Comparison of the Effectiveness of Parent-Child Relationship-Based Play Therapy and Attachment-Based Play Therapy on Internalizing and Externalizing Behavioral Disorders in Children with Learning Disabilities

Introduction

Learning disabilities are one of the most important topics in school psychology (Lockwood et al., 2022) and are among the most common developmental disorders diagnosed during childhood. Epidemiological studies report comparable prevalence rates of 4-9% for reading deficits and 3-7% for math deficits (American Psychiatric Association, 2013). Academic skills such as reading, writing, and mathematics, which were previously classified as separate problems in earlier versions of the DSM, are now referred to as specific learning disorders in the DSM-5 (American Psychiatric Association, 2013). Specific learning disorders, such as dyslexia and dyscalculia, are studied by researchers to inform diagnosis and intervention strategies. Furthermore, students with specific learning disorders are examined to enhance our understanding of the mechanisms underlying learning in the affected areas. Reading and math are core subjects in formal education and predictors of academic achievement (Ritchie & Bates, 2013).

One of the dominant frameworks used in developmental research to understand the underlying mechanisms in the development of such neuro-cognitive abilities is the study of children with specific learning disorders. The logic behind studying selected groups of children facing specific deficits is that understanding the causal and related factors of their deficits can provide broader insights into the neuro-cognitive mechanisms underlying the development of impaired competencies (Peters & Ansari, 2019). Recently, studies have begun exploring the relationship between deficits in various learning domains (i.e., dyslexia and mathematical learning problems) to better understand their overlap instead of focusing on a single deficit. Findings suggest that children with a deficit in one learning domain often have deficits in other learning domains as well (Dirks et al., 2008). One of the problems these children face is behavioral disorders (internalizing and externalizing) (Dekker et al., 2002). Disorders categorized as internalizing manifest in issues such as aggression and attention-deficit/hyperactivity disorder (ADHD), while externalizing disorders manifest in problems like anxiety, depression, fear, social withdrawal, and somatic complaints (Lansford et al., 2014). Previous studies indicate that students with learning disabilities experience more behavioral disorders compared to other healthy children (Hamidi et al., 2014).

In terms of internalizing disorders in children with learning disabilities, these children exhibit more problems related to ADHD compared to healthy children, showing greater inattention and lack of focus in the classroom (Zablotsky & Alford, 2020). Furthermore, these students display more externalizing behaviors, such as aggression, compared to healthy students (Sofologe et al., 2022). On the other hand, learning problems such as dyslexia, difficulty in math, and writing disorders can adversely affect various aspects of the lives of children with learning disabilities (Fish & Morgan, 2021). They may experience greater social exclusion and loneliness (Steele et al., 2008), and their ability to reason and solve problems diminishes, affecting their quality of life (Arkhoudi Qalaei Noei et al., 2021).

Parent-child relationship-based play therapy is a therapeutic intervention for children, grounded in child development and behavior theories, including attachment theory (Bowlby, 1982), Baumrind’s parenting styles (1966), and social learning theory (Bandura & Hall, 2018). Parent-child relationship-based play therapy assumes that the parent-child relationship is shaped by interactions that influence parents' and children's thoughts, emotions, and behaviors (Batzler et al., 2018). This therapy involves a dual intervention with two therapeutic stages. The first stage, child-directed interaction, aims to strengthen secure parent-child relationships and improve problematic child behaviors through positive behavior support strategies. These strategies include differential attention, praise for positive behaviors, and skill-building (e.g., enhancing speech and language skills, modeling social interactions) (Eyberg & Funderburk, 2011). The second stage, parent-directed interaction, focuses on discipline, teaching parents how to give effective commands and enforce consequences (Eyberg et al., 2014). Parent-child relationship-based play therapy was originally developed to treat externalizing and disruptive behavioral disorders in young children, and it has a substantial evidence base supporting its use for these issues (Thomas & Zimmer-Gembeck, 2007; Ward et al., 2016). Additionally, this therapy has evolved for use in treating various other conditions, such as autism spectrum disorder (Soder et al., 2019), anxiety (Phillips & Maichalsen, 2021), and selective mutism (Katchpoli et al., 2019).

Research on parent-child interaction therapy suggests it plays an essential role in fostering a sense of security in children (Salo et al., 2020), reducing behavioral disorders (Obalasi et al., 2022), and improving children’s quality of life (Orooji Aghdam et al., 2020). It also leads to more constructive parent-child relationships (Bahmani & Jahan-Bakhshi, 2020). Furthermore, attachment-based play therapy shares a close theoretical and research foundation with parent-child relationship-based play therapy (Sadeghi et al., 2022). It is a short-term intervention based on attachment theory, aiming to enhance self-regulation (Booth & Jernberg, 2009) and increase parental self-efficacy and the child’s emotional needs (Sundberg et al., 2020).

Based on previous research, children undergoing attachment-based play therapy experience a reduction in behavioral disorders (Van Zeijl et al., 2006) and improvements in parent-child attachment quality (Zekayi Ashtiani et al., 2022). Studies by Sadeghi (2020) on the effectiveness of attachment-based play therapy on maternal parenting self-efficacy, emotional regulation, and social adaptation in children; Zabihi (2016) on the effectiveness of attachment-based play therapy on maternal sensitivity and mother-child interaction; Mostafavi (2021) on the effectiveness of parent-child relationship-based therapy on emotional regulation and mental well-being of children with learning disabilities; and Saadat (2018) on the effectiveness of parent-child relationship-based play therapy (filial therapy) on parent-child relationships, happiness, and socio-emotional learning in children aged 4 to 6 have all been examined.

It is clear that both parent-child relationship-based play therapy and attachment-based play therapy are effective in reducing children's problems. However, what is important is to examine the effectiveness of these play therapy interventions on children with learning disabilities and compare the effectiveness of these two types of play therapy to identify a more effective therapeutic intervention for children with learning disabilities. Therefore, the research question is whether there is a difference in the effectiveness of parent-child relationship-based play therapy versus attachment-based play therapy on internalizing and externalizing behavioral disorders in children with learning disabilities.

Methods

Study Design and Participants

The research method, based on its goal, is applied, and in terms of data collection, it is quantitative and quasi-experimental with a pre-test, post-test design and a control group. The statistical population consisted of all elementary school children with learning disabilities in Birjand City during the 2022-2023 academic year, totaling 125 students. One school was selected from the available schools, and 45 eligible children were selected through purposive sampling and randomly assigned to three groups of 15. It is worth noting that Cohen's table was used to determine the sample size. At a 95% confidence level, with an effect size of 0.70 and a statistical power of 0.91, the required sample size for each group was 12. However, to account for potential attrition and increase the generalizability of the results, the sample size was increased to 15 per group. Inclusion criteria included informed consent to participate in the study, a score of 60 or higher on the Colorado Learning Disabilities Questionnaire, an age range of 7 to 12 years, enrollment in elementary school, and not receiving concurrent training. Exclusion criteria included incomplete responses on the post-test and follow-up questionnaires, and missing more than two play therapy sessions.

After coordinating with officials from the special education schools in Birjand, a call for interested participants to join the research project was issued. Since the research design was quasi-experimental, 45 children who scored above 60 on the Colorado Learning Difficulties Questionnaire were randomly assigned to three groups (15 in the parent-child relationship-based play therapy group, 15 in the attachment-based play therapy group, and 15 in the control group) using simple random sampling. Pre-tests measuring internalizing and externalizing disorders were administered to all three groups under the same conditions. The first experimental group received ethical approval before undergoing the therapeutic interventions, while the control group did not receive any play therapy interventions and continued their regular daily activities, remaining on a waitlist. After the therapy sessions, post-tests were administered to all three groups under similar conditions.

Measures

Learning Disabilities

This questionnaire contains 20 questions scored on a 5-point Likert scale, where 1 = never, 2 = sometimes, 3 = I don’t know, 4 = often, and 5 = always (Koryakina et al., 2019; Deh et al., 2020). The questionnaire developers assessed convergent validity by correlating it with academic achievement, reporting significant correlation coefficients ranging from 0.30 to 0.64 at the 0.01 level (Wilcutt et al., 2011). In Iran, the questionnaire was translated and standardized by Hajloo and Rezaei Sharif (2013), with Cronbach’s alpha coefficients ranging from 0.71 to 0.88 for different components and 0.90 for all items, indicating good internal consistency. Factorial validity was also evaluated, showing adequate model fit indices, confirming the questionnaire’s construct validity (Hajloo & Rezaei Sharif, 2013). In other studies, Cronbach’s alpha was reported as 0.83 (Veisi et al., 2019), 0.86 (Shivandi & Khalili, 2020), and in one study, Cronbach’s alpha was 0.90 with a test-retest reliability of 0.94 (Ghadiri Alamdari et al., 2022).

Behavioral Problems

The Child and Adolescent Behavioral Disorders Self-Report Form is designed for ages 4 to 18 and takes approximately 15 minutes to complete. It includes 112 items that assess three general categories: internalizing disorders (depression/anxiety with items 14, 29, 30, 31, 32, 33, 35, 45, 50, 52, 71, 91, 112; withdrawal with items 5, 42, 65, 69, 75, 102, 103, 111; somatic complaints with items 47, 51, 54, 56), externalizing disorders (delinquent behavior with items 2, 26, 28, 39, 43, 63, 67, 72, 81, 82, 90, 96, 99, 101, 105; aggressive behavior with items 3, 6, 19, 20, 21, 22, 23, 37, 57, 68, 86, 87, 89, 94, 95, 97, 104), and total problems (social problems with items 11, 12, 25, 27, 34, 36, 38, 48, 62, 64, 79; thought problems with items 9, 18, 40, 46, 58, 66, 70, 76, 83, 84, 85, 100; attention problems with items 1, 4, 8, 10, 13, 17, 41, 61, 78). Other behavioral issues are assessed with items 7, 24, 44, 53, 55, 74, 77, 93, 110. Certain items, such as 15, 16, 49, 59, 60, 73, 80, 88, 92, 98, 106, 107, 108, and 109, were removed from the questionnaire due to factor loadings below 0.30 (Habibi Asgarabad et al., 2009). The questionnaire is scored on a 3-point Likert scale, where 0 = not true, 1 = somewhat or sometimes true, and 2 = very true or often true (Faramarzi et al., 2011). In one study, test-retest reliability coefficients ranged from 0.67 to 0.90 (Yousefi et al., 2013). In international studies, Cronbach’s alpha was reported as 0.90, indicating high reliability (Kim-Spoon et al., 2019). Another study reported a Cronbach’s alpha of 0.76 (Hassan et al., 2019).

Interventions

Parent-Child Relationship-Based Play Therapy

This study used the parent-child relationship-based play therapy model developed by Adili et al. (2020), which was approved by the research supervisor and conducted in nine 60-minute sessions.

Session 1: The first session introduces the parent and child to the therapy process, setting the foundation for a trusting relationship. Goals and therapeutic principles are discussed, including the importance of empathy, parent sensitivity to the child’s needs, and positive reinforcement. Parents are introduced to the significance of play and the structure of future sessions, including setting consistent time and space for parent-child play.

Session 2: This session focuses on recognizing and empathizing with the child’s emotions, particularly joy, sadness, anger, and fear. Parents learn how to identify these emotions and respond empathetically. They are also introduced to core principles of play therapy, such as letting the child lead during play, and practice these skills through role-play exercises.

Session 3: Parents are taught four key principles of play therapy: allowing the child to direct the play, attending to the child’s emotional expressions, reflecting the child's emotions back to them, and setting clear, firm limits when necessary. The session also discusses the selection of appropriate toys for emotional expression and creativity.

Session 4: The focus is on the dos and don’ts of play sessions, emphasizing the importance of structure, consistency, and avoiding criticism or guided questions. Parents learn how to describe the child’s play verbally, enforce limits assertively, and allow the child to assume responsibility within the play space.

Session 5: Parents are trained in the three-step process for setting limits on inappropriate behaviors, starting with empathetic reflection of the child’s feelings, then stating the limit clearly and concisely, and finally providing an acceptable alternative. Timing of limit-setting is also discussed.

Session 6: The session revisits the importance of understanding the child’s emotions. Parents review essential play therapy skills, including maintaining structure, following the child’s lead, and avoiding directives or questions. The focus is on engaging in play, using imaginative roles, and aligning verbal and non-verbal communication with the child’s emotional state.

Session 7: Parents learn how to offer the child choices in a way that empowers them. Strategies for choice-giving are discussed, including using choices as positive consequences and reinforcing household rules. The session also reinforces core play therapy skills for the parents.

Session 8: This session reviews all previously covered topics, emphasizing the application of play therapy skills at home. Parents are encouraged to continue using choice-giving, limit-setting, and positive reinforcement. The session aims to consolidate the therapeutic techniques learned throughout the intervention.

Session 9: The final session focuses on advanced limit-setting, including explaining the consequences of actions. Parents learn how to generalize these techniques outside of the play sessions, applying them in daily life. A post-assessment is conducted to evaluate the child’s progress and the overall effectiveness of the intervention.

Attachment-Based Play Therapy

The attachment-based play therapy model developed by Zekayi Ashtiani et al. (2022) and Sadeghi et al. (2022) was also used, approved by the research supervisor, and conducted in nine 60-minute sessions.

Session 1: The session begins with introductions and an explanation of attachment theory, helping parents understand its relevance to their relationship with their child. Parents are encouraged to observe and reflect on their child’s attachment behaviors, while initial rapport-building play activities are introduced to strengthen the parent-child bond.

Session 2: This session focuses on engaging the parent and child in preliminary play activities, guiding the mother to recognize and respond to the child’s attachment cues. The emphasis is on creating a secure emotional connection through sensitive interactions.

Session 3: The first structured play interventions are introduced, allowing the child to express their emotions while the mother verbalizes and reflects on the child's behaviors. The focus is on observing and modifying negative parental representations in the mother-child relationship.

Session 4: The session continues with structured play, where the mother actively engages in reflective listening and verbalization of the child’s behaviors. Feedback is provided to the mother to help shift negative perceptions and strengthen the positive aspects of the relationship.

Session 5: Parents are encouraged to practice play skills at home, focusing on increasing their insight into their child’s behaviors. Empathy-building exercises help parents understand the child’s anxiety and behavioral challenges, with an emphasis on reducing negative parental responses.

Session 6: The session reviews the parent’s experiences with play at home. Feedback is provided, and role-modeling exercises help parents reinforce positive exploratory behaviors in their child while reducing anxiety-related responses. The session focuses on deepening parental sensitivity.

Session 7: The session continues to emphasize play between the mother and child, while addressing barriers to sensitive maternal behavior. The parent is guided in reshaping their mental representations of the mother-child relationship and understanding the child’s attachment needs.

Session 8: The focus is on increasing maternal responsiveness through reflection and observation of the child’s cues during play. Techniques are practiced to help the mother respond more sensitively, thereby reducing behavioral issues.

Session 9: The final session provides feedback on the overall progress of the mother-child relationship. The therapist reviews attachment behaviors, helps the parent consolidate new skills, and conducts a post-assessment to evaluate changes in the child’s internalizing and externalizing behaviors.

Data Analysis

Data from the pre-test and post-test were analyzed using appropriate statistical tests. Descriptive statistics, including means and standard deviations, were calculated, and inferential statistics, including mixed-design ANOVA, were used. The comparison between parent-child relationship-based play therapy and attachment-based play therapy and the comparison of pre-test and post-test stages were analyzed using SPSS version 24.

Findings and Results

The demographic results indicated that 62.5% of the target population were between 9 and 10 years old, while 37.5% were aged between 11 and 12 years. Descriptive statistics for the behavioral disorder variable, including the mean and standard deviation for the three study groups at pre-test, post-test, and follow-up stages, are presented in Table 1.

To ensure the normal distribution of the data, the Shapiro-Wilk test was conducted, as shown in the table below. The results indicated that the significance level for both groups was greater than 0.05, supporting the null hypothesis that the data for the behavioral disorder variable in the experimental and control groups were normally distributed at all three stages. Additionally, other assumptions necessary for multivariate covariance analysis were examined. Levene’s test for equality of variances showed significance levels of 0.13, 0.8, and 0.33 for internalizing, externalizing, and overall disorders, respectively, all above 0.05, confirming the homogeneity of error variances. To test the homogeneity of regression slopes, the F-interaction between the pre-test and group was calculated. Since the significance level for the interaction effects was greater than 0.05 for all three components (0.364, 0.339, and 0.2, respectively), the assumption of homogeneity of regression slopes was accepted.

The ANCOVA results in Table 2 showed that both parent-child relationship-based play therapy and attachment-based play therapy significantly reduced behavioral disorders in children with learning disabilities. Additionally, the effect size for the group variable was reported as 0.864, 0.773, and 0.654 for internalizing, externalizing, and overall disorders, respectively, indicating that these two interventions explained 86.4%, 77.3%, and 65.4% of the variance in internalizing, externalizing, and overall behavioral disorders in children with learning disabilities.

The Bonferroni test results for mean comparisons, as shown in the table above, indicate that the mean scores for internalizing, externalizing, and overall disorders in both the parent-child relationship-based play therapy and attachment-based play therapy groups were significantly lower compared to the control group. However, no significant difference was found between the two experimental groups in terms of mean scores for internalizing, externalizing, or overall disorders. This suggests that both parent-child relationship-based play therapy and attachment-based play therapy effectively reduced internalizing, externalizing, and overall disorders, but no significant difference was observed between the two in terms of effectiveness.

Discussion and Conclusion

In the second half of the 20th century, the world witnessed significant demographic changes. Global fertility rates dropped from five children per woman to 2.7 children. Part of these global demographic shifts is influenced by the globalization of fertility attitudes and behaviors. Similarly, Iran has experienced a significant decline in total fertility rates in recent decades. For instance, in 1966, the total fertility rate in Iran was around 7.7 children per woman, which decreased to 6.3 by 1976. Therefore, this study aimed to investigate the low motivation of young couples for childbearing in Shiraz through developing a conceptual model using a quantitative approach.

There was a significant difference between the economic support component and the components of personal growth inhibition, body self-concept, semantic attitude, communication, and social judgment, with the mean value of economic support being higher than that of the other components. This significance favored economic support. It can be explained that, although children give meaning to parents' lives, considering the financial conditions of families, parents view having children as requiring financial resources to meet their needs and expenses. According to the women interviewed, when parents are in poor financial conditions, having an additional child imposes significant costs. Given that modern life demands substantial financial resources, and since children today live in a world of hyper-consumption, the preference leans towards having fewer children to better meet their financial needs. Moreover, due to financial constraints, where the father’s income alone cannot cover living expenses, the mother also enters the workforce, contributing to the family’s income and child-related costs. However, this leads to a gap between the ideal and actual number of children. The primary concern of most people is economic challenges and financial problems. According to previous research, the main barriers to childbearing are concerns about securing a child’s future, increasing economic difficulties, and insufficient income. In this study, most participants cited financial concerns, economic instability, inflation, unpredictable economic parameters, and job insecurity as factors influencing their decision to have children or have more children. Economic fears, job insecurity, and fragile economic parameters are key factors in creating doubt about childbearing, as corroborated by other studies (Mousavi & Ghafelehbashi, 2013; Motlagh et al., 2016; Erfani & Shojaei, 2019). This finding aligns with the theoretical model of Fahlen and Ola (2018), which suggests that economic security (job and income security) affects individuals' sense of safety, which in turn influences their fertility intentions. A study by Abbasi-Shavazi and Khani (2014) also showed that economic insecurity impacts women’s low fertility behaviors and ideals.

On the other hand, people face numerous concerns, including economic, educational, social, and cultural concerns. Families, due to reduced institutional and social support, feel alone with these concerns, increasing their fear and hesitation about childbearing. Social responsibility was another factor that preoccupied respondents. Participants viewed the decision to have children as a responsible and conscious decision that comes with obligations and commitments. According to the theory of planned behavior, performing a behavior or achieving a goal is considered a rational act. Achieving intentions may be influenced by real limitations (such as low income) and interacts with perceived behavioral control (how income is perceived in relation to achieving the goal). Therefore, the current economic insecurities and social insecurities that participants mentioned affect their decisions regarding childbearing, leading to decisions to have fewer or no children. Supporting this finding, Lutz et al. (2006) argue that social security declines, risks, and economic uncertainties are factors influencing fertility intentions. Since young people are more exposed to these insecurities, their fertility ideals and intentions decline. Contrary to the study by Parvinian et al. (2018) and Aghayarihir et al. (2016), which attributed low fertility to the diminished value of motherhood, this study found that participants saw low fertility as a result of perceived responsibility for raising and supporting a child. This result aligns with the findings of Abdollahi and Farjadi (2016) and Khalajabadi-Farahani and Kiani-Aliabadi (2018).

There was no significant difference between personal growth inhibition and body self-concept, but there were significant differences between personal growth inhibition and the components of semantic attitude, communication, and social judgment, with the mean value of personal growth inhibition being higher than that of other components. The most significant meaning that women associate with low fertility is self-support. This indicates that women consider supporting their physical, psychological, and social conditions as a reason for their preference for having fewer children. The aspiration for career advancement, better social opportunities, and psychological well-being are dimensions of this self-support. Avoiding lagging behind their husbands in social and economic progress can result from a lack of confidence in the continuity of the marriage and insufficient trust in their spouse. Some women believed that if they focused solely on homemaking and childbearing without progressing socially and economically alongside their husbands, they might face physical and emotional exhaustion. Upon achieving social and economic success, their husbands might no longer find them desirable. Therefore, they do not want to sacrifice their current opportunities for future progress.

In contemporary society, with the increased importance of self and personal responsibility, the power of choice has also grown (Abbasi-Shavazi et al., 2014). As a result, individuals start to make choices regarding childbearing. They view having children as a personal choice and prioritize it after achieving their financial and social goals. They believe that pregnancy and childbearing can hinder personal growth. Due to their desire for self-advancement and self-realization, they prefer to focus on self-development before considering having children. It appears that some propositions of the second demographic transition theory apply here, as the theory attributes the shift to below-replacement fertility to changing values, personal development ideologies, and the importance of individual and social freedom. In this regard, the findings of this study regarding the centrality of self in childbearing align with the results of Parvinian et al. (2018) and Khalajabadi-Farahani and Kiani-Aliabadi (2018). The outcome is a value shift regarding fertility, where low fertility is supported by a set of new values, some of which result from the expansion of social connections at regional and transregional levels and are influenced by societal institutional resources (Mahmoudian et al., 2011).

There were significant differences between body self-concept and the components of semantic attitude, communication, and social judgment, with the mean of body self-concept being higher. Body image refers to an individual’s perception of their physical attributes, such as weight, shape, height, and skin color. It is a multidimensional perception involving cognitive, emotional, behavioral, and perceptual aspects. Physical appearance is a crucial part of body image, as it is the primary source of information in social interactions. Changes in body image, whether visible or invisible, can have a profound effect on an individual’s personality. Body dissatisfaction is a person’s negative subjective evaluation of their physical appearance. In the modern era, where a beautiful and flawless body is considered a source of status, body management is important to the women interviewed. As society places increasing focus on the human body, and beauty standards are continuously shaped by media and social atmospheres, some women associate pregnancy with fears of disrupting their physical appearance. For these women, preserving their body’s beauty and fitness is a significant factor, making them cautious when deciding about childbearing. Most women believed that pregnancy and childbirth would take them away from maintaining their ideal body image. These results are consistent with studies by Hajian et al. (2015), Hosseini and Beigi (2012), and Keyfi-Razavizadeh et al. (2015).

There were significant differences between the semantic attitude component and the communication and social judgment components, with the mean values of communication and social judgment being higher than that of semantic attitude. There was no significant difference between communication and social judgment. The fear of being judged by others, the stigma of being ridiculed, and societal pressures are other important factors that push parents toward limiting fertility. To conform and avoid social blame, parents limit their childbearing. These findings are consistent with studies by Hosseini and Beigi (2012), Keyfi-Razavizadeh et al. (2015), Rezaei et al. (2022), and Mehrizi et al. (2017). Finally, based on the model fit indices, it was observed that all indices were at acceptable levels, indicating that the model had a good fit.

Suggestions and Limitations

From this study, it can be concluded that using a qualitative approach and developing a conceptual model helped to investigate the low motivation of young couples for childbearing in Shiraz. There were significant differences between the economic support component and the components of personal growth inhibition, body self-concept, semantic attitude, communication, and social judgment. The mean value of the economic support component was higher than the others, favoring economic support. Based on this research, it is recommended that future studies focus on improving attitudes toward body self-concept, social judgment, semantic attitudes, and communication regarding childbearing. Experimental and quasi-experimental studies should be used to further explore this topic. The limitations of this research are related to its field study design and the distribution and return of questionnaires. Additionally, the study was conducted within a limited time frame, so the results may change over time.

Authors’ Contributions

All authors have contributed significantly to the research process and the development of the manuscript.

Declaration

In order to correct and improve the academic writing of our paper, we have used the language model ChatGPT.

Transparency Statement

Data are available for research purposes upon reasonable request to the corresponding author.

Acknowledgments

We would like to express our gratitude to all individuals helped us to do the project.

Declaration of Interest

The authors report no conflict of interest.

Funding

This research was carried out independently with personal funding and without the financial support of any governmental or private institution or organization.

Ethical Considerations

The study protocol adhered to the principles outlined in the Helsinki Declaration, which provides guidelines for ethical research involving human participants. This article is derived from the first author's Ph.D. dissertation at Marvdasht Branch, Islamic Azad University, Marvdasht, Iran. The dissertation topic was approved by the Department of Educational and Graduate Studies of the Faculty of Humanities, Marvdasht Branch, on November 29, 2021, with the registration code 162535589. We extend our gratitude to all participants in this study