Volume 13, Issue 3 (May & Jun 2023)                   J Research Health 2023, 13(3): 153-162 | Back to browse issues page


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Ashori M. Level 4 Triple-P Positive Parenting Program and the Interaction of Parent-child With Special Needs: A Meta-analytic Study in Iran. J Research Health 2023; 13 (3) :153-162
URL: http://jrh.gmu.ac.ir/article-1-2175-en.html
Department of Psychology and Education of People With Special Needs, Faculty of Education and Psychology, University of Isfahan, Isfahan, Iran. , m.ashori@edu.ui.ac.ir
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1. Introduction
Raising a child with special needs requires acquiring skills such as support and care. Being a parent to a child with special needs is not easy; these parents need help [1]. Parental training is a practical and useful method to promote parents’ parenting styles and prevent and treat various behavioral and psychosocial problems in children [2]. Challenges related to parenting are seen as a fundamental general health problem, and public policy reflects on it [3]. Positive parenting behaviors include consistent discipline, positive reinforcement, supervision, and parental involvement [4, 5]. Parenting improvement is a conventional method for enhancing parent-child interaction [6]. Parent-child interaction significantly impacts children’s social, physical, emotional, and cognitive development [7]. The factors such as dependency on family, poor parenting, and family conflicts adversely affect children’s development [8].
With regard to the interaction between the parent and the child with special needs, more conflicts and dependency can be seen compared with the parents of other children [9, 10]. Insecure attachment, inconsistent discipline, inflexible or rigid practices, inadequate supervision, and conflict in the family increase emotional and behavioral problems in children [11]. These factors play an important role in the attachment style of children with special needs [12]. The present study investigates a model of parenting program called Positive Parenting Program or Triple-P that aims to better equip parents in the role of parenting. 
The Triple-P aims to improve parents’ skills and interaction with their children. Indeed, this program increases and improves self-control, self-efficacy, well-being, and parent-child interaction [6]. The Triple-P is a behavioral family program whose underlying principles were drawn from Bandura’s social learning theory. In other words, This comprehensive program is a parenting intervention developed by Sanders [6]. It is an Australian intervention that contains behavioral and cognitive principles and concepts [13]. Triple-P is a multilevel system that supports child rearing and parenting [12, 14]. Triple-P consists of 5 levels, and the intervention intensity gradually increases from one level to the next [15]. The first level is global screening and parenting through media. This level suits families with few challenges in raising their children. The second and third levels suit families with more problems raising their children and include brief interventions. The fourth and fifth levels require more intensive parental training and family therapy. These levels are suitable for families with many problems raising children or children with special needs [16]. Triple-P can improve behavioral and emotional problems in children and interaction between parent-child through interactions by informing about the different needs of the parent and their children, parent-child interaction, family function, and parenting styles [17]. One of the Triple-P goals is to provide adequate support for each family [15]. Triple-P is recommended for the parents of children and adolescents with special needs [18], and it emphasizes the relationship with children, controlling and managing behavior. This program also improves children’s development through parent training, contributes to the parents’ general health, and helps them acquire social competency and self-control parenting skills [6]. Triple-P follows these goals: improving improving self-efficacy, self-confidence, and parent-child relationships [19]. 
Although Triple-P significantly affects parent-child interaction with special needs [15], conducting a meta-analytic study would help clarify the interventions’ true effect size. Meta-analysis is a formal and quantitative research design used to systematically assess previous studies to derive conclusions about that body of research [20]. Indeed, many studies were conducted to identify and solve the problems of children with special needs; however, it does not mean all their problems and challenges can be addressed [16]. Some studies aimed to examine the impact of Triple-P on parent-child relationships in different ages and groups. For example, the findings of Ruane and Carr demonstrated that Triple-P was an effective intervention for reducing behavioral challenges in children and improving parental relationships, parenting style, and parenting self-efficacy [15]. Lohan et al. suggested that Triple-P was a beneficial intervention for reducing parenting stress and enhancing parent-child interaction [19]. Wolfenden et al. reported that Triple-P significantly affected participants’ family functioning and mental health [21]. Hajkhodadadi et al. suggested that Triple-P positively and significantly would affect the parent-child relationship quality [22]. Hatamifar et al. concluded that the Triple-P significantly and positively impacted the parent-child relationship [23]. Saberi-Rad et al. reported that the Triple-P intervention greatly influenced mother-child interactions with behavioral disorders [24]. Ashori and Ghaforian [25] and Ashori and Jalil-Abkenar [26] reported that the Triple-P positively affected the relationship profile of mothers and hearing loss children. Rashidi Asl et al. [27] and Taheri et al. [28] showed that the Triple-P intervention significantly positively affected mother and slow-paced child interaction. Pourhaydari et al. [29], Momeni and Taziki [30], and Abedi-Shapourabadi et al. [31] concluded that the Triple-P intervention improved the interaction of mothers and their children with attention-deficit/hyperactivity disorder. Nazemian and Shams [32] and Aslani [33] showed that the Triple-P significantly affected the mother-child relationship. Pourmohamadreza-Tajrishi et al. [34] and Ashori et al. [35] reported that Triple-P positively affected the interaction of the mother-child with an intellectual disability. Nori and Hoseinian [36] concluded that the Triple-P intervention significantly affected social adjustment in inadaptable children.
The present research is the first meta-analytical research examining the effect of level 4 Triple-P on parent-child interaction with special needs in Iran. Focusing on one article can lead to a limited representation of the impact of Triple-P. In contrast, the present research combines the results of many articles into more homogeneous results to show a comprehensive picture of the effects of Triple-P on parent-child interaction. If the effectiveness of Triple-P interventions in Iran is determined, this program can be used more confidently to educate parents of children with special needs. This issue indicates the necessity and importance of the present research. In recent years, more attention has been paid to the effect of level 4 Triple-P on parent-child interaction in Iran. In addition, 15 studies have been conducted on this intervention over the past 10 years, but no meta-analytical research has been undertaken. This issue shows the gap in research in this field. Consequently, this study aimed to meta-analyze the effect of level 4 Triple-P on the interaction of parent-child with special needs in Iran.
2. Methods 
The present study is a meta-analysis. All studies conducted in Iran with the keywords of “Triple-P” and “parent-child interaction” were collected. Therefore, studies on level 4 Triple-P were reviewed for meta-analysis. Google Scholar, Irandoc, IranMedex, Magiran, and SID during 2012-2021 were used for database searching. We examined suitable and published studies (articles and dissertations) about the effect of level 4 Triple-P on the interaction of parent-child with special needs in Iran. Studies in languages other than Persian and unpublished studies were not included. The study selection diagram based on PRISMA (preferred reporting items for systematic reviews and meta-analyses) method is shown in Figure 1.

The inclusion criteria included reporting statistics, effect size, being Persian, having a control group, using intervention and original data. The exclusion criteria included duplicate articles, review articles, methodological problems, and non-compliance with the title with Triple-P level 4. According to Figure 1, 37 studies were found in databases and other sources in the first stage. In this next stage, 10 studies were excluded due to being duplicates or having invalid sources. In the second stage, 6 studies were removed due to title mismatch with level 4 Triple-P. In the next step, 4 studies were excluded based on their abstract content (without a control group, not in Persian, and review article only). Therefore, 17 studies remained. In the fourth stage, two full-text studies were excluded due to the lack of a control group, not the original data, and not an intervention study. Thus, 15 articles remained. In the final stage, 12 eligible studies were tabulated based on the quantitative and qualitative synthesis and entered into the meta-analysis.
Before analyzing the effect size of the mean differences, the PRISMA method was used to investigate the decision tree model. The PRISMA 2020 statement comprises a 27-item checklist addressing a systematic review report’s introduction, methods, results, and discussion sections. Then, the effect size of level 4 Triple-P was investigated and analyzed through a meta-analysis method. The study instrument was a meta-analysis checklist, which included the researcher’s name, research title, year of execution, source, research method, tool, sample size, statistics, its value, significance level, and effect size. Funnel plot, fail-safe number, and Cochran Q test were used to assess the publication bias, expected confidence, and effect size heterogeneity, respectively. The descriptive data and study effect size were analyzed by comprehensive meta-analysis (CMA). 
3. Results
The descriptive indexes and research results on the effect of level 4 Triple-P on parent-child interaction with special needs in Iran are reported in Table 1.


According to Table 1, the intervention was effective in all studies, but their effect size is different. The results of the meta-analysis of the effect of level 4 Triple-P on the interaction of parent-child with special needs are shown in Table 2.


According to Table 2, the largest Cohen effect size belonged to research No. 7 and the lowest to research No. 10. According to Cohen (1998), for the r index, the effect sizes of 0.1, 0.3, and 0.5 are small, medium, and large, respectively. Also, Cohen effect sizes from 0.2 to 0.3, 0.5, and 0.8 and above are small, medium, and large, respectively [37]. Indeed, the mean effect size of the independent variable (level 4 Triple-P) on the dependent variable (interaction of parent-child with special needs) was 0.59. According to the Cohen effect size, it is considered medium, and its significance level is 0.0001. Therefore, level 4 Triple-P moderately affected parent-child interaction with special needs.
One important issue in any meta-analysis is the assessment of publication bias. A meta-analysis does not include all the studies that have been done on the research subject. Because some studies have not been published for various reasons. Publication bias reduces the accuracy of the final meta-analysis results. Therefore, it is necessary to identify and correct the publication bias to increase the validity of the results. If there is no publication bias, the graph is symmetric. Studies with a low standard error are focused at the top of the funnel chart and have no publication bias. The extent of this bias is shown in Figure 2.

Figure 2 presents a funnel chart of standard error by Fisher’s z. According to this graph, the studies at the top have a low standard error and no publication bias. The expected confidence level was calculated by estimating the fail-safe number and heterogeneity of the effect size of studies, the results of which are reported in Table 3.


According to Table 3, the fail-safe number for this meta-analysis is 461 unpublished studies. Accordingly, there should be the same number of unpublished studies so that the Triple-P does not affect the parent-child interaction. Because this number is so large, the intervention has significantly impacted parent-child interaction with special needs. The heterogeneity of the effect size of studies was assessed using the Cochran Q test. The lack of significance of homogeneity indicates the homogeneity of the effect size of the studies. That is, no other variables affect the dependent variable, and the scatter between effect sizes is due only to sampling error. When the value of Q is significant, and the effect sizes are heterogeneous, other variables affect the dependent variable. The scatter between the effect size of the studies is not just due to sampling error. In this situation, the intervening variables should be considered, and this is done by classifying the data into at least two subgroups. Because the statistical samples were not completely separated and transparent, dividing the research into subgroups based on moderator variables was impossible. In other words, the researcher was limited in identifying these variables.
4. Discussion
This study aimed to meta-analyze the effect of level 4 Triple-P on parent-child interaction with special needs in Iran. Meta-analysis of the effectiveness of level 4 Triple-P on the interaction of parent-child with special needs is one of the topics not being studied in Iran. The results of this meta-analysis indicate that the effect size of level 4 Triple-P on the interaction of parent-child with special needs was 0.59, which is medium according to the Cohen table. In the present meta-analysis, an attempt was made to evaluate the success rate of this model by integrating Triple-P interventions.
The main finding of this meta-analysis suggested that the level 4 Triple-P improved the interaction of parent-child with special needs in the experimental group. This finding was consistent with Hatamifar et al. [23], Saberi-Rad et al. [24], and Ashori and Jalil-Abkenar [26], who concluded that the Triple-P had a significant and positive effect on the parent-child interaction. The present study’s finding was similar to Wolfenden et al., who reported that Triple-P significantly affected the participants’ family functioning and mental health [21]. Ruane and Carr demonstrated that Triple-P intervention was an effective program for improving parental relationships, parenting self-efficacy, and parenting style [15]. Rashidi Asl et al. and Taheri et al. showed that the Triple-P intervention had a significant and positive effect on the interaction of the mother and slow-paced child [2728]. The finding of this study was consistent with Hajkhodadadi et al., who concluded that Triple-P had a positive and significant effect on the quality of the parent-child relationship [22]. Furthermore, Lohan et al. also concluded that Triple-P was a beneficial program for enhancing parent-child interaction [19].
It can be concluded that parents of children may have difficulty managing emotions, but effective parenting interventions can help them a lot [38]. On the other hand, one widely used parenting program is the Triple-P [21]. Based on cognitive behavioral principles and social learning theory, Triple-P aims to modify maladaptive parenting behaviors and improve confidence in the parenting role [6]. Triple-P is a vital issue where parents, including mothers of children with special needs, may need support and help [19]. Effective parenting programs seem to contribute significantly to raising awareness among parents of children with special needs. Since these parents may cope with problems in predicting and controlling behaviors and emotions, they need a special intervention such as the Triple-P program that emphasizes behavior management, parenting style, and child-rearing [1]. 
To explain the similar results to our research, it can be stated that for many years, it was assumed that children with special needs live isolated in their homes and communities, and they cannot learn. Today, social perspectives have shifted, and it has been revealed that these children can learn if they are taught with an appropriate method [16, 39]. On the other hand, proper family and social support can alleviate some of the problems [40]. Children with a disability, compared with normal children, more negatively influence their interaction with parents [7]. The parent of children with a disability requires more parenting programs and family therapy interventions [11]. In the Triple-P intervention, parents learn about children’s specific problems discussed in group meetings and can receive appropriate information and support. Also, parents can understand their children’s problems by learning enough information and applying parenting skills and behavior management techniques [41]. Triple-P gives parents practical and simple strategies to help them build healthy and strong interactions [6]. This multilevel program provides prevention and treatment for children at risk of behavioral, emotional, and social problems via parenting methods to enhance parents’ parenting skills, knowledge, and confidence [42]. For this reason, level 4 Triple-P reduces conflict between family members and increases positive interaction between parents and children with special needs.
Every research has certain limitations. One of the limitations of this research was the lack of access to resources and research that were conducted and published in a specific field. In this study, only research studies conducted in Iran were used. Another limitation is the lack of a coherent and regular database in the country to conduct such research. It is also rare for studies used in meta-analysis to report all the statistical indicators required for analysis. This is one of the main limitations of performing a meta-analysis. The methodological limitations of the present study included the small sample size, no control or comparison group, and the effect size was not reported in some studies.
It is suggested that more attention be paid to the repetition of research on various topics to review further studies. In this case, by putting together the results of different studies, a better view of the reality of society will be available. Pay attention to the research done in other countries in the next research is suggested. It is also recommended that all the necessary research information, including research method, sample size, questionnaires, statistical analysis method, Mean±SD, significance level, and effect size of each research that is done, be fully and accurately reported so that they can be used in meta-analysis. A final practical suggestion is to conduct separate meta-analyses on the effect sizes of other parenting programs and compare the results.
5. Conclusion
Having a child with special needs significantly affects the life of family members, especially parent-child interactions. In contrast, Triple-P has positive results and improves the interaction between parents and children with special needs. Because level 4 Triple-P is an intervention to improve parent-child interaction, a meta-analysis helps determine the actual effect size of this intervention. Findings revealed that the mean effect size of level 4 Triple-P on parent-child interaction was medium. Since this level of Triple-P had a moderate effect on parent-child interaction with special needs, it can be used as a suitable method in parenting and child-rearing.

Ethical Considerations
Compliance with ethical guidelines

The instructions of the National Ethics Committee and the COPE (The Committee on Publication Ethics) regulations have been considered in the article’s writing. 

Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or nonprofit sectors.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The author sincerely thanks all the researchers whose articles have implicitly contributed to this meta-analytic research.

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Type of Study: Review Article | Subject: ● Psychosocial Health
Received: 2022/11/26 | Accepted: 2023/01/24 | Published: 2023/05/28

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