1. Background
Behavioral problems refer to the behaviors that are observed in the individuals with low intelligence quotient (IQ) in contrast with the general norms of the community. These issues may be severe, repetitive, and persistent in different times and places (1). Behavioral disorders encompass a wide range of disorders and generally refer to abnormal, repetitive, and annoying behaviors such as nail biting, hair scratching, thumb sucking, nervous ticks, aggression, drug abuse, inattention, and hyperactivity, which cause impairment in social function, learning, communication, and academic achievement (2, 3).
According to studies conducted in various communities, the prevalence of behavioral disorders varies in children (4). In Iran, several cross-sectional studies have also indicated that the prevalence of behavioral disorders in children varies significantly in different regions, so that in the children in western Azerbaijan, the prevalence has been reported to be 0.35% (5), while the estimated rate is 31.1% in Tehran (6).
According to the literature, children exhibit relatively rapid responses to life stressors, and their responses also change immediately after the stressor is eliminated. Since children heavily rely on their parents and others and are immature in terms of their physical and mental abilities, they might show behavioral problems in the face of stressors and discomfort, which may be either environmental or internal. In fact, children speak through their behaviors; when children have numerous problems in relation to others and the expression of their needs and emotions, they are at the higher risk of behavioral and psychological disorders (7).
The follow-up and identification of behavioral disorders in children is of utmost importance as delayed diagnosis and treatment increases the risk of mental diseases in adolescence; such examples are personality disorders, drug abuse, and delinquency (8, 9). Furthermore, several studies have reported that the likelihood of post-puberty and adulthood disorders is 4% - 7.5% (10). The epidemiological studies regarding behavioral problems in children and adolescents have indicated that most adults with antisocial personality have a history of behavioral issues in childhood (10).
Behavioral problems in children are manifested differently, and various factors are involved in their development, the most important of which are biological, environmental, social, cultural, and familial factors. Among family relations, most studies have been focused on the relationship between the child and mother and the impact on the incidence of behavioral issues in childhood. In recent decades, psychologists have emphasized on the relationship between the child and caregivers as they believe that parental interactions and intimacy lay the basis for the cognitive and emotional development of children and reduce the risk of mental disorders. In a family environment as a small community, the action and reaction between the family members largely influences the reduction or increase of various problems. In such environment, presenting the one-way effect (either the child or parent) on each other does not apply (11).
According to the literature, in-family factors such as parental incompatibility, threats, beatings, economic problems, and factors related to school (e.g., relationship between the teacher and student, school status), and social, cultural, and hereditary factors could contribute to behavioral disorders (12). Evidence suggests that parenting quality has a great impact on the growth and development of children. Therefore, clinical specialists and researchers have been thoroughly investigating the quality of the interactions between parents and children, claiming that some of the characteristics of parents and variables of the family framework could the parental response to the needs of children. Therefore, proper approaches should be used to identify the mechanisms of the relations between parents and children as part of prevention and care programs, especially in situations where these relations become tense and challenging (13).
Family is a network of communication patterns and childhood is an important life stage with a key role in the formation of personality. Most incompatibilities and behavioral disorders in adolescence and adulthood are rooted in the suppressed emotions and behavioral problems in childhood, as well as inadequate guidance in the process of growth and development. Over the past decades, special attention has been paid to the emotional and social development of children (14).
Considering the large number and variety of the problems faced by children in different areas, various therapeutic approaches have been proposed in this regard, among which Triple P is known to be superior over other methods owing to its unique characteristics. In this treatment, a behavior modification program is applied to children in the natural environment of home by parents as the individuals who have the most interactions with children (7). Positive parenting program is a family-oriented intervention designed based on social learning principles and is recognized as a potent intervention to help children with behavioral problems; several studies have also confirmed the effectiveness of this intervention (15, 16).
To date, parenting styles have been extensively studied and associated with variable positive effects; such examples are the effectiveness of the positive parenting program on symptom reduction in children with oppositional defiant disorder (ODD) (17), behavioral problems in children with attention-deficit/hyperactivity disorder (ADHD) (18, 19), behavioral problems in preschool children (20), improvement of relations with adolescents (21), and reduction of behavioral disorders in children (16). Moreover, several studies have confirmed the effectiveness of the Triple P (positive parenting program) in the reduction of behavioral problems in children (22) and the positive effects of multidimensional and evidence-based parenting programs for parents on improving the behaviors of children (23). In general, the Triple P has gained acceptance among parents (24).
2. Objectives
Given the importance of parenting and its effects on children and their future, as well as its comprehensive effects on the target community, the present study aimed to investigate the effects of the Triple P on the reduction of behavioral problems in children and increasing their behavioral, intellectual, lingual, emotional, and social efficiency, along with parental knowledge, skills, self-confidence, and self-efficacy in the education of children as the key objectives of the program (25).
3. Methods
This quasi-experimental study was conducted with a pretest-posttest design and a control group. The sample population of consisted of the mothers employed in the hospitals affiliated to Kurdistan University of Medical Sciences, Iran in 2012 who had children aged 2 - 12 years with behavioral problems. The sample population were invited to participate in the study, and after reviewing the inclusion and exclusion criteria, 78 mothers with the mean age of 33 years were selected via simple random sampling and randomly assigned to the experimental (n = 39) and control groups (n = 39).
The inclusion criteria were as follows: (1) having a child aged 2 - 12 years with behavioral problems; (2) minimum education level of fifth grade of elementary for the parents; (3) written consent of the for the informed and committed participation in the study; and (4) no participation in similar programs. The exclusion criterion was having a child with neurological disorders, known medical conditions, severe aggression, mental retardation, psychosis, and bipolar disorder.
3.1. Family Background Checklist
The family background checklist contained data on the child (name, age, gender, history of severe psychiatric disorders) and parental status, relationship with the child, and the education level, occupation status, physical/mental health status of the parents and other siblings.
3.2. Parenting Scale
The parenting scale was developed by Arnold et al. in 1993. It is a 30-point scale used to evaluate the responses and reactions of parents to the behaviors of children within the range of 1 - 7 degrees. The results of the parenting scale shows whether parents are able to use constructive educational practices. The scale has three subscales and a general score. For each scale, the total score and factor score were determined; the factor score was the total score of each scale divided by the number of the evaluated items for each indicator. The subscales included laxness, overactivity, and verbosity. The coefficient was estimated at 0.84 for the internal consistency of the entire test, 0.83 for the laxness subscale, 0.82 for the overactivity subscale, and 0.63 for the verbosity subscale. In addition, the reliability coefficient of the questionnaire has been reported to be 0.84, 0.83, 0.82, and 0.79 for the entire scale and its subscales, respectively based on retest (26).
3.3. Strengths and Difficulties Questionnaire
The strengths and difficulties questionnaire was developed by Goodman in 1997, who reported the mean Cronbach's alpha of 0.73 and reliability coefficient of 0.62 based on retest over a period of 4 - 6 months. This questionnaire has 25 items to evaluate the behavioral and emotional problems of children from the perspective of parents. The items are scored in an ascending order within the range of 0 - 2 (not correct, to some extent correct, and completely correct). The total score is calculated within the range of 0 - 40. The questionnaire consists of five subscales, including hyperactivity, emotional symptoms, conduct problems, peer problems, and prosocial scale (27).
3.4. Depression, Anxiety, and Stress Scale
This 42-item scale was used to evaluate the levels of anxiety, depression, and stress in the parents. In addition to the total score, the scale also provides the scores of anxiety, depression, and psychological stress separately. The scale has been developed by Lovibond and Lovibond, and the reliability coefficients of depression, anxiety, and stress have been estimated at 0.91, 0.84, and 0.90, respectively (28).
After describing the details of the program and obtaining informed consent from the participants, the experimental and control groups completed the research tools in the first and final session. The positive parenting method was developed based on the Triple P (positive parenting program), which has been developed by Sanders et al. at the University of Queensland (Australia), and its implementation permission is based on the agreement between the Cognitive Sciences Institute and Iranian Child and Adolescent Psychiatry Association (25). The program was presented at five levels, with one level devoted to the parental group training to enhance parenting skills (18) in eight weekly sessions and the first four sessions per group (two hours per session per week).
In the first session, the participants were trained on positive parenting program and the causes and goals of changing and recording behavioral problems in children. In the second session, the training was focused on the growth strength of children, positive relations with children, encouragement of good behavior, and development of new skills and behaviors. In the third session, the parents received training on the management of children's behaviors and routine parenting practices, and the fourth session was focused on planning for the future, essential recommendations for the family, and high-risk situations. The duration of the following four sessions was 15 - 30 minutes to obtain the feedback of the participants on the proper implementation of the training materials and possible questions in this regard, which was accomplished individually per week via phone call. Notably, the control group received no training intervention.
Data analysis was performed in SPSS version 19. The analysis of covariance (ANCOVA) was used to determine the number of the intervention sessions with the dependent variables, and pretest and posttest were carried out as well.
Table 1.Mean and Standard Deviation of the Studied Variables in the Pre-Test and Post-Testa
| Variable | Pre Test | Post Test |
|---|---|---|
| Strengths and difficulties | ||
| Hyperactivity | 7.2 (1.4) | 4.5 (1.2) |
| Emotional symptoms | 7.4 (1.5) | 4.5 (1.8) |
| Conduct problems | 6.8 (1.4) | 4.4 (1.5) |
| Peer problems | 7.3 (2.4) | 4.5 (1.4) |
| Prosocial | 7.3 (1.5) | 4.4 (1.3) |
| Parenting | ||
| Laxness | 53.7 (6.3) | 45 (6.5) |
| Ovractivity | 62.7 (6.1) | 47.2 (9.3) |
| Verbosity | 30.6 (4.5) | 28.1 (4.8) |
| Items not on a factor | 20.2 (1.5) | 16.2 (3.6) |
| Depression anxiety stress | ||
| Depression | 12.15 (6.8) | 4.84 (3.38) |
| Anxiety | 10.17 (5.2) | 4.35 (3.2) |
| Stress | 14.56 (6.5) | 5.41 (3.32) |
aValues are expressed as mean (SD).
4. Results
In total, 78 employed women with the mean age of 33.52 ± 3.9 years were enrolled in the study. None of the women were excluded, and they were all assessed at the end of the study. The mean age of the children was 4.2 ± 1.6 years, and 47.4% and 52.6% were male and female, respectively. In terms of parental education level, 1.3% of the mothers had high school diploma, 12.9% had diploma/associate degree, and 85.9% had undergraduate education. In terms of occupation status, 5.1% of the mothers were hospital helpers, 11.5% were social workers, 62.8% were nurses, and 20.5% had other occupations. Table 1 shows the mean values of the research variables at the pretest and posttest.
In order to compare the scores of the research variables before and after the intervention, the ANCOVA assumptions were initially studied (Table 2), and the results of Levene's test confirmed the assumptions (P < 0.05). Therefore, ANCOVA could be used to analyze the study results, and the obtained results are presented in Table 3.
Table 2.Levin Test Results to Examine the Assumption of Variance of Groups' Equality in the Variables Studied
| F | df1 | df2 | P Value | |
|---|---|---|---|---|
| Hyperactivity | 3.000 | 1 | 76 | 0.064 |
| Emotional symptoms | 2.000 | 1 | 76 | 0.096 |
| Conduct problems | 7.000 | 1 | 76 | 0.009 |
| Peer problems | 1.000 | 1 | 76 | 0.000 |
| Prosocial | 1.000 | 1 | 76 | 0.000 |
According to the information in Table 3, there were significant differences between hyperactivity (F = 15,000, P < 0.05), emotional symptoms (F = 13,000, P < 0.05), conduct problems (F = 19,000, P < 0.05), peer problems (F = 6,000, P < 0.05), prosocial scale (F = 22,000, P < 0.05), laxness (F = 115,000, P = 0.05), overactivity (F = 91,000, P < 0.05), verbosity (F = 76,000, P < 0.05), other aspects (F = 135,000, P < 0.05), general parenting (F = 120,000, P < 0.05), depression (F = 201,000, P < 0.05), anxiety (F = 155,000, P < 0.05), and stress (F = 187,000, P < 0.05) before and after the intervention. These differences indicated the effectiveness of the Triple P in the research variables.
Table 3.The Results of Covariance Analysis for the Efficacy of Intervention on Strengths and Difficulties, Parenting and Depression, Anxiety and Stress
| Variable | Sum of Square | df | Mean Square | F | P Value |
|---|---|---|---|---|---|
| Strengths and difficulties | |||||
| Hyperactivity | 32.000 | 1 | 32.000 | 15.000 | 0.000 |
| Emotional symptoms | 34.000 | 1 | 34.000 | 13.000 | 0.000 |
| Conduct problems | 32.000 | 1 | 32.000 | 19.000 | 0.000 |
| Peer problems | 24.000 | 1 | 24.000 | 6.000 | 0.013 |
| Prosocial | 46.002 | 1 | 46.002 | 22.000 | 0.000 |
| Parenting | |||||
| Laxness | 1782.000 | 1 | 1782.000 | 115.000 | 0.000 |
| Overactivity | 2609.000 | 1 | 2609.000 | 91.000 | 0.000 |
| Verbosity | 1286.000 | 1 | 1286.000 | 76.000 | 0.000 |
| Items not on a factor | 506.000 | 1 | 506.000 | 135.000 | 0.000 |
| Total parenting | 9734.038 | 1 | 9734.038 | 120.000 | 0.001 |
| Depression anxiety stress | |||||
| Depression | 1449.000 | 1 | 1449.000 | 201.000 | 0.000 |
| Anxiety | 887.000 | 1 | 887.000 | 155.000 | 0.000 |
| Stress | 1163.000 | 1 | 1163.000 | 187.000 | 0.000 |
5. Discussion
According to the results of the present study, positive parenting based on the Triple P for the mothers could reduce the behavioral problems of their children in terms of hyperactivity, emotional symptoms, conduct problems, peer problems, and prosocial scale. This is consistent with the study by Belali and AghaYousefi (22) regarding the effectiveness of the parenting program in the reduction of behavioral problems in children, as well as the findings of Tehrani Doost et al. (18) on the effectiveness of the Triple P for parents in the reduction of behavioral problems in children. Furthermore, our findings are in congruence with the results obtained by Jalali et al. (17) regarding the teaching of the Triple P to decrease the symptoms of children with ODD. Similarly, Swanson et al. (20) reported the effectiveness of parenting programs in the reduction of behavioral problems in preschool children, which is consistent with the studies by Leung et al. (16) and Bodenmann et al. (23). To justify, it could be stated that these programs have effectively decreased the behavioral problems of children by changing the misplaced expectations of their parents and teaching the better management of the symptoms of behavioral problems and proper communication with children.
According to the findings of the current research, the Triple P for the mothers could reduce inappropriate parenting, especially in the three subscales of laxness, overactivity, and verbosity, thereby improving the parenting methods of the mothers. This is consistent with the study by Mohareri et al. (21) regarding the effectiveness of Triple P interventions in the enhancement of parenting methods, increasing the parental sense of adequacy, improving the symptoms of depression, anxiety, and psychological stress and the relationship between parents and adolescents, and reducing their behavioral problems.
The research by Bodenmann et al. (23) also indicated the effectiveness of a multidimensional parenting program in increasing trust and decreasing the stressors in the management of children, which is in line with our findings. To justify, it could be stated that teaching parenting methods to mothers makes parenting methods homogeneous, thereby raising the awareness of parents on the problems of children, reducing their negligence in parenting and managing the behaviors of children, and decreasing conflicts, remarks, and long speeches with children, which in turn reduces the behavioral problems of children and enhances efficient parenting.
The results of the present study confirmed the effectiveness of this educational method in reducing the depression, anxiety, and fear of parents, which is consistent with the study by Tehrani Doost et al. (18) on the effectiveness of Triple P for mothers in reducing the behavioral problems of children with ADHD, as well as the depression, anxiety, and mental stress of mothers. Similarly, Swanson et al. (20) reported the effectiveness of parenting methods in reducing depression and anxiety in the parents of preschool children. To justify, it could be stated that as the mission of parenting is difficult and stressful and many parents have insufficient information and awareness about the effective methods of managing children, they tend to experience more fear and anxiety when their children have behavioral problems. These parents often report symptoms of mood disturbances and depression when they are unable to resolve the problems of their children. Therefore, the implementation of educational parenting methods could raise their awareness on effective parenting methods, as well as the proper techniques to manage the behavioral problems of children, which in turn enhances the sense of family adequacy and self-confidence in relation to children and decreases the signs and symptoms of anxiety and depression.
5.1. Limitations
Since the sample population of the present study was composed of mothers with the minimum education level of fifth elementary grade, the data could not be generalized. Another limitation of the study was the assessment of families with only child, and further investigations in this regard must also consider mothers who are nursing or illiterate and those with several children.
5.2. Conclusions
According to the results, the use of the Triple P as a preventive strategy to reduce the behavioral problems and disorders of children could improve the parent-child interaction cycle, parenting skills, parental satisfaction, and parenting adequacy, while also reducing parental differences. However, the sample population consisted of working and literate mothers in Sanandaj (Iran), and it is recommended that further studies examine the effectiveness of this program in low-grade housewives and fathers in other cultural areas. In addition, it is suggested that comparative studies be conducted using other therapeutic and educational protocols.
