Introduction
An adoptive family is a unique and special type of family. Adoption could provide stability, durability, and mental and physical health for children who cannot live with their biological parents (Brodzinsky, 2008; Palacios et al., 2019; Waid & Alewine, 2018). Although many adoptive parents are satisfied with their choice and do not report a particular problem, some complex challenges and issues may affect their parenting (León et al., 2018; Selwyn et al., 2014). For example, they could undergo infertility stress (Baden et al., 2013; Brodzinsky, 2013; Hogström et al., 2012), anxiety, and uncertainty about revealing the reality of adoption (Alexander et al., 2004). In addition, low psychological and social adjustment due to past problems and injuries, externalized and internalized problems (Barnett et al., 2018), and the lack of secure attachment in adopted children affect them (Brodzinsky, 2008; Welsh et al., 2008). According to previous studies, distress (Bird et al., 2002; McGlone et al., 2002; Rijk et al., 2006) and post-adoption depression (Foli et al., 2012; Mott et al., 2011) are the significant consequences of such challenges.
Low levels of parents’ psychological well-being and the adoptee’s behavior and characteristics can affect parenting quality and increase parenting stress (Bloomfield & Kendall, 2012). This pressure could be accompanied by anxiety and increase the risk of burnout. Hence, this will affect the quality of services provided to the family. In every person’s life and work, various factors can create stress and affect the quality of life. These factors should be controlled as much as possible. In particular, families who adopt a child should be more concerned (Farhangi & Khajehnasiri, 2020; Khajehnasiri et al., 2021). Parent-child relationships, family functioning, and children’s development are highly affected by parenting stress (Canzi et al., 2019; Eanes & Fletcher, 2006). In addition, parents’ beliefs related to their ability to handle their parenting responsibilities, i.e. parenting self-efficacy, are a determining factor in parent-child relationships and successful parenting (Albanese et al., 2019). However, adoptive parents are at risk for lower parenting self-efficacy and higher parenting stress due to the increased risks of psychological problems in adoptees and the possibility of experiencing failure in dealing with these conditions (Kerr & Cossar, 2014; Sánchez-Sandoval, 2015).
Therefore, adoptive families need specialized support to tackle these challenges and their consequences. Post-adoption services can help improve family health and function by focusing on the challenges faced by these families (Dhami et al., 2007). Several parenting interventions have been performed on specific and limited dimensions to help adoptive families, such as attachment-based interventions (Baker, 2018; Colonnesi et al., 2013), systemic family therapies (Barbato et al., 2019; Weir et al., 2013), cognitive behavioral therapies (Henderson & Sargent, 2005; Rushton et al., 2010), and psycho-educational interventions (Bammens et al., 2015; Baskin et al., 2011; Selwyn et al., 2009). Some of these interventions focus on emotional aspects, like promoting the parent-child emotional relationship (Allen et al., 2014; Chakawa et al., 2020), developing a secure relationship (Carnes‐Holt & Bratton, 2014; Opiola & Bratton, 2018), and providing appropriate attachment experiences (Selwyn, et al., 2016; Yarger et al., 2019). Some programs emphasize behavioral aspects, such as reducing behavioral problems and increasing children’s positive behavior (Rushton et al., 2010). Addressing different aspects of marital relationships is emphasized in other interventions, while cognitive elements, such as self-efficacy, are discussed in separate programs (Baskin et al., 2011; Loew et al., 2012; Henderson & Sargent, 2005). Hence, previous interventions cannot be considered comprehensive, indicating the necessity of a multidimensional intervention.
The main advantage of the integrative program developed in this study is its simultaneous focus on multiple centers, which were considered separately in previous studies. The common elements are integrated to enhance the effectiveness of this intervention and solve challenges faced by this type of family. The present study develops an integrative parenting program for adoptive families by identifying the common elements of the existing interventions. Further, this study determines the effectiveness of the proposed program on parenting stress and self-efficacy in adoptive parents.

Materials and Methods
This study combined qualitative and quantitative elements using an intervention-development variant of the mixed method design. This approach collected qualitative data to develop a beneficial intervention that could work with the study participants. Qualitative data were included in the trial design, which might change the outcomes of the intervention (Creswell & Clark, 2011). In the qualitative phase, the parenting program for Adoptive families was developed based on the common elements of the existing interventions. Next, the efficacy of the developed intervention was examined.

Qualitative phase
The common elements approach, introduced by Garland et al. (2008), was used in the qualitative phase by taking the following steps:

Step 1: Identifying interventions with high efficacy
First, a search was performed to find journal articles related to adoption in academic databases, such as Science Direct, Emerald, ProQuest, Web of Science, Eric, Scopus, and Wiley Online Library. A total of 141 papers were retrieved, and participant selection was done via purposive sampling. Among these articles, 105 were excluded from this study as they did not contain parenting programs for the adoptive family. Out of the remaining 36 articles, 6 were systematic reviews of parenting programs for adoptive families, and 30 were independent studies. The inclusion criteria were the publication date from 2000 to the present and having high-impact factors, indicating the efficacy and validity of the articles (as defined by the American Psychological Association’s (APA) criteria). The parenting interventions introduced in the review articles were examined, and 15 articles fulfilled the inclusion criteria. Furthermore, independent articles were evaluated, and none met this study’s requirements. Finally, 15 evidence-based parenting programs were selected for adoptive families. The flow diagram of participant selection in the qualitative phase is shown in Figure 1.



Step 2: Assessing the supporting materials
All the available supporting resources related to these 15 programs, including books, journal articles, and intervention manuals, were retrieved. Independent reviews were conducted to identify the core elements of each program as presented in the intervention materials. Three team members reviewed the materials related to each intervention. The concepts were extracted in response to the question, “What would be the basic premise of each intervention to promote parenting in adoptive families?” Then, the concepts were categorized based on similar themes, and core intervention elements were obtained. Each coder separately produced the initial lists of core elements. Next, the core elements were reviewed and discussed by the research team. In cases of disagreement about the elements, team members reviewed the materials to reach an agreement. Elements found in the majority of intervention reviews were considered common ones. The core elements of interventions were compared and classified into the following four categories: intervention content, intervention technique, aspects of the working alliance, and intervention parameters.

Step 3: Surveying experts to reach an agreement
The preliminary list of common core elements was sent to six psychology and counseling specialists. They were asked to indicate how much they agreed with selecting common elements for adoptive families by content validity index and content validity ratio form and add their comments if they thought something was missing or had to be included. This survey aimed to obtain the consensual validity of the common elements. The specialists endorsed all core elements. The final list of common elements was similar to the initial list.

Quantitative phase

Study participants
The participants were two adoptive mothers and one adoptive father chosen via the available sampling method. The inclusion criteria for the quantitative phase of the study were as follows: a) The age of the adoptee was from infancy to 12 years, b) The legal process of children’s adoption was completed, and the adoptive parents were the permanent and legal parents of their child, and c) There was no psychiatric diagnosis in the medical records of the adopted child. All three participants were eligible, and their informed consent was obtained.

Case description
The first participant was a 35-year-old adoptive mother who was married for 14 years. She was a housewife with a bachelor’s degree. She had adopted her child about two years ago, and her child was three years old at the time of intervention. Her 40-year-old spouse was an employee with a high school diploma. The second participant was a 34-year-old adoptive mother who was married for 16 years. She was a housewife with a high school diploma. She had a two-year-old adopted child who was adopted a year before. The second participant’s spouse was 44 years old. He was an employee and had a high school diploma. Unlike other participants, the third participant had three adopted children. He was a 35-year-old adoptive father and was married for about 13 years. He was an employee with a master’s degree. His children were four, six, and eight years old, and he adopted them four, five, and seven years ago, respectively. His spouse was a 33-year-old housewife with a master’s degree. In this study, none of the participants had a biological child.

Study design
A single-subject, multiple baseline design across the participants was used to evaluate the effectiveness of the developed parenting program on parenting stress and self-efficacy. Since the parenting program designed in this study was new, using this method could have advantages compared to other experimental designs. This method helps provide a detailed examination and analysis of the functional relationship between intervention and development in the valuable results (Horner et al., 2005; Zanuttini, 2020). In addition, the high internal validity of this method and the small sample size (Simonsen & Little, 2011) make it suitable for special populations such as adoptive families.

Study instruments

Parenting stress index-short form
Parenting stress was measured using the Persian version of the parenting stress index-Short Form (Abidin, 1983; Fadaei et al., 2010). This self-report measure includes 36 items and three subscales: parental distress (PD), dysfunctional parent-child interaction (PCDI), and difficult child characteristics (DC). PD items measure the level of stress experienced by parents. The PCDI items evaluate how parents feel about meeting their child’s expectations, and the DC items assess parents’ perceptions about the difficulty of managing their child’s behavior. This scale was used to measure the stress level experienced in the parenting role based on a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree). The range of possible scores was between 36 and 180. Abidin (1995) reported the Cronbach α coefficients of 0.91 for PSI-SF total, 0.87 for PD, 0.80 for PCDI, and 0.85 for DC subscales. The reliability coefficients of the total stress score were reported as 0.92 for adoptive mothers and 0.91 for adoptive fathers (Salcuni et al., 2015). The Persian version of this scale demonstrated high test re-test reliability for all three subscales of the total stress scale among Iranian mothers. The reliability coefficient was computed at 0.75. Additionally, the convergent validity was assessed by calculating the correlation between the scores of this scale and the depression anxiety stress scales (r=0.68) (Fadaei et al., 2010).

Parental self-agency measure
Parenting self-efficacy was evaluated using the Persian version of the parental self-agency measure (Dumka et al., 1996; Talei et al., 2011). This measure, developed by Dumka et al. (1996) to assess the general levels of parenting self-efficacy, has ten items (five positive and five negative expressions) and evaluates parents’ confidence in their ability to have a successful parenting performance. Responses to all items were scored based on a 7-point Likert scale ranging from 1 (rarely) to 7 (always). Higher/lower scores indicate higher/lower self-efficacy. This instrument demonstrated good construct validity and reliability (α=0.92) (Dumka et al., 1996). The Cronbach α coefficient for the Persian version of the scale was 0.7 (Talei et al., 2011). Additionally, the face validity of this scale was reported to be appropriate for the Iranian population.

Study procedure
Invitations titled “invitation to participate in a training course for adoptive parents” were sent through social networks. A total of 13 adoptive parents announced their readiness to attend the course. Six parents did not meet the inclusion criteria and were excluded. Then, the study’s objectives, timing, and the procedure of sessions were explained to the participants. Informed consent was obtained from all volunteers. Then, the electronic link of the research instrument was sent to the volunteers to determine the first stage of the baseline. The second baseline was measured one week later, and the third was measured ten days after the first. Four volunteers were excluded from the study since they did not participate in all sessions and provided inaccurate responses to questionnaire items. Thus, three adoptive parents (two mothers and one father) participated in all nine sessions and completed the questionnaires with sufficient accuracy.
After checking the baseline stability, the sessions were scheduled and conducted according to the integrative parenting program for adoptive parents. Each participant attended a separate meeting. Due to the COVID-19 outbreak during the intervention, the sessions were held online through Skype and WhatsApp. The participants were asked to complete the questionnaires after the first, third, fifth, seventh, and ninth sessions. After finishing the sessions, the participants responded to the electronic link of the scales three more times in three maintenance sessions.

Data analysis
Visual analysis of the data was conducted to assess the effectiveness of the developed parenting program in reducing parenting stress and increasing parenting self-efficacy. The analyses were performed at two levels, including within-condition and between-condition levels. Within-condition analysis consisted of each situation’s variability, level, and trend (baseline, intervention, and maintenance). These parameters were compared between adjacent situations in between-condition analysis (Lane & Gast, 2014).

Results

Qualitative phase
A total of 44 concepts and nine categories (common core elements) were obtained by examining 15 parenting programs for adoptive families. These nine elements included rebuilding attachments, enhancing the spouse subsystem, rebuilding the family structure, improving parenting self-efficacy, emotional-cognitive regulation, managing the child’s behavior, laying the groundwork for integrated child development, promoting the child’s social health, and improving the child’s self-esteem.
The content validity index coefficient was calculated as 1 (complete agreement) based on experts’ opinions to examine the content validity of the extracted common elements.
The aforementioned nine main categories were selected as the intervention contents in the next step. Then, all related sources, including scientific books and journal articles, were studied to identify the techniques and skills related to each of these intervention contents. Intervention techniques were extracted for each of the intervention contents. Table 1 shows the common elements of parenting interventions for adoptive families as intervention contents. Intervention techniques related to each are also presented.





Table 2 presents the sessions of this integrated program based on common elements. The program covers the objectives of the intervention in nine sessions.



Different aspects of the working alliance and intervention parameters are shown in Table 3.



Quantitative phase
In this stage, the effectiveness of the developed parenting program on parenting stress and parenting self-efficacy was assessed in adoptive parents. The results of the visual analysis are represented in tables and graphs. Figure 2 displays the graphs related to participants’ scores in parenting stress and parenting self-efficacy in baseline, intervention, and maintenance stages.



Parenting stress
The data relating to parenting stress for all participants in baseline, intervention, and maintenance stages were within the stability envelope. In the intervention phase, the parenting stress of the first and second participants decreased compared to the baseline phase. However, the third participant’s scores indicated an increased level of parenting stress as compared to the baseline phase.
The data trend for the first participant is ascending in the baseline and maintenance conditions and descending in the intervention condition. The mean scores decreased from the baseline (mean=84) to the intervention (mean=66.8) condition. In addition, since the percent of non-overlapping data (PND) is at its highest level and the percent of overlapping data (POD) is zero in two adjacent situations (baseline to intervention), the intervention can be considered very effective for this participant. For the second participant, the data trends in all conditions are slightly descending. The mean in the intervention phase (mean=66.8) decreased compared to the baseline (mean=84). The PND and POD coefficients between the baseline and intervention conditions indicate a high level of efficacy. The data from the third participant indicate an overall upward trend in all three conditions (baseline, intervention, and maintenance). The mean scores increased from baseline (m=79) to intervention (mean=88.6). Further, since PND is at its lowest and POD is at 100 between the baseline and intervention stages, the intervention can be considered ineffective with high confidence for this participant. Table 4 provides more information on the visual analysis related to the variables of parenting stress.




Parenting self-efficacy
The results of parenting self-efficacy are within the stability envelope in all three conditions. The scores of all participants have increased compared to the baseline, which indicates an improvement in parenting self-efficacy. For the first participant, baseline and maintenance data trends are slightly ascending, and the trend of intervention data is ascending. The mean increased from baseline (mean=47.66) to intervention (mean=55) condition. PND and POD coefficients between baseline and intervention conditions indicate high-reliability efficiency. The scores of the second participant show that the data trend is downward in the baseline, constant in the intervention, and upward in the maintenance condition. The mean increased from baseline (mean=41) to intervention (mean=50.8). The PND and POD calculations indicate that the intervention is highly effective for this participant. As for the third participant, the data trend is descending in baseline and maintenance phases but fixed in the intervention condition. The mean increased from baseline (mean=36.66) to intervention (mean=45.4). PND and POD coefficients showed that the intervention positively affected this participant. Table 5 presents additional information on the visual analysis of parenting self-efficacy variables.




Discussion
This study developed a comprehensive parenting program that integrates elements from previous interventions to improve parenting in adoptive families. It examines how common elements like rebuilding attachments, enhancing spousal relationships, managing child behavior, promoting child development, and …, can reduce parenting stress and increase parenting self-efficacy. These elements can help adoptive parents improve their parenting in specific ways. For example, rebuilding attachments alleviates attachment injuries and creates positive bonds in parenting. Rebuilding attachments can be accomplished by balancing the four dimensions of attachment (i.e. structure, emotional engagement, challenge, and nurture) (Weir et al., 2013; Selwyn, et al., 2016; Wydra & O’Brien, 2018).
Furthermore, strengthening the spouse’s subsystem can result in better parenting in adoptive families. Parents in these families face more incentives and risks, which may increase marital conflicts and challenges for children with adjustment issues (Sinclair et al., 2004). According to Erel and Burman (1995), marital dissatisfaction and ineffective parenting are associated with poor child adjustment. Conflicting and negative marital relationships can make parents emotionally drained and irritable and cause them to respond less sensitively to their children. However, parents with a satisfactory and supportive marital relationship are emotionally available and can respond more sensitively to their child’s needs (Goldberg & Carlson, 2014; Knopp et al., 2017). The quality of parenting can be improved by rebuilding the family structure by resolving sibling disputes, encouraging hierarchy within families, and creating transparency in parent-child relationships (Weir, 2011).
A high level of parental self-efficacy is beneficial to parenting. Parents with high self-efficacy consider themselves a part of creating security for their children and are better able to respond to challenges (Selwyn, et al., 2016). These parents have strong, positive experiences, which help them become more confident in their abilities (Selwyn et al., 2014).
In addition, the ability to regulate emotions can influence adoptive parents’ parenting. Parents can act differently depending on their emotional strategies. Extreme reactions are caused by a lack of emotional regulation and uncontrolled responses (Barros et al., 2015) and negatively affect parenting. However, parents’ control of negative emotions could facilitate parenting (Sagui-Henson et al., 2020).
Parents can manage their children’s problematic behavior using positive and solution-oriented techniques. In this case, there are no power struggles between the parents and the children. Rather than punishing their children, they encourage them to take responsibility for their actions (Harris et al., 2015). Therefore, parenting can be enhanced by managing children’s behavior.
Laying the groundwork for a child’s integrated development can improve parenting by increasing parental awareness of the child’s development. Such parents know that every behavior and feeling at any time reflects past experiences and circumstances. Even though they know the potential problems associated with early life experiences, they recognize that positive experiences in their child’s life will help them move toward a more positive outlook (Allen et al., 2014). Thus, parenting could be promoted by being attentive and sensitive to the child’s developmental stages.
Promoting the child’s social health is another aspect that can contribute to adoptive parents’ successful parenting. Parents can benefit from this element by reducing communication issues and optimizing interpersonal communication (Gilkes & Klimes, 2003). Strengthening a child’s self-esteem can enhance parenting by creating a positive relationship between the child and the parents and using child-centered activities (Blanco et al., 2017; Opiola & Bratton, 2018).
Parenting stress and parenting self-efficacy were affected by comprehensive parenting processes in this program. This research’s results align with the study of Kasperzack et al. (2020) and Chorão et al. (2022). Models of parental stress show that child-parent characteristics, marital relationships, parent-child relationships, and contextual characteristics play essential roles in the experience of parenting stress (Abidin, 1990; Cain & Combs-Orme, 2005; Kalil et al., 2005; Mulsow et al., 2002). In this regard, all interventions addressing the factors affecting parental stress will likely reduce parents’ perceived stress. Since integrated programs incorporate components of effective interventions, they can handle different aspects of parenting stress. The program of the present study focused on individual factors (e.g. emotional-cognitive regulation of parents), marital factors (e.g. enhancing spouse subsystem), factors related to parent-child relationships (e.g. managing child’s behavior, rebuilding attachments), and contextual factors (e.g. rebuilding the family structure). Therefore, this program targeted a set of factors that reduced parental stress.
Additionally, the results indicated that the integrated parenting program could increase parenting self-efficacy in adoptive parents. According to Bandura’s self-efficacy model, parental efficacy can be conceptualized using four dimensions: Physiological information, vicarious experience, verbal influence, and performance achievements (Bandura, 1997; Wernand et al., 2014). The ability to communicate emotionally, be empathic, show protective behavior, and perceive order has been linked to parental self-efficacy (Coleman & Karraker, 1998; Junttila et al., 2015). For instance, all the elements in the program presented in this study can help improve performance achievements, and every component of this program assists parents in developing their parenting skills and techniques. Furthermore, since positive experiences promote strong beliefs in abilities (Bandura, 1997), the current program can help enhance self-efficacy.
As for the third participant, factors threatening internal validity, such as history and growth, can affect results (Lane & Gast, 2014). The case study of this participant showed that the health problems of one of the children during the training course (this parent had three adopted children) affected the research results. Examining the trend line in the visual analysis showed that the parenting stress of this participant did not increase considerably compared to the baseline condition until the fifth session, after which a score increase was observed. Further, the trend line of parenting self-efficacy indicated that data changes were slightly downward in the baseline condition and constant in the intervention condition.

Conclusion
Adoptive families have a different structure from normal families; therefore, they require special parenting conditions. Although interventions can effectively promote parenting in these families, each intervention has certain elements that are concentrated. In this research, identifying the common aspects of these interventions and combining them in a single protocol provides a more comprehensive focus for promoting parenting. Combining the common elements of previous interventions while using the benefits of each intervention can be the catalyst for faster changes in the field of parenting in this type of family. This integrated perspective provides a comprehensive picture both in the field of conceptualizing parenting problems and in the field of modifying processes related to adoption, based on which all cognitive, behavioral, emotional, and systemic processes affecting parenting are considered.

Study limitations and implications
This study faced some limitations. Previous studies have shown differences between maternal and paternal parenting stress and self-efficacy. However, the results could be biased since these differences were not considered in this study. In addition, variables such as education, socioeconomic status, and the number of adopted children can influence the dependent variables. However, this study did not control or investigate their effects, which can impact the results. It is suggested that experimental designs be used in future research to maximize control over research variables and determine the effectiveness of the parenting program. Further, due to the crucial importance of pre-adoption education, it is recommended that future research develop or integrate pre-adoption parenting programs for couples who want to adopt a child.

Ethical Considerations

Compliance with ethical guidelines
This study reported the results of the master’s thesis in family counseling approved by the University of Bojnord Research Council (Code: 5738). All procedures performed in this study were following the ethical standards of the University of Bojnord, Iran. During the study, we informed all participants about the research’s purpose and their right to withdraw whenever they desired. Furthermore, the confidentiality of their information was guaranteed.

Funding
This article is extracted from the master’s thesis of Atiyeh Aghakeshmiri, approved by Department of Counseling, Faculty of Human Sciences, University of Bojnord.

Authors' contributions
All authors equally contribute to preparing all parts of the research.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors thank the University of Bojnord and all participants (adoptive parents) for their honest presence and cooperation throughout the program.





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