it is chronic , progressive , and costly , and creates several complications . for individuals with diabetes it is difficult to accept these threads which may change their lifestyle . in most cases it will not be weird to see mood disorders such as depression in these individuals ( 1 ) . depression has a two - way relationship with diabetes and has been proposed as a risk factor for it . depression is a debilitating and highly morbid disease with a higher prevalence ( estimated to be about 33 percent ) in diabetic patients than in general population ( 8 to 20% ) ( 2 ) . depression is a mood disorder characterized by the symptoms of low mood , reduction of energy and interest , feeling of guilt , difficulty in concentration , loss of appetite , thoughts of death and suicide , chronic daily stress , lower levels of psychological well - being and consequent low quality of life , insomnia or hypersomnia , significant loss of weight , and dysfunction ( 4 ) . the other variable studied is the feeling of guilt which is defined as a violation of norms and values taught by ancestors and eradicates self - confidence of the person . in fact , feeling of guilt affects the individual s performance by anxiety and fear in the workplace and makes him fail in adjusting with different environments ( 5 ) . because of the need for self - care , and in most cases , care by family members , diabetic children may feel themselves as a burden on families , compared to children of the same age . the way of interpreting the annoying thoughts is an important factor in determining the severity of the discomfort and anxiety caused by the consequence of this opinion , such as being an extra member in family , because of raising financial burden on the family , ascribing any action to himself in the family , so that the interpretation of thoughts can be influenced by cognitive biases . failure to express emotions , or anxiety and worry which leads sometimes to feelings of guilt ( 6 ) . this feeling may be incompatible with excitement which is not easily amendable and brings stress , inhibition and psychological damage and severe intellectual ruminations occur . individual s sense may be relieved by compensatory works , partly , but it does not go away completely and can cause mental disorders in diabetic children with feeling of loneliness and alienation , because they assume themselves to be intruders in the family ( 7 ) . the aim of diabetes treatment is prevention of its complications and in addition , maintaining optimal psychological well - being of the patients . in the past it was thought that doctors were able to provide favorable conditions for individuals by doing effective treatment and control of disease symptoms , but the evidence suggests that psychological well - being and in wider context quality of life , is something that does not concern only controlling symptoms ; when it has special relevance in treating a chronic disease such as diabetes , in addition to controlling symptoms , it has to improve psychological well - being and process of patient s life ( 8) . psychological well - being is the psychological part of the quality of life structure and is defined as understanding people from living in the area of emotional behaviors , psychological functions and dimensions of mental health ( 9 ) . diabetic children do not have appropriate emotional responses and are experiencing lower psychological well - being due to the difficulties imposed by diabetes such as dietary , activity limitation , invasive monitoring of blood glucose , daily insulin injections , physical chronic complications , hospitalizations , and shortened life expectancy ( 10 ) . the prevalence of negative psychological outcomes among people with diabetes especially children and adolescents , and their frustration toward the process of medical treatment has implications for the intention of developing psychological interventions in the field of clinical and health psychology . publicly health instructions for diabetics have always been given based on teaching of self - care . acceptance and commitment therapy is different from the traditional cognitive behavioral therapy ( cbt ) . act has two major goals : ( a ) , and ( b ) commitment and action toward living a life according to one s chosen values ( 11 ) . this treatment is trying to increase person s psychological acceptance in the case of subjective experiences ( thoughts and emotions ) and reduce ineffective control measures mutually and add to the psychological awareness in the present moment ( 12 ) . there are numerous psychological therapies for the treatment of depression and psychological consequences associated with it in diabetic patients . some researchers believe that applying this method can increase effectiveness beside reducing disease symptoms , due to its underlying mechanism such as acceptance , awareness raising , desensitization , living in the present moment , observing without judgment , confrontation , and release ( 13 ) . results of previous studies showed that the use of mindfulness method will cause a decrease in depressive attacks ( 3 , 14 ) . boey showed that acceptance of diabetes and its related cognitions significantly associated with lower values of hba1c and also decreased depression in patients simultaneously . many of these studies included hba1c , the primary marker of glycemic control , as an indicator of disease management ( 15 , 16 ) . despite many words very little this study seeks to answer the question of whether acceptance and commitment therapy ( act ) is effective for depression , psychological well - being and feeling of guilt in 7 - 15 years old diabetic children ? the present study is a clinical trial with control group along with random assignment and pre - test -post - test . the study population included 34 participants out of all 7 - 15 years old patients referred to the diabetes association in tabriz , iran , of whom 40 participants were selected using convenient sampling . the experimental group participated in therapy sessions and the control group did not receive any interventions . entry criteria for this study included : age less than 15 years , having diabetes for at least one year without having major psychiatric disorder . exclusion criteria , determined by treating physician in most cases , included : needing significant change in the dose of insulin administered during the research , acute or chronic medical illness that makes problems in venesection or intolerance in long sessions , cinching up severe medical complications of diabetes , receiving psychiatric treatment or use of psychotropic drugs and drug abuse during the study period . following the research , in order to obey research ethics in addition to obtaining written consent of the children and their parents to participate in research , the evaluations of pre - test were also conducted . three members of the experimental group and 3 patients of the control group were excluded for various reasons , including being absent in more than three sessions , not participating in pro - test , disease and change of residence city . finally 17 patients in the experimental group and 17 patients in the control group were randomly settled . for data collection , the following tools were used : the rcds is a 30-item self - report measure of depressive symptoms developed by reynolds ( 17 ) . the items assess symptoms of depression from the criteria listed in major depression and dysthymia in the diagnostic and statistical manual of mental disorders - third edition - revised ( dsm - iii - r ; american psychiatric association ) . all but one of the items assesses clinically relevant depressive symptoms on a 4-point likert - type scale , ranging from 1  almost never  to 4  all the time  . items 1 , 5 , 10 , 12 , 23 , 25 , and 30 were reversed scored so that higher scores on each item reflect higher levels of depressive symptoms . the total score of the rcds can range between 30 and 121 points . internal - consistency reliabilities were upper 0.80 seconds , lower 0.90 seconds within and across grades , gender , ethnic groups , and for a subset of learning disabled students . validity studies support the test based on its congruence with diagnostic systems ( in the time ) , correlations with other established measures ( mid 0.70 seconds ) , and convergent and divergent studies yielded predictable results ( 17 ) . this test consists of 30 items and with a scoring range of 0 and 1 . asgari ( 18 ) to assess the reliability of this questionnaire made use of cronbach s alpha and bisection and for each one achieved the coefficients of 0.67 and 0.68 to arrange . to assess its validity , correlated its score with criterion question score and it was determined that there is a significant relationship between questionnaire scores and criterion question ( p < 0.001 and r = 0.28 ) . to measure psychological ( 19 ) well - being , a questionnaire was used which has been introduced by diener , emmons , larsen and griffin , having 5-item answering seven degree scale ( 1 = completely disagree to 7 = strongly agree ) . park et al . ( 20 ) to determine the reliability of psychological well - being scale obtained a significant negative correlation between the scale and the beck depression test scores . ( 21 ) reported the validity of psychological well - being scale by using cronbach s alpha coefficient for samples of american , german , japanese , mexican and chinese , 0.90 , 0.82 , 0.79 , 0.76 , and 0.61 , respectively . schimmack and associates also found a significant correlation between scores on psychological well - being scale with extraversion ( 0.46 ) and neuroticism ( 0.48 ) scores . the topics for each session included : 1 ) building the therapeutic contract and functional analysis ; 2 ) creative hopelessness :  the man in the cave  and  the farmer and the donkey metaphors ; 3 ) values clarification and building a commitment ,  the funeral  exercise . metaphor :  eat the whole apple  ; 4 ) control as the problem :  the rule of 95 - 5%  and control as the problem :  pink elephants  and  what s the name of your mother ?  exercises ; 5 ) the alternative to control , be willing as a possibility , acceptance exercises :  eyes on  exercise ; 6 ) cognitive defusion :  the ride with posters ,  milk , milk , milk  exercises and establishing language conventions :  i m having the thought that i m failure  instead of saying i m a failure  ; 7 ) self as context : metaphor :  chessboard  , and screening for barriers and strengthening values : metaphors :  the journey  and  welcome to all and the rude  ; 8) acceptance and commitment , fear of commitment : metaphor :  now you know how to drive  ; 9 ) remember session , internal dialogue :  this is nt working , it s always the same , and i thought it was o.k . , but it is nt ...  metaphor :  the rider  ; 10 ) remember session and relapse prevention . after 10 sessions of intervention for the experimental group only all assessments of participants were conducted by a psychologist who was not the therapist and who was blind to subject s treatment . due to the illiteracy in some subjects , the data were collected orally for them . in accordance with the code of ethics , we performed a descriptive study of the dependent variables of interest ( means and standard deviations ) . data analysis was performed with the spss statistical package ( v. 19.0 ) and a 5% a priori type i error . the rcds is a 30-item self - report measure of depressive symptoms developed by reynolds ( 17 ) . the items assess symptoms of depression from the criteria listed in major depression and dysthymia in the diagnostic and statistical manual of mental disorders - third edition - revised ( dsm - iii - r ; american psychiatric association ) . all but one of the items assesses clinically relevant depressive symptoms on a 4-point likert - type scale , ranging from 1  almost never  to 4  all the time  . items 1 , 5 , 10 , 12 , 23 , 25 , and 30 were reversed scored so that higher scores on each item reflect higher levels of depressive symptoms . internal - consistency reliabilities were upper 0.80 seconds , lower 0.90 seconds within and across grades , gender , ethnic groups , and for a subset of learning disabled students . validity studies support the test based on its congruence with diagnostic systems ( in the time ) , correlations with other established measures ( mid 0.70 seconds ) , and convergent and divergent studies yielded predictable results ( 17 ) . this test consists of 30 items and with a scoring range of 0 and 1 . asgari ( 18 ) to assess the reliability of this questionnaire made use of cronbach s alpha and bisection and for each one achieved the coefficients of 0.67 and 0.68 to arrange . to assess its validity , correlated its score with criterion question score and it was determined that there is a significant relationship between questionnaire scores and criterion question ( p < 0.001 and r = 0.28 ) . to measure psychological ( 19 ) well - being , a questionnaire was used which has been introduced by diener , emmons , larsen and griffin , having 5-item answering seven degree scale ( 1 = completely disagree to 7 = strongly agree ) . park et al . ( 20 ) to determine the reliability of psychological well - being scale obtained a significant negative correlation between the scale and the beck depression test scores . ( 21 ) reported the validity of psychological well - being scale by using cronbach s alpha coefficient for samples of american , german , japanese , mexican and chinese , 0.90 , 0.82 , 0.79 , 0.76 , and 0.61 , respectively . schimmack and associates also found a significant correlation between scores on psychological well - being scale with extraversion ( 0.46 ) and neuroticism ( 0.48 ) scores . the topics for each session included : 1 ) building the therapeutic contract and functional analysis ; 2 ) creative hopelessness :  the man in the cave  and  the farmer and the donkey  metaphors ; 3 ) values clarification and building a commitment ,  the funeral  exercise . metaphor :  eat the whole apple  ; 4 ) control as the problem :  the rule of 95 - 5%  and control as the problem :  pink elephants  and  what s the name of your mother ?  exercises ; 5 ) the alternative to control , be willing as a possibility , acceptance exercises :  eyes on  exercise ; 6 ) cognitive defusion :  the ride with posters i m a failure  ; 7 ) self as context : metaphor :  chessboard  , and screening for barriers and strengthening values : metaphors :  the journey  and  welcome to all and the rude  ; 8) acceptance and commitment , fear of commitment : metaphor :  now you know how to drive  ; 9 ) remember session , internal dialogue :  this is nt working , it s always the same , and i thought it was o.k . , but it is nt ...  metaphor :  the rider  ; 10 ) remember session and relapse prevention . after 10 sessions of intervention for the experimental group only , the post - test was performed on both groups . all assessments of participants were conducted by a psychologist who was not the therapist and who was blind to subject s treatment . due to the illiteracy in some subjects , the data were collected orally for them . in accordance with the code of ethics , we performed a descriptive study of the dependent variables of interest ( means and standard deviations ) . data analysis was performed with the spss statistical package ( v. 19.0 ) and a 5% a priori type i error . table 2 shows mean and standard deviation of variables depression , psychological well - being , and feeling of guilt in the experimental and control group . values are presented as mean  sd . to measure the equality of variances , data were evaluated 
 with levine s test of homogeneity of variance . the results showed that variances of the experimental and control group for depression ( f = 0.712 , p = 0.405 ) , psychological well - being ( f = 3.07 , p = 0.089 ) and feeling of guilt ( f = 1.93 , p = 0.174 ) were equal . the results showed significant homogeneity using mancova tests including pillai s trace , wilks lambda , hotelling s trace and roy s largest root . experimental and control group differ from each other , at least in two dependent variables . mancova results on the variables of depression , psychological well - being , and feeling of guilt in both control and experimental group after controlling the pre - test are shown in table 3 . this analysis shows that the two groups are different from each other in three investigated variables according to the means presented in table 2 . furthermore , an increase in psychological well - being and a decrease in depression and feeling of guilt scores were observed in the experimental group as compared with the control group . the results showed that acceptance and commitment therapy ( act ) is effective on reducing depression and feeling of guilt , and increasing the psychological well - being of diabetic children . ( 3 ) , kaviani et al . ( 23 ) and hayes et al . ( 24 ) . they believe that applying this method can increase effectiveness besides reducing disease symptoms , due to its underlying mechanism such as acceptance , awareness raising , desensitization , living in the present moment , observing without judgment , confrontation and release ( 13 ) . it should be noted that this treatment modality is a short - term and structured intervention and like traditional cognitive therapy , the purpose of mental care education , is not to change the content of the thoughts , rather the aim is to create an attitude or a different relationship with the thoughts , feelings and emotions which includes maintaining full attention with an attitude of acceptance and away from the judgment ( 25 ) . the focus of this act process is to develop and enhance clients willingness to have and accept their private experiences . treatment involves exploring the futility of emotional control and avoidance , which can often paradoxically increase individuals level of distress and deter them from engaging in purposeful and vital , value driven behavior . instead , individuals are encouraged to accept their private experiences , doing so helps them engage in valued behavior . based on acceptance and commitment therapy , the concept of interlinking or emotional defusion is the impact rate that a thought has on behavior ; such as the effects of subjective interpretation on the children s feeling of guilt . context - dependent behavior and think dependent behaviors are placed on the continuum between interlinking or emotional defusion . when a person blends with his thoughts , he does not distinguish his own subjective judgment from reality ( 24 , 26 ) . thus increasing psychological flexibility of pediatric patients in acceptance and commitment therapy and creating a thinking based on mindfulness can increase the patient s ability to cope with symptoms of disease , following the prescribed diet and some family adversity . naturally , improvement of symptoms depression and individual commitment to carry out some behaviors in the long term would increase psychological well - being of the child . limitation of study population and scarecity of similar studies in iran and elsewhere can be regarded as a limitation to this study . it is recommended to consider this treatment as a new psychological and supportive treatment in diabetic patients . it can also be useful in other groups of patients such as aids , cancer and patients with depression and its relined variables . it is recommended to consider this treatment as a new psychological and supportive treatment in diabetic patients . it can also be useful in other groups of patients such as aids , cancer and patients with depression and its relined variables .