compassionate to their children.
There appears to be limited evidence to support the use of therapeutic approaches to increase individual self-compassion as an effective intervention to improve parental mental wellbeing and, consequently, the child's well-being [1,24,25].Therefore, there is justification to undertake a systematic review to investigate the impact of self-compassion on parents' health and well-being when caring for their children.

Objective
To assess the impact of providing self-compassion education or training for parents and/or families when caring for their children.

Review Questions
(1) What is the impact of providing self-compassion education and training to parents and/or families when caring for their children?
(2) How do self-compassion education and training influence parents' and families' health and well-being?
(3) Does having the ability to give self-compassion assist parents in caring for themselves and their children?

Eligibility Criteria
The eligible studies met all of the following criteria: Type of studies: All types of studies, published or unpublished quantitative and mixed methods studies were included.Articles were restricted to the English language only and published after 2000.Studies that included any self-compassion scale used for evaluation and at least two components of self-compassion were recorded as outcomes.Type of participants: Target population (parents, mothers, fathers, family or families, and adoptive parents) of any age or gender who received education or training about self-compassion.Participants were described as parents, caregivers or guardians, or adoptive parents, and they had one or more children aged from (one month to 18 years).Children of the parents included may or may not have any behavioural, cognitive, or mental disability or special needs.Participants may have received the intervention in any setting (schools, primary or secondary community centres, rehabilitation centres, service agencies, primary or secondary mental health care centres, and hospitals).Type of interventions: All self-compassion studies where the intervention described the inclusion of selfcompassion training provided for participants in any form of education, training, programs, workshops, or sessions targeted were included.These interventions were stand-alone or other interventions in any form or means of education (through face-to-face, one-to-one, group work, webinar, digital or online programs).In addition, these interventions were provided by any health professionals or qualified or trained educators (health workers, social workers/counsellors, psychologists, nurses, midwives, meditation practitioners, and mindful trainers).Type of outcomes included: Self-compassion measured by any validated or non-validated tools, participants' health, and well-being after receiving selfcompassion training or education.
Excluded studies criteria: Self-compassion studies with no training or education (i.e., protocol trials, reviews, abstracts with no full text).Self-compassion education for all other populations (i.e., health professionals).Qualitative studies and theses.Studies that discussed one component of selfcompassion, such as mindfulness alone Studies that discussed empathy or meditation.

Information Sources
A comprehensive search of several resources was undertaken to maximize the inclusion of all relevant studies.The systematic review protocol has been published that describes in detail the methodology [26].

Search Strategy
The search strategy was designed to find published and unpublished studies from the time period 2000 until January 2021.In total, seven electronic databases, registries and websites were searched.These databases were Medline, Embase, PsycINFO, Emcare, Cochrane library, Scopus and ProQuest.A three-step search strategy approach was conducted as recommended by Tufanaru et al. [27].

Selection Process
Review authors downloaded all titles and abstracts retrieved by the electronic databases search strategy into EndNote (citation management software).Duplicate records were identified, manually reviewed, removed, and uploaded into Covidence software (systematic review software).Two review authors (SO, DW) independently screened the titles and abstracts for assessment against the inclusion criteria for the review.The fulltext of the studies that met the inclusion criteria were retrieved and then imported into Covidence software.The full text of the identified studies was further assessed against the inclusion criteria with a third reviewer (MS).Full-text studies that did not meet the inclusion criteria were excluded based on a discussion involving two authors (SO, MS).Any disagreement was discussed until a consensus was reached as to whether to include or exclude a study.The review was guided by The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [28].See (Fig. 1) PRISMA flowchart.

Data Collection Process
The first author (SO) extracted data from included studies and utilized a data extraction form used in an early review [29].This data extraction form included study characteristics, including study citation, country, design, methods, settings, and population.This form also collected data on scales used to measure self-compassion, education and/or training program, findings, authors' conclusion, and recommendations.The extracted information was then checked and reviewed by a second review author (MS).No disagreement was found between the two review authors.Due to the clinical heterogeneity of the included studies (i.e., interventions, population, study designs, settings, different self-compassion scales, and outcome measures), a meta-analysis could not be conducted.Therefore, the findings are presented in a narrative format.(See Data Extraction Table 1).

Assessment of Methodological Quality and Critical Appraisal and Risk of Bias
Two review authors assessed and critically appraised all identified studies (SO, MS) for their methodological quality to be included in the review.The Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) and (JBI critical appraisal checklist for randomized controlled trials and quasi-experimental studies) standardized appraisal tools were used to critique identified studies [27].Any study assessed as being low-quality of evidence would be excluded at this stage.However, all included studies were assessed as having a high-quality level of evidence (level 1 and 2) and achieved "YES" for at least 69% of the assessment checklist questions.(See Critical Appraisal of the included studies, (Tables 2 and 3).At Primary schools.
To examine the therapeutic effectiveness of gestalt intervention groups for anxious parents who had children studying in grades 3-6.
Self-compassion scale (Neff, 2003) to During the first three sessions, mothers learn to apply mindfulness and acceptance, patience, and trust, with themselves.From session 5: mothers started practicing and applying awareness to themselves and their children and applying mindfulness in stressful situations.The toddlers and their mothers were welcomed with a song and received an explanation about the program, followed by formal meditation (mothers were invited to bring their attention to themselves only in moment they feel space to do so and when the child is secure in the situation).The training was developed by a mindful parenting specialist (EP), an online intervention specialist (VS).
Participants were randomized before completing the pretest assessment.
The intervention group participants were requested to complete 8 weeks of intervention within 10 weeks and to submit the post-test assessment after completing the intervention.This was followed by another 10 weeks as a followup after the intervention.
The waitlist control group completed a waitlist assessment, followed by

Study Selection
A total of 10311 articles resulted from searching seven databases, registries, and websites.After removing 4558 duplicates, 5753 articles were reviewed by the title and abstract, and 267 were eligible for full-text screening.At this stage of screening, 257 articles were excluded for the following reasons: wrong target population (n=63), wrong intervention (n=62), theses (n=38), wrong indication (n=33), ongoing trials/protocol trials (n=32), no full-text or included only a conference abstract (n=14), wrong study design (n=8) and others (n=7).Ten studies met the inclusion criteria.The study selection and search strategy were guided by the preferred reporting items for systematic reviews and meta-analyses (PRISMA) methodology [28]

Study Characteristics
There was heterogeneity between the included studies' designs and methods.Of the ten included studies, four were pilot randomized controlled trials, group-based randomized micro-trials or randomized controlled trials or randomized controlled trials with two cohorts, and post-assessment and randomized waitlist-controlled trial design [30 -33].While the other six were quasi-experimental studies, including pre-, posttest evaluation study, or pre-, post-test study with a control group, longitudinal design with a waitlist, pre-test, post-test, and follow-up [34 -39].
In terms of the country in which the studies were undertaken, three studies were conducted in the Netherlands and three in the United States.In addition, one study was located in the United Kingdom, one in Australia, one in Iran, and one in Hong Kong.All included studies were conducted between 2012 and 2021.Eight of the included articles mentioned the setting where the study was conducted.These studies were conducted at different settings; local non-profit agency [34], adoption agency [35], school district [30,36], health centres [37] or primary or secondary mental health care centres [38,39].Only one study was conducted online [33]; (Table 1).

Participants' Characteristics
Participants from seven (70%) of the included studies were reported to have children requiring additional needs/support for developmental-behavioral disorders or relationship problems, i.e., developmental disabilities [34], children with special needs [30], or children with attention-deficit/ hyperactivity disorder (ADHD) [37].Three studies (30%) involved parenting stress [33,35,38], and one study focused on the regulation and relationship difficulties of the mother and/or child [39].Only three studies (30%) included participants and children having no additional challenges [31,32,36].The parents, caregivers, or adoptive parents who participated in these studies were reported to have one or more children whose ages ranged from one month to 12 years old [31,32,36,38,39].However, five studies did not report the children's age range [30, 33 -35, 37].
The participants' sample size was different for every study.The four (40%) randomized controlled trials included a total of 183 parents or caregivers [30 -33].The six quasi-experimental studies included a total of 314 parents or caregivers who completed the questionnaires [34 -39].(See Data Extraction Table 1).

Self-compassion Scale used in the Included Studies
All included studies used different self-compassion scale types of measurements and evaluations.Four studies [33,36,38,39] used the three components measured within the original self-compassion scale (SCS) developed by Neff and Germer [8].Three studies used all of the 26-items of SCS, representing six subscales [30,31,34].Kirby and Baldwin [31] used additional compassion scales; the fear of compassion scale, -15-items; the compassion motivation scale -11-items; and the compassion to others scale -24-items.In addition, one study used 24 items for the SCS [32], and another study [35] used the short-version 12 items self-compassion scale [19].Finally, one study [37] measured self-compassion and used the DASS-21 scale for three subscales (depression, anxiety, and stress) with 21 items.However, this study did not report a specific selfcompassion scale being used, and the corresponding author was contacted with no response.

Who Provided the Training or Education?
The training or the education was provided through certified or trained specialists; an experienced and trained mindfulness-based stress reduction (MBSR) teacher [34], instructors who have had professional training in the MBSR program, or mindfulness-based cognitive therapy (MBCT) [30], a fully qualified mindfulness practitioner [35], a psychologist [37], certified teachers [32], and a mindfulness trainer and an Infant Mental Health (IMH) specialist [38,39].The training program, which was provided online, was developed by a mindful parenting specialist (EP) and an online intervention specialist (VS) [33].However, two studies [31,36] did not provide information on who delivered the education.

Self-compassion Training or Education (Type of Interventions)
All included studies provided a self-compassion education program or training to their participants.The program education or training package contained a mix of teaching activities and learning methods, including lectures, video recordings, group discussions, questions and answer periods, printed materials and handouts, interactive materials such as practice sessions, breathing exercises, daily home practices, and assignments.The majority of the included studies discussed self-compassion, active compassion for others, mindfulness practices, group mindfulness, mediation, awareness of sensations, appreciation, and gratitude.
Only four of the included studies designed their education and training programs based on mindfulness-based stress reduction (MBSR) programs [30,33,34,38].All training programs for eight of the included studies had at least four sessions with a maximum of eleven sessions, and each session ranged between 35 minutes to 2 hours [32 -39].Except for two studies, participants received the training for eleven sessions that lasted between 2 and half hours and two full days [30], and a study received audio recordings for 15 minutes [31].
In terms of follow-up after providing the education program, four studies conducted longer follow-up periods between eight weeks and one year time [30,34,38,39].

Effect of Self-compassion Training on Parents' Health and Well-being
After attending a self-compassion training program, most participants, including parents, caregivers, primary caregivers, or adoptive parents, showed improvement in psychological well-being, decreased parental distress and perceived distress, low level of anxiety, and a low level of anxiety avoidance of negative experiences.In addition, there was a statistically significant improvement in the participants' self-compassion scores, improved mindfulness, and increased level of kindness towards oneself and others [31, 33, 35, 36 -39].Furthermore, the self-compassion scale scores showed significant positive correlations with social connectedness, emotional intelligence, and life satisfaction (self-compassion level and psychological wellbeing were increased by 20% and 9%, respectively, following the program).In contrast, significant negative correlations with self-criticism, perfectionism, depression, and low anxiety were observed (27% reduction in perceived stress level following the program) [34].For the studies with a longer follow-up, the participants had an improvement and maintained a higher level of self-compassion and psychological well-being over time.However, one study discussed that there was no correlation reported between these variables (self-compassion and well-being, anxiety, and stress) [30].

Effect of Self-compassion Training on Children
Only two studies reported the effect of providing selfcompassion training on children and their parents [32].Poehlmann-Tynan et al. [32] reported a significant impact of Cognitive Based Compassion Training (CBCT) on child physiological stress (children's cortisol level), evidenced by the decreased level of cortisol of infants and children of parents in the CBCT group over time ((mean = 54.26,SD= 95.16) for the intervention group, versus the control group (mean = 238.22,SD = 690.81)).In addition, parents reported feeling calmer in stressful situations and feeling differently with their children, including self-compassion and gratitude.Another study reported a decreased level of the child's psychopathology and improved dysregulation after attending the CBCT training [39].

DISCUSSION
Parenting can create significant anxiety and stress, with many parents struggling to cope with the expectations and daily demands of providing care and support to their child/children.Pollack (p. 24) [40], in reference to Freud, concluded that parenting is 'an impossible profession'.Acknowledging the innate challenges associated with parenting, this review sought to understand if self-compassion education could support parents in this role.
Being kind and compassionate to yourself has been largely overlooked as a self-care strategy [41].A parent's inner voice is often self-critical and self-blaming.However, self-compassion can be cultivated to help parents accept that it is okay to not be perfect.The 'good enough mother' was a concept first recognized by Winnicott, a paediatrician and parent-infant therapist [42].Therefore, the idea of 'good enough parenting' recognizes that parenting can take many forms and that there is no one 'right' way to parent.This concept advocates that parenting is 'good enough' when parents are able to provide sensitive and responsive care.Teaching parents to be selfcompassionate may facilitate a more responsive approach to parenting and this may also assist parents in accepting their imperfections and acknowledging that it is normal to feel overwhelmed and that negative experiences are universal [40].
Of note, the majority of included studies explored parents with additional demands placed upon them, i.e., child/children with developmental and/or intellectual disabilities.While not the primary focus of this review, these studies clearly demonstrate that these parents experience higher levels of distress and daily stressors associated with their children's disorders and behaviours when compared with parents who do not have children with additional needs [3,4].For these parents, self-compassion education was beneficial as an intervention that decreased anxiety and supported their mental well-being.It would be valuable to undertake further research exploring the impact of self-compassion on parents who do not have additional needs to ascertain the degree of benefit of selfcompassion education for a universal application.
A further finding that warrants discussion is the impact of self-compassion on improved social connectedness.Social support is a well-documented approach to promoting mental well-being [43 -45].Evidence demonstrates a clear link between maternal mental health and social networks, where the most connected mothers experience the best mental health outcomes [46].Social relationships can reduce parenting stress, improve maternal well-being and self-efficacy, and buffer the experience of postpartum depression [47 -49].Exploring selfcompassion in relation to social connectedness and its impact on perinatal well-being could be warranted.
Self-compassion has been studied broadly and there is now clear evidence that demonstrates the benefits of educating and training the mind of parents to be compassionate to self and others.In addition, self-compassion has health and well-being benefits for people in general [17].There is also a growing body of evidence to suggest that self-compassion is related to positive health and well-being outcomes for several target populations, such as veterans [41]; nurses and midwives [50]; student nurses [51].This review contributes further to this evidence, identifying that self-compassion education may be a strategy to support parental mental well-being.
Neff, (p140) [7] defined self-compassion as "being caring and compassionate towards oneself in the face of hardship or perceived inadequacy".This definition clearly relates to the challenges of parenting, and self-compassion is generally considered to be an adaptive emotional regulation strategy to enhance self-care [52,53].Mindfulness is interwoven with the concept and practices of self-compassion and has its origins derived from Buddhist core teachings [54].Many of the studies in this review used mindfulness-based approaches (MBA) such as MBSR, MBCT, and CFT, which focused on mindfulnessawareness and involved taking a balanced approach to negative emotions and neither suppressing nor exaggerating these and a willingness to acknowledge negative emotions with openness and clarity [41,55].There is emerging evidence linking selfcompassion and mindfulness to neuroscientific changes in the brain [32,56], which recently showed that cognitively based compassion training for parents reduced cortisol levels in infants and young children.This is an area to undertake further research.
In summary, the authors of this review draw on a quote from Pollack [40] (p24), who suggests that: 'mindfulness and compassion are not just practices for exhausted, stressed-out parents who are trying to juggle too many balls without dropping them all', they are tools for life.

CONCLUSION
This review provides evidence that self-compassion education and training were beneficial for parents to reduce anxiety and promote positive well-being, particularly for parents who had a child requiring additional care and support.It is recommended that further research is undertaken to explore the impact of self-compassion education as a mental well-being strategy for all parents.

CONSENT FOR PUBLICATION
Not applicable.

STANDARDS OF REPORTING
PRISMA guidelines were followed.

Table 3 . Critical Appraisal of the included studies. JBI Critical Appraisal Checklist for Randomized controlled trials
: Y= Yes N= No U= Unclear NA= Not Applicable. Note