In this randomised controlled clinical trial of an online positive parenting training program as a potential preventive intervention for previously healthy parent-child dyads, Online PPP significantly improved the primary outcome measure-parents’ sense of competence compared to active comparator control group over time. Among the range of other secondary outcomes, parents reported increased authoritative and decreased permissive parenting styles within each group during 14 weeks of the follow-up period, which did not differ between groups. Moreover, significantly reduced children’s emotional problems and overall behavioural problems, as reflected by total difficulties scores on the SDQ, were also noted at 6 weeks after the end of the intervention period.
The traditional positive parenting programs such as the Triple P-Positive Parenting Program23 and the Korean Parent Training Program34 had been shown to have a wide range of desirable child, parent and family outcomes in both short- and long-term. For example, the programs reduced emotional and behavioural problems of children, promoted effective parenting, improved parenting satisfaction and efficacy in addition to strengthened parental relationship similar to previous online positive parenting programs. There is evidence to demonstrate that online positive parenting programs improved parental competency and reduced parental mental health problems and also ameliorated children’s behavioural and emotional problems3,20,22,35. According to a meta-analysis, components of highly effective positive parenting programs included teaching parental self-control, guiding parents to foster problem-solving skills and self-control in their children, promoting child’s development through play, and increasing the quality of time spent together22. Consistent with previous traditional and online parenting programs, Online PPP for intervention group in this present study focused on building and strengthening parent-child relationship, supporting caregiver’s mental health and well-being, promoting effective communication, fostering daily routine and activities schedule, and managing both desirable and undesirable behaviours through live instruction via video conferencing, discussion and exchange of opinions, in addition to role play for some sessions. Small and whole group discussions in our study utilised transformative learning theory. If caregivers were unable to participate in live sessions, they were able to acquire the basic knowledge via an edited video recording. This modality provided the flexibility for parents to access parenting techniques via video recordings even when they may be busy on the specified day of the live sessions. In the active intervention control group, general knowledge which did not overlap with the specified Online PPP curriculum was provided via communication application. Furthermore, Online PPP was suitable for facilitating and supporting parents in dealing with their children during the COVID-19 pandemic.
Due to the nature of online platform and the flexibility of the program, parents could access sessions that they missed via video recordings. This led to the high “attendance” and completion of all sessions (median=8 sessions/person). Attendance of previous parenting programs were often reported as 35-50% of all lessons, and only 60% of parents fully attended the program22. Furthermore, the attrition rate was about 33%20 as compared to our study’s attrition rate of 7.69% for the intervention group. Consequently, various online parent training programs have been developed to address accessibility concerns such as multi-point videoconferencing36, web-based online parent training sessions and telephone-based program3, and tailored program utilizing text messages20. These online positive parenting programs have high rates of program satisfaction due to saved cost and travel time in addition to effectiveness as rated by the parents3,20,35−37. Program attendance rate was higher in online parent training program with up to 74% of participants who attended all sessions38.
In the intervention group, the parenting sense of competency minimally decreased initially at 8 weeks but later greatly improved at 14 weeks. We suspected that this was likely due to the nature of transformative learning strategy which may take some time to change behaviours, skills and attitudes. As the intervention period coincided with the new wave of the COVID-19 outbreak in Thailand leading to lockdown restriction including public orders to work from home and implement online schooling to minimise the spread of infection, parents had to spend more time with their children and inevitably had to manage more children’s problematic behaviours. Moreover, some families had increased exposure to economic and social stressors and worsening mental health of parent-child dyads that resulted from stay-at-home orders30–32. These external stressors may, in turn, affect parents’ ability to apply lessons learnt for further self-improvement. Thus, this may partially explain the attenuated effect of the intervention at 8 weeks and the lack of change in stress level despite improved parents’ sense of competence at 14 weeks. This finding differed from a previous study which showed decreased parental distress after parenting intervention20. In addition, baseline characteristics of parenting styles were rather positive in both groups and therefore may not change significantly in 14 weeks for both groups. As an example, after 14 weeks of intervention, both groups reported more authoritative parenting style, and the control group reported less permissive parenting style, possibly due to relatively high positive parenting skills at baseline and participants’ high education and household income which may lend to more support and means to positive child-rearing practices. Although the raw score of parenting sense of competence in the intervention group may appear to increase minimally at 14 weeks compared to the control group, GEE model showed that total score of PSOC in the intervention group was significantly greater compared to the control group over time.
This research found that emotional concerns within each group significantly improved at 14 weeks for both intervention and control groups. Furthermore, over time, children’s behavioural concerns decreased in both groups. This may in part be explained by improved parenting sense of competence over time in intervention group and increased positive parenting, defined as more authoritative and less permissive parenting, in both groups at 14 weeks in addition to relatively high levels of positive parenting reported at baseline. The decrease in emotional and behavioural concerns as caregivers became more responsive and competent in their own parenting skills exemplified the transactional model and bidirectionality in parent-child relationships. Positive parenting has been found to be associated with desirable behaviours such as lower screen time in children39. Additionally, searching for positive parenting information online these days has never been easier, which may mean that the control group may attain such information from other sources as it would be unethical to restrict the control group from navigating other online resources for parenting support. Moreover, those in the control group still received weekly general parenting education via group communication application for 8 weeks in the forms of text articles or videos which may increase parental awareness and practice in such topics. As a result, the efficacy of the intervention in reducing behavioural concerns did not differ significantly between the intervention and control groups. This study, along with previous work by Sanders and team, found that both online parent training and self-help workbooks were effective in reducing disruptive behaviours23.
The lack of change in stress level as evident on PSS and PSI may be due to the fact that Online PPP included intensive, weekly 1.5-hour sessions lasting for 8 weeks with a gentle reminder a day before each scheduled session. The program itself may cause more stress for parents as they had to “take time off” from taking care of their children in order to attend live, interactive sessions. From these outcomes, we found that our online positive parenting program benefited both parents and children.
There are some limitations in this study. First, as this research aimed to administer Online PPP as a modality for primary prevention in order to increase parents’ sense of competence and minimise overall behavioural concerns, we specifically selected caregivers with low stress and caregivers and children who did not have any chronic physical or mental health illnesses. This may cause selection bias; however, given the aim of testing Online PPP as a primary preventive measure, we decided to define the inclusion criteria as such. Therefore, both primary and secondary outcomes at various time points may not significantly differ. Secondly, the intervention group required direct discussion with the facilitators based on transformative learning theory and some Thai parents might not feel readily comfortable talking and sharing among strangers. As a result, live, interactive sessions may not be suitable for all Thai parents. In addition, due to the virtual, interactive nature of our intervention, completely blinding participants was not possible. Nonetheless, all caregivers were informed that they will receive parent training via one of the two modes, either live video conference or one-way information-sharing via communication application. None of the participants knew whether they were in intervention or control group and the desired outcomes of the study. Participants received their personal identification code which served as blinding for the researchers analysing the outcomes. Thirdly, caregivers from our study had relatively high education, household income and high positive parenting style at baseline. Consequently, this may limit the generalizability of our results. Fourthly, during the study, there was a new wave of COVID-19 outbreak in Thailand which may have led to the lack of apparent reduction of stress levels in parents. Noteworthily, the stress levels did not statistically significantly increase in both groups. Fifthly, children’s behavioural problems measured by Strengths and Difficulties Questionnaire were completed by only the main caregiver, which may not be representative of behavioural problems from other perspectives or settings such as classroom teachers. Nevertheless, given that the main caregiver spent the majority of each day with the child during the COVID-19 pandemic, this measurement could serve as reflection of children’s overall behaviours. Sixthly, as the participants were followed up to 14 weeks, this precluded us from determining the long-term effectiveness of Online PPP. Finally, even though our study did not include cost-effectiveness analysis as our main outcome, the total cost of hosting Online PPP was estimated to be 4,000 Baht (equivalent to £87.00) per family for the whole course. In comparison to the long-term, high annual cost of behavioural and mental health disorders, preventive programs such as Online PPP may lessen the overall economic burden and the national budget may be better spent investing in building parenting skills. The topics included in Supplementary Table 1 have proven to be effective targets for primary care providers to utilise in virtual clinical settings as tools in increasing parental sense of competence and positive parenting skills and ultimately reducing children’s emotional and behavioural concerns.
In spite of these limitations, to the best of our knowledge, this research is the first randomised controlled trial examining the effects of online positive parenting program, designed with the integration of transformative learning theory, on healthy parents and children as compared to general parenting education via a communication application alone in Thailand. Our study further showed that parents had higher parenting sense of competency after Online PPP and more positive parenting styles in both groups, which ultimately led to less emotional and overall behavioural concerns at 14 weeks.