Effect of Training Positive Parenting Program on Mother-child Relationship among Mothers of Children with Externalizing Disorders

Introduction

Family is the first founder of personality and intellectual values playing an important role in determining the destiny, style, and policy of the individual future life (1). Childhood is one of the most significant and effective periods during human life, in which the personality is established and formed (2). The quality of parental relationships, especially mother-child relationship, has a decisive role in shaping the social personality, cognitive function, and mental health of the child in future. The long-term effects have been proven to affect the growth and development of the child (3).

Eslamieh et al. in a study in Iran on 1420 primary school students revealed the prevalence of behavioral problems to be 31.1% among the primary school students (4). Moreover, Ghobari-banab et al. reported the prevalence of 20.3% in their research on 1407 primary school children in Tehran (5). The prevalence of 21% was also the result of a study performed by Khoddam et al. on 2600 school-age children in Gorgan (6).

Behavioral Disorders are among the most common psychological problems of children and affect the psychosocial functions of all the family members. Meanwhile, mothers as the member of the family who has the most interactions with the child might be at higher risk for such problems (7). The quality of parent-child interaction emphasizes on the impact of communication, attitudes towards children, and development of an emotional atmosphere by the parents (8).

It should be noted that the mental health is established during the early years of life. As a result, the children with less attachment and affectionate relationships have lower emotional and mental development. The mentioned conditions may lead in poor social interactions, reduced ability to establish long-term relationships, and hostile offensive behaviors in these children (9). The results of various studies by the pediatric psychiatrists on childhood emotional disorders indicate that most of these disorders are due to maternal deprivation or disrupted mother-child interaction (10).

The parents of children with emotional problems are not convinced with their parental role, estimate that parenting is very stressful, and confront their spouses. Therefore, regarding the quality of parenting and mother-child relationship, efforts to improve the mental health of children need to be taken into account (11). On the other hand, some studies investigated the parental self-confidence and ability to manage the child behaviors and reported that self-confidence in parents may improve the quality of mother-child interaction (12).

Normal development of children depends on the social and environmental conditions, including the family, peer system, and larger social and cultural contexts (13). The principle of mutual communication in the mother-child interaction is quite evident. The mood and characteristics of children affects the quality and quantity of the care they receive (14).

The mother-child interaction refers to the maternal parenting style that occurs during mother-child relationships (15). The mother-child interactions entail four subscales, namely child acceptance, overprotection, underestimation, and child rejection (16). Accordingly, it seems necessary to identify the strategies for positive management of children. In this regard, Jafari et al. showed that parenting programs lead to enhanced child management skills, increasing parental self-confidence and reducing parental stress (17).

A positive parenting group program is one of the methods of child management education, that is used for parents of children aged 2-12 years. It contains five levels, with the higher levels indicating an augmentation in intervention rates. This method is practiced based on the preventive orientation and in line with the strategies to support the family made by Sanders et al. (18-20).

The goal of this program is to elevate the parental self-sufficiency and self-efficacy in controlling the behavior of children, nurturing environments with less conflict for children, in addition to increasing the knowledge and positive attitude of parents in educating their children. This aim is achieved by promoting child development, sense/social competence, and self-control (21). Moreover, this program strives to increase the positive child-parent interactions through training and to reduce their unstable and suppressive parenting style (18).

Efficacy of the positive parenting program (Triple P) has been confirmed in several studies, including Sanders et al. (22), Leung et al. (23), and Cann et al. (24). This program has a very good background in child behavioral problems, disorders, parenting styles, and mother-child interaction.

Different dimensions of externalizing disorders have been the basis of many theories and scientific research. In addition, many researchers consider the therapies of these disorders due to the growing problems in the life of the children and their relatives. It is extremely important to keep the bridge between the child and parents in a way that effectively eliminates the differences and conflicts between the child and the parents, preventing the deterioration of the relationship between them.

The cost and time in this regard are not only for the child-parent, but also the community will benefit from this process because the behavior of any individual is the basic manifestation of his/her personality and psychosocial structure. Therefore, the healthier the personality and mental structure of a person grows, the more he/she can adapt to the personal and social situations with greater balance among the behavioral dimensions. This will not happen unless the person learns the emotions and thoughts (25).

The effect of parenting program on children with definite psychiatric diagnosis, psychiatric records of externalizing disorders, as well as more personal and familial issues is invaluable. Furthermore, there is a great need for lasting change in the quality of mother-child relationships. With this background in mind, the present study aimed to investigate the effect of parental education by Triple P based on the model proposed by Sanders on the mother-child relationship.

Methods

This clinical trial with pretest posttest design on two groups was conducted in Mashhad, Iran in 2015. The Ethics Committee of Mashhad University of Medical Sciences approved this study. The study population included all the mothers of children aged 6-12 years affected with externalizing disorders. The samples were collected using convenience sampling method from the subjects who referred to the Children and Adolescent Psychiatric Clinic of Ibn-e-Sina Hospital and Community Mental Health Centers (CMHC) affiliated to Mashhad University of Medical Sciences.

The inclusion criteria entailed 1) diagnosis of externalizing disorders by the child and adolescent psychiatrist, 2) absence of any mental and psychological disorders in the child and parents, 3) not participating in the same educational programs, and 4) the parents not working in medical professions.

The research units were divided into the two groups of intervention and control randomly (based on the day of referral to the clinic) with homogenization regarding the different diagnoses, such as hyperactivity, confrontational, conduct, and concomitant disorders. Next, the even and odd days of the week were allocated to each study group through drawing and all the eligible subjects entered the relevant group on a daily basis. The reason for using this method was to reduce information leakage between the two groups. In order to homogenize the various diagnoses, sampling was continued on any even or odd days that did not have the sufficient frequency of each of the diagnoses.

The formula for comparing the means was used to obtain the minimum sample size by conducting a pilot study on ten subjects in each group and determining the study indices separately with a confidence interval of 95% and a test power of 80%. Eventually, 60 children were selected and 30 parents were allocated to each of the two groups. Considering that there was no drop out in this study, all the 60 parents were analyzed at the end of the four-week period and the mothers were selected as participants who would be trained.

One of the researchers explained the study objectives to the participants and then written consents were taken. The researcher completed the demographic profile form, as well as the Strengths and Difficulties Questionnaire (SDQ) for all the eligible subjects by interview. The pretest assessment in both intervention and control groups was completed using the Mother-Child Relationship Evaluation (MCRE) questionnaire. The data collection tool included family status questionnaire containing information about the family and children, educational level and occupational levels of parents, in addition to the mental health of parents and children in general.

Goodman designed the SDQ in 1997 reporting a mean Cronbach's alpha of 0.73, and reliability coefficient of 0.62 through test-retest with 4-6 months interval. In Iran, Tehrani-Doost et al. validated this questionnaire with mean Cronbach's alpha of 0.74. It is a 25-item scale with four sub-scales (i.e., emotional symptoms, conduct problems, attention deficit/hyperactivity disorder, peer problems). Moreover, this tool evaluates the children behavioral and emotional problems from their parents’ point of view. The score has a range of 0-2, for which the options are "not true", "somewhat true", and "certainly true". The total score can range from zero to 40 with the higher scale score indicating more child problems. The cut-off point is 12 (26). The SDQ reliability was confirmed using Cronbach's alpha test. Ten people were evaluated and the calculated Cronbach's alpha coefficient for the total tool was 0.77.

Roth developed the MCRE questionnaire in 1961. In Iran, Zamiry et al. measured the validity and reliability of this tool in 2005 finding the coefficients of internal consistency as 0.77, 0.71, 0.72, and 0.78 for the child acceptance, radical underestimation, child rejection, and overprotection dimensions, respectively (27). This is a 48-item scale encompassing questions about the way of communication between mother and child.

The latter questionnaire assesses the attitudes of mothers in four 12-question dimensions, including child acceptance, overprotection, radical underestimation, and child rejection. All the questions are on a 5-point Likert scale from strongly agree to strongly disagree. The higher subscale score indicates the higher attitude and lower scores mean lower attitude level (15). In this research, Cronbach's alpha test was used to confirm the reliability of mother-child interaction scale. The Cronbach's alpha coefficients were obtained as 0.71, 0.87, 0.7, and 0.78 for child acceptance, overprotection, radical underestimation, and child rejection, respectively.

Afterwards, a group Triple P training was implemented for the parents of intervention group. This program is based on the mother-child interaction model and identifies the two-sided nature of child-parent interactions. The program consisted of eigth two-hour training sessions with intervals of one week for two months (Table 1).

At the end of each session, a written summary of the meeting outline and assignments related to that session were presented to the participants to practice at home. Three days after the educational

Table 1. Content of training sessions

session, the researcher had a phone call with the individuals in the intervention group to follow up the homework assignments. Moreover, the researcher contacted the intervention group participants one day before the next meeting to remind them the class. The control group only received the routine trainings, including visits and counseling sessions for three months by a children and adolescent psychiatrist.

In both intervention and control groups, pharmacological treatment (Ritalin administered by the children and adolescent psychiatrist) was continued according to the routine manner. The post-test was performed immediately after the trainings in the intervention group and simultaneously in the control group.

In terms of ethical considerations, the families were assured about the non-invasiveness and safety of the interventions. In addition it was explained to the participants that they could leave the research at any time they desired. The conditions of research units were monitored at all the stages of research. Educational pamphlets were delivered to the people of control group after the end of research to follow the ethical principles of parenting research.

All the data collected from the questionnaires were analyzed by SPSS using the statistical tests of independent t-test, paired t-test, Wilcoxon, Chi-square, analysis of covariance, and Fisher's exact test.

Results

The males accounted for 63.3% (n=19) of the intervention group and 53.3% (n=16) of the control group. The age range of children in each group was 6-12 years. The mean age of children was 8.8±1.6 years in the intervention group and 8.6±1.8 years in the control group (Table 1). Among the fathers, 36.7% (n=11) had primary school degree in the intervention group and 26.7% (n=8) had high school diploma in the control group. Moreover, sconcerning the educational level of mothers, 36.7% (n=11) had high school diploma in the intervention group and 26.7% (n=8) had associate and bachelor degrees in the control group.

In the intervention and control group, 80% (n=24) and 50% (n=15) of the mothers were housewives, respectively. Concerning occupation of the fathers, 36.7% (n=11) and 36.6% (n=11) were employees in the intervention and control groups, respectively. The two groups were homogeneous in terms of the variables discussed (Table 2).

According to the results of independent t-test, the mean score of "child acceptance by mothers" was significantly different between the pre- and post-intervention times. The analysis of covariance was used to eliminate the effect of child acceptance by mother in the pre-intervention stage on the score of the same variable in the post-intervention phase. The findings indicated that the child acceptance score was significant in the post-intervention phase by eliminating the effect of pre-intervention stage (P<0.001).

In the intragroup comparison, the paired t-test revealed a significant difference in the pre- and post-intervention stages between the intervention and control groups (P<0.001). (Table 3). The independent t-test demonstrated a statistically significant difference betweenthe two groups in terms

Table 2. Mean and standard deviation of demographic profiles in the intervention and control groups in terms of age

* Independent t-test, ** Chi-square exact test

Table 3. Mean scores of mother-child relationship dimensions pre- and post-intervention in the two intervention and control groups

* Independent t-test, ** Paired t-test, *** Wilcoxon test

of the mean score of "overprotection of mothers" after intervention (P=0.03). In the intragroup comparison, the paired t-test showed that the difference in the pre- and post-intervention stages between the intervention and control groups was significant (P<0.001) (Table 3).

Concerning the mean score of "radical underestimation of mothers" in the intergroup comparison, the independent t-test reported a statistically significant difference between the two groups after the intervention (P=0.02). Furthermore, the intragroup comparison by the paired t-test and Wilcoxon test exhibited a significant difference in the pre- and posttest stages between the two groups (P<0.05). The latter change was significant (Table 3).

In addition, the mean "child rejection by mothers" in the intergroup comparison was found to be significantly different between the two groups after the intervention (P=0.003). In the intragroup comparison, the results of paired t-test showed a significant difference in the pre- and post-intervention stages between the intervention and control groups (P<0.001) (Table 3).

Discussion

The present study investigated the impact of Triple P on mother-child relationships among the mothers of children with externalizing disorders. The findings of this study showed that Triple P could cause a significant improvement in child acceptance, overprotection, and child rejection subscales, although the underestimation subscale was higher in the control group, compared to the test group.

In a study performed by Nazemian and Shams zarmehri, 30 mothers of primary school girls were evaluated in terms of mother-child relationship in the two groups of intervention and control after implementing Triple P. They revealed that after the intervention in test group, the child acceptance subscale significantly enhanced and the overprotection subscale significantly reduced. However, there was no significant difference between the two groups regarding the radical underestimation and child rejection subscales (28).

Taherinia et al. carried out a study on 20 mothers of primary school children in two groups of intervention and control. They investigated the impact of Triple P on mother-child relationship, self-efficacy of mothers, and behavioral problems of children. After intervention, the child acceptance and self-efficacy of mothers augmented significantly, while the child rejection subscale showed a significant decrease. However, there was no significant difference concerning the scales of radical support, freedom, and behavioral problems (29).

In a study conducted by Abedi et al., 25 mothers of children with attention deficit hyperactivity disorder (ADHD) were evaluated in two groups of test and control. Mother-child relationships were evaluated after implementation of Triple P. The test group demonstrated a significant diminish in the conflict and dependence post-intervention. Moreover, increasing proximity generally improved the mother-child relationship (30).

Varasteh et al. completed a study on 30 mothers of primary school children divided into two groups of intervention and control. The two groups were examined for the child-parent relationships in three stages of pretest, posttest, and follow-up. After Triple P, the results indicated that this program enhanced the mother-child interaction (31).

Various studies on the effects of Triple P on improving the quality of mother-child relationship might have differences with the present study in the target groups and duration of intervention. However, the results of these researches are consistent with the findings of our study because of the same type of intervention and methodology.

The current study is contrary to the results of the study performed by Ghashang et al. (32). The results showed that education level of mothers did not affect the stress reduction in mother-child relationship and stress of mothers. One of the possible reasons for Triple P not being effective in the study by Ghashang can be the methodological differences. The difference in the type of intervention program, possibly the failure to complete all the intervention sessions, and the duration of the sessions (four sessions) were some of the differences between the study of Ghashang and the present study.

We utilized Triple P, which is one of the most comprehensive parental education programs developed based on the theory of social learning, and deals with all the aspects, whereas Ghashang et al. used Barkley's parental education program. Another possible reason for the ineffectiveness of Barkley's parental education program might be the inadequate and inappropriate program. This program has specific instructions for each session and deleting or merging these commands can reduce the impacts. The duration of intervention could also be considered as another difference. Ghashang et al. held four sessions and gave parenting styles guidance to the mothers of children aged 3-5 years with behavioral disorder.

It was found that maternal education did not reduce stress in mother-child relationship. In the present study, the intervention was conducted within eight sessions. An increase in the number of sessions can examine the process of implementing the program by mothers and may solve their problems during the procedure.

Maternal relationship model plays an important role in the emotional and social development of the child in the future and can provide a context for improving behaviors of children. Therefore, it seems that parenting education sessions that increase the positive parent-child interactions can lead in enhanced perception and parenting skills in the mothers. All these changes will result in development of social skills and adaptation of children in the future and reduce their behavioral problems. Consequently, raising the awareness level of parents by holding classes in schools and kindergartens, as well as the mass media will greatly help to achieve these goals.

The present study confronted some limitations, including individual personality differences in the children and caregivers, which can affect the way of exposure and participation in the intervention. Most of these differences are not measurable and we did not review them in this study. The type of family in terms of openness or closeness, which has role in the level of family interaction with others and the community, was not assessed in this study because of the measuring difficulty. Another limitation of this research was the lack of the cooperation from half of the fathers of the intervention group families due to their working conditions.

Implications for Practice

The results of this study can be used in therapeutic and care programming in mental areas. Applying the education of caregivers based on parenting programs can promote the quality of childcare and make effective mother-child relationships. Therefore, it is recommended to study the effect of training Triple P on mother-child relationship and the feeling of parenting in the mothers of children with internalizing disorders. Moreover, further studies on the effect of training Triple P on the father-child relationship and children with externalizing/internalizing disorders are recommended.

Acknowledgments

This article is a part of M.Sc. thesis in Pediatric Nursing with the project code of 931283 at Mashhad University of Medical Sciences. This research was registered at the Iranian Registry of Clinical Trials with the code of IRCT20150122020755N2. The authors would like to thank and appreciate all the faculty members and officials of the Mashhad University of Medical Sciences, Ibn-e-Sina Hospital, Community Mental Health Centers, as well as the parents and children participating in the study.

Conflicts of Interest

The authors declare no conflict of interests for publication of this article.