Abstract
BACKGROUND:
Educating parents and teachers is very important in managing child behavior, so the present study investigates the effect of parent-teacher educational intervention on reducing ADHD symptoms in children.
MATERIALS AND METHOD:
This quasi-experimental study with a randomized control group before and after. The multi-stage cluster sampling method was used in this study. Seventy-two children and their parents and teachers participated in this study. They were selected using the multistage cluster sampling method and randomly divided into two groups of test and control. Data collected by CSI-4 questionnaire and researcher-made questionnaires (knowledge, attitude, practice) of parents and teachers. Parents and teacher in test group participated in training sessions. Student’s ADHD symptoms were assessed before and after the educational intervention.
RESULTS:
In this study, the mean (SD) age of the parents was 37.28 (6.24) and the age of the teacher was 45.50 (6/45). Covariance test show that, two months after the intervention, based on parent and teacher report, the mean total score of attention was increase significantly only in test group students. Also, the mean total of hyperactivity score was decreased significantly only in test group students (P < 0.001). Also, the score of knowledge, attitude, and practice of parents as well as teachers 2 months after the intervention was significantly higher than the control group (P < 0.001).
CONCLUSION:
Parents and teachers training and developing appropriate strategies to increase their awareness, attitude, and practice can diminish ADHD symptoms in all three aspects including inattention and reduce the side effects of ADHD. Planning in educating parents and teacher is essential to prevent impulsive and hyperactive behaviors.
Keywords: ADHD, education, intervention, Iran, parents, student, teachers
Introduction
Defining as a neurodevelopmental disorder, attention deficit disorder with hyperactivity (ADHD) is the most common developmental age disorder,[1] which affects many children around the world and progresses with hyperactivity, lack of attention, and impulsivity.[2] According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V-TR), there must be at least six of the nine problematic behaviors in a child confirmed by a mental health professional in order to diagnose ADHD. To ensure the diagnosis, it must last for at least 6 months, develop in two environments (e.g., school and home), and cause problems in the child’s academic and educational performance.[3] ADHD is highly heritable.[4] It is more common in boys than girls (5.2% vs. 2.7%).[5] The prevalence of the disorder is increasing worldwide.[6,7,8] Because of heterogeneity in the methodological approaches to diagnosis and reporting systems, various studies have reported prevalence rates for ADHD in a very wide range (from 0.2 to 34.5%).[9] In Yadegari et al.[10] study In IRAN, the prevalence of this disorder was reported to be 12% among students.
Many children with ADHD have at least one comorbid psychiatric disorder such as Learning Disorders, Anxiety Disorder, Behavior Disorder, Oppositional Defiant Disorder, and Depression.[11] The consequences of this complex disorder not only adversely affect the different aspects of the functioning of the individual but also affects the members of the family and society.[12,13] Due to the multiplicity and variety of problems of these children in different areas of behavioral, social,[14] psychological, educational,[15] emotional and cognitive,[16] different therapeutic approaches have been presented. The most effective of these are comprehensive management, which includes the use of stimulant medications, educating children and their parents, as well as behavioral correction techniques at school and at home.[17,18,19]
Parent training is one of the important behavioral treatments for children with ADHD.[20,21] Numerous studies have found parental education as one of the most effective methods in the treatment and control of ADHD.[22,23,24] Because of the consequence of their symptoms and executive functioning deficits or self-regulatory, children with ADHD pose significant problems for themselves and their families. Thus, it is important that parents be involved in any kind of ADHD treatment.[4] Knowing how to treat a hyperactive child properly makes parents understand that the child’s inappropriate behavior is not intentional. As a result, their understanding and acceptance of the child will increase, and they will have a positive attitude toward these children.[25] A community-based study of children with and without ADHD revealed that even when taking into account the severity of child ADHD symptoms and other comorbid conditions, negative parenting behaviors were associated with poorer child social and emotional functioning.[26]
On the other hand, teachers are in direct contact with students’ educational and behavioral issues on a daily basis. And they have a key role to play in identifying, referring, and treating hyperactive students.[27] So it is necessary to have the right knowledge and attitude toward these children, in order to be able to show proper performance.[13,20] Knowing how to properly treat a hyperactive child makes teachers realize that the child’s inappropriate behavior is not intentional, therefore, they would improve their understanding and acceptance of the child[28] and will have a positive attitude toward them. It also makes the children feel better about themselves and use a more effective way to improve their behavior instead of self-blaming.[29] Therefore, teachers need efficient knowledge about the problems and special needs of children with ADHD and they have to plan effective behavior management strategies in dealing with those children.[13,30] Although parent and teacher training programs have beneficial effects for children with ADHD, these approaches often target only one system (e.g., at home or at school).[30,31] However, the effectiveness of simultaneous intervention with regard to improving ADHD symptoms is limited.
However, the effectiveness of simultaneous intervention with regard to improving ADHD symptoms is limited. due to the high prevalence of attention deficit/hyperactivity disorder and its effect on Child’s mental health, as well as its irreparable consequences in adulthood, plus the prominent role of parents and teachers In the treatment of this disorder, seems a concurrent intervention program for parents and teachers is necessary to reduce symptoms of attention deficit/hyperactivity disorder, till the child behavior monitored in a coordinated manner at both home and school.
The study hypothesizes that parents and teacher participation in the intervention would lead to a decrease in children’s ADHD symptoms.
Materials and Methods
Study design and setting
This quasi-experimental study with a randomized control group before and after was conducted in Isfahan province of Iran, in the autumn of 2020. The multistage cluster sampling method was used in a way.
Seventy-two children and their parents and teachers participated in the study. Initially, among the six Education Offices in Isfahan, one of them was randomly selected (Office 3); then, 12 elementary schools were chosen randomly from the list of the elementary schools in that area (six public primary and six private schools). Selected schools were randomly assigned as the intervention group or the control group. In selected schools, all students with a definitive diagnosis of ADHD as obtained from their medical records were identified and their parents and teachers were invited to participate in the study and were evaluated for inclusion criteria. Finally, based on inclusion criteria the eligible student, parents, and teachers participated in the study as intervention or control.
For inclusion in the research, students in both groups were required to: (a) be between the ages of 6 and 12 years, (b) have a confirmed diagnosis of ADHD by a specialist, and (c) have no history of pervasive developmental disorder, neurological disorder, and traumatic brain injury according to the parent report. Parents were considered eligible to participate in the study if meet the following inclusion criteria: (a) have children who fulfilled mentioned above inclusion criteria, b) being willing to participate, and c) be able to read and write. To participate in this study, teachers required to meet the following inclusion criteria: (a) being willing to participate and (b) having at least two years’ work experience as a schoolteacher. Parents and teachers were excluded from the study if they were unavailable to complete the post-test or dropped more than two sessions of training.
Study participants and sampling
In selected schools in both groups, all students with a definitive diagnosis of ADHD based on their medical records were identified and their parents and teachers were invited to participate in the study. Those (80 parents) and (50 teachers) were evaluated for inclusion criteria. Finally, based on inclusion criteria the eligible parents (72 parents) participated in the study as intervention (n = 36) or control (n = 36) groups and teachers (48 teachers) participated in the study as intervention (n = 24) or control (n = 24) groups.
Participation in the study was voluntary. Before taking part in the study, selected parents and teachers were signed written consent, also study goals were described to them. After being informed by a member of the research project, eligible parents and teachers in selected schools (in both groups) attended a single assessment session of 30 minutes to complete the assessment tools before the intervention. The training sessions were provided only for the parents and teachers in the intervention group. After 2 months, participants in both groups completed the questionnaires again. Participants in the control group were offered free educational sessions after completion of the study.
Data collection tool and technique
In this study, in addition to demographics, 3 questionnaires were used. The first part is student and teacher demographic information. The second part is a researcher-made questionnaire (knowledge, attitude, and practice) of parents and teachers. Part 3 is the standard CSI-4 questionnaire of parents and teachers to determine the symptoms of the ADHD.
Developing by researchers, a self-reported questionnaire was used to data collection. These questionnaires was developed based on a review of the literature to assess teachers’ and parents’[32] knowledge, attitudes, and behaviors to support children with ADHD. An expert’s panel who was selected based on their qualifications and experience in health education, psychology, and ADHD determined the face validity and content validity of the questionnaires. This tool had two main parts: The special edition for parents of this tool includes 10 awareness questions, 10 attitude questions, and 10 performance questions and a special edition the teacher of this tool includes 12 knowledge questions, 12 attitude questions, and 12 performance questions. Cronbach’s alpha for parenting questions equals 0.74. Also Cronbach’s alpha for teacher questions equals 0.89.
Developed by Gadow KD, Sprafkin, the parent and teacher versions of the ADHD Symptom Checklist-4, a DSM‐IV-referenced rating scale, were used to measure ADHD symptoms.[33]
The 50-item ADHD-SC4 comprises six scales: ADHD: Hyperactive-Impulsive (HI), ADHD: Inattentive (IA), ADHD: Combined, Peer Conflict Scale, Oppositional Defiant Disorder, and Checklist of the Symptom Side Effects. However, in the current study, only items from the 9-item IA and 9-item HI scales were used. All items on the scales are scored on a Likert-type scale ranging from zero (never) to three (very often). Internal consistency and reliability also convergent and discriminant validity with respective scales for the IA and HI scales have been examined and supported previously.[33,34,35] The psychometric properties of the IA and HI scales (patent and teacher versions) in Iran have been examined and confirmed by Mohammad Esmaeel.[36] The important characteristics of Children, their parents, and teachers as sex, age, school type, and pharmacotherapy for ADHD were assessed with the demographic information checklist.
Intervention
Performing separately for parents (10 sessions) and teachers (6 sessions), the intervention was provided as group training sessions offered through a neighborhood public school that was consisted of weekly sessions only for the participants in the intervention group, spread over 2 months. The research team chose the parent training manual, Defiant Children[37] as an intervention design framework and adapted it as possible for use with Iranian families. And Classroom Accommodations for Children with ADHD were chosen by researchers as an intervention design framework for teacher.[38]
The trained and skilled educator in the field of ADHD delivered every session. Every session ran for 60 to 90 minutes (including a 10-min break) and it was presented in lecture format. In addition, role-playing, and active participation in-group discussion were used as supportive activities in the intervention.
The participants were encouraged to contribute their comments and questions during the presentation. In each session, two trained facilitators encouraged parent and teachers to explore, discuss, and practice-learned behavioral techniques. By engaging in-group work, parents had the best opportunity to listen, pay attention to others’ experiences, and share similar experiences with each other. Each session is briefly presented below.
Parent training
Session 1: General information on ADHD
In the beginning, to improve parent’s knowledge about ADHD and parental perceptions of the degree of deviance of their child’s behavioral problems, the educator provided a brief overview of the nature, prognosis, developmental course, and etiologies of ADHD. Facilitators provided parents with additional reading materials such as pamphlets and books.
Session 2: The causes of defiant/oppositional behavior
In the second session, the educator tried to correct potential misconceptions that parents have about defiance. So major contributors to the development of defiant or oppositional behavior in children such as child and parent characteristics, situational consequences for coercive and oppositional behavior, and stressful family were deeply discussed.
Session 3: Improving parental attention
In this session, to increase the value of parents’ attention to their children, more effective ways of attending to child behavior were trained. In this technique, occasional positive statements and verbal narration are provided to the child only when he/she displays appropriate behaviors. Parents were trained to increase their attention to compliant child behaviors while greatly reducing the amount of attention to unsuitable behaviors, as well as ignoring as much negative behavior as possible.
In addition, techniques of giving effective commands, eliminating or reducing setting activities that compete with child task performance, increasing imperatives, reducing task complexity were educated.
Session 4: Creating a Home Token Economy
In this session first, the concept of the token economy was taught to parents. The educator emphasized that to maintain suitable behavior and compliance, children with ADHD require more immediate, frequent, and noticeable consequences for their behaviors. Therefore, establishing a home token economy is critical to managing behavioral problems of children with ADHD. Parents were asked to list most of the children’s home responsibilities and privileges and then allocate point or chiP values such as points recorded in a notebook to each. To maintain the motivating properties of the program, they were encouraged to have a variety of incentives reinforces on their menu.
Session 5: Creating a home token economy (continued)
Since the token economy is an unfamiliar concept in the culture of Iranian families, most of the parents reported much difficulty implementing the home token economy. Hence, the fifth session extended the home token economy developed in session 4. Participants were encouraged to express their challenges and concerns. The educator and facilitators patiently answered the parent’s questions.
Session 6: Applying time out technique for noncompliance behaviors
To enable families to use response cost (removal of points or chips) contingent on noncompliance, an effective time-out-from-reinforcement technique was taught to parents.
First, the time-out procedure was introduced and its conditions and rules were expressed. Then parents practiced how to use this technique by role-playing.
Session 7: Applying time out technique for noncompliance behaviors (continued)
Similar to the token economy concept of the time-out procedure is unfamiliar in the culture of Iranian families; therefore, they reported much difficulty to implement it in their home. Parents in this session learned no new material; instead, any prior problems and challenges with applying this technique were reviewed and improved. Parents shared their experiences with each other and extended their abilities to use time out to noncompliant behaviors.
Session 8: Managing noncompliance behaviors in public places
Participants were trained to generalize their home behavioral management procedures to troublesome public places. They learned just before entering public places, stop and review two or three rules with their child, which the child may have formerly disobeyed and explain to he/she what reinforces are obtainable for obedience in the place, then explain what punishment may occur for disobedience, and finally give the child an activity to do during the outing.
Session 9: Refining child school behavior from home
To help parents appropriately support their child’s teacher with the management of behavior problems in the classroom, the educator focused on the use of a home-based reward program. The daily school behavior report card was introduced to parents. In addition, they were taught how to use this report card as the means by which consequences later in the day will be dispensed at home for classroom behavior.
Session 10: Review and summary
In the last session, the concepts and techniques taught in previous sessions were concisely reviewed, problems and difficulties, which have arisen in the last days, were discussed, and correction plans suggested to them.
Teacher training
Session 1: The definition of ADHD, its symptoms and diagnosis, ADHD etiology and epidemiology, short-term and long-term consequences of ADHD, manifestations in the classroom, common treatment strategies.
Session 2: The main principles that must be considered for the planning and management of programs for affected students with ADHD.
Session 3: The main behavior strategies that must be taken by the teacher to increase incentives, for example, increase praise, approval, and appreciation of student’s good behavior and work performance.
Session 4: Self-awareness training, to display student work productivity on a daily chart or graph on the public.
Session 5: Fundamental methods and measures to make rules and time clearer for affected students with ADHD.
Session 6: The appropriate punishment methods in case of necessity. Also in the last session, a summary of medications used for treatment of ADHD was provided to point out the effect of probably side effects such as stomachaches, insomnia, decreased appetite, growth problems, and irritability.
Ethical consideration
Research Deputy of Isfahan University of Medical Sciences provided ethical approval for the study (397796). Also, the Ethical Committee of Isfahan University of Medical Sciences approved the study proposal (ID code: IR.MUI.RESEARCH.REC.1398.297). In addition, the Education Department of Isfahan City provided the required permission.
Statistical analysis
Even though, we randomly assigned the parents and teachers to the two groups, possible differences could exist between them. The main demographic characteristics such as parents and teacher’s age and level of education, student’s sex, school type (private or public), attending any training workshop about ADHD were compared between the parents and teachers in intervention and control groups using descriptive statistics, Chi-square test and independent-sample t-test.
Independent t-tests were applied in both groups to examine the effects of the intervention on parent and teacher-rated symptoms of ADHD before and after the intervention. To examine the effect of the educational intervention analysis of covariance (ANCOVA) was applied. The post-intervention scores were set as the dependent variables and the group (two levels: intervention and control group) was set as a fixed factor as well as pre-intervention scores were set as covariates and controlled for.
Statistical analyses were done by the 20th version of the Statistical Package for the Social Sciences (SPSS) for Windows, with P = .05 as the significance level.
Results
The parents of 72 students with the disorder, who were eligible for the study, as well as 48 teachers of the same students were selected for the study. Each of them was divided into two groups [Figure 1].
Figure 1.
Flow-chart of the study
Independent t test showed that there was no significant difference between the mean and standard deviation of age of Study people, in the experimental and control groups. In addition, the average work experience of teachers in the experimental and control groups was not significantly different and the groups were in the same situation P ≥ 0.05).
Table 1 shows the characteristics of the study population in the experimental and control groups. The number of students who take the medicine was about 20% and 25% in the experimental and the control group, respectively. The majority of students in both groups lived with their parents (about 75% and 78% in the experimental and the control group, respectively). According to the demographic characteristics analysis, no significant differences were found all (p ≥ 0.05) between the parents and teachers in intervention and control groups.
Table 1.
Child and family characteristics for the Two Groups (Intervention vs. Control)
| Variable | Experimental |
Control |
P | ||
|---|---|---|---|---|---|
| Num. | % | Num. | % | ||
| Gender | |||||
| Female | 18 | 50 | 18 | 50 | 0.527 |
| Male | 18 | 50 | 18 | 50 | |
| Type of school | |||||
| Public | 24 | 66/7 | 27 | 66/7 | 0.599 |
| Private | 12 | 33/3 | 12 | 33/3 | |
| Taking medication | |||||
| Yes | 7 | 19/4 | 9 | 25/0 | 0.274 |
| No | 29 | 80/6 | 27 | 75/0 | |
| Live with | |||||
| Parents | 27 | 75 | 28 | 77/8 | 0.434 |
| One parent (mother) | 4 | 11/1 | 5 | 13/9 | |
| One parent (father) | 4 | 11/1 | 4 | 11/1 | |
| Mother Education | |||||
| A.D | 6 | 16/7 | 8 | 22/2 | 0.451 |
| B.S | 8 | 22/2 | 9 | 25 | |
| M.A or M.S | 20 | 55/6 | 17 | 47/2 | |
| Higher | 5 | 5/6 | 4 | 11/1 | |
| Father Education | |||||
| A.D | 6 | 16/7 | 8 | 22/2 | 0.500 |
| B.S | 8 | 22/2 | 5 | 13/9 | |
| M.A or M.S | 19 | 52/8 | 17 | 47/2 | |
| Higher | 3 | 8/3 | 6 | 16/7 | |
| Father’s job | |||||
| Employee | 23 | 63/9 | 20 | 55/6 | 0.367 |
| Freelancer | 9 | 63/9 | 12 | 55/6 | |
| Worker | 4 | 25 | 4 | 33/3 | |
| Mother’s job | |||||
| Employee | 16 | 44/4 | 13 | 36/1 | 0.594 |
| Housewife | 20 | 55/6 | 23 | 63/9 | |
As shown in Tables 2 and 3, at baseline, the scores on knowledge, attitude as well as behavior were not significantly different between the two groups. However, two months after the intervention, ANCOVA showed that the intervention group scored significantly higher on all three outcomes (P ≤ 0.001). The results of the paired t test showed a significant improvement in knowledge, attitude as well as behavior in the intervention group. However, in the control group, there was no statistically significant pre-to-post improvement on any teacher’s measures.
Table 2.
Mean scores and standard deviations knowledge, attitude, behavior of teacher for the two groups (intervention vs. control)
| Variable | Intervention group (n=24) |
Control group (n=24) |
P b | ||||||
|---|---|---|---|---|---|---|---|---|---|
| Baseline M (SD) | End M (SD) | Change M (SD) | P a | Baseline M (SD) | End M (SD) | Change M (SD) | P a | ||
| Knowledge | 26.45 (6.10) | 34.45 (6.99) | 8 (9.17) | <0.001 | 26.22 (6.97) | 27.04 (7.26) | 0.41 (1.31) | 0.135 | <0.001 |
| Attitude | 22.79 (8.52) | 31.50 (6.10) | 8.70 (7.34) | <0.001 | 25.12 (7.45) | 25.20 (7.39) | 0.08 (1.41) | 0.775 | <0.001 |
| Behavior | 25.20 (7.36) | 36.58 (7.58) | 11.37 (6.90) | <0.001 | 24.33 (6.20) | 24.04 (6.34) | -0.29 (0.69) | 0.051 | <0.001 |
P<0.05 was significant. Data reported based on Mean (SD). aP value was obtained from paired t-test. bP value was obtained from ANCOVA adjusted for baseline
Table 3.
Mean scores and standard deviations knowledge, attitude, behavior of parent for the two groups (intervention vs. control). PARENT
| Variable | Intervention group (n=36) |
Control group (n=36) |
P b | ||||||
|---|---|---|---|---|---|---|---|---|---|
| Baseline M (SD) | End (n=36) M (SD) | Change M (SD) | P a | Baseline M (SD) | End M (SD) | Change M (SD) | P a | ||
| Knowledge | 23.8 (2.637) | 30. (0.000) | 6.11 (2.63) | <0.001 | 23.63 (4.498) | 23.58 (4.674) | -0.55 (1.09) | 0.762 | <0.001 |
| Attitude | 21 (5.975) | 27.1 (5.975) | 6.14 (5.88) | <0.001 | 21.1 (4.738) | 20.91 (4.866) | -0.83 (1.25) | 0.692 | <0.001 |
| Behavior | 22.66 (3.699) | 31.97 (5.131) | 9.32 (4.24) | <0.001 | 23.55 (1.948) | 23.72 (2.132) | 0.166 (.8451) | 0.245 | <0.001 |
P<0.05 was significant. Data reported based on Mean (SD). aP value was obtained from paired t-test. bP value was obtained from ANCOVA adjusted for baseline
In the experimental group, the results showed a significant improvement on parent-reported inattention, hyperactivity symptoms. In the control group, there was no significant pre-to-post improvement on parent measures. On teacher measures, there were significant changes in either inattention, hyperactivity symptoms in the experimental group but there were no significant changes in the control group [Tables 4 and 5].
Table 4.
Mean and standard deviations of ADHD scores according to teacher report over time for the two groups (intervention vs. control)
| Variable | Intervention group (n=24) |
Control group (n=24) |
P b | ||||||
|---|---|---|---|---|---|---|---|---|---|
| Baseline M (SD) | End (n=24) M (SD) | Change M (SD) | P a | Baseline M (SD) | End M (SD) | Change M (SD) | P a | ||
| Inattentive (IA) | 26.91 (6.84) | 22.23 (6.55) | -4.67 (3.49) | <0.001 | 28.25 (6.43) | 28.02 (6.48) | -0.22 (1.14) | 0.245 | <0.001 |
| Hyperactive-Impulsive (HI) | 28.41 (5.28) | 23.32 (5.78) | -5.08 (3.81) | <0.001 | 27.33 (6.72) | 26.94 (6.74) | -0.38 (1.07) | 0.057 | <0.001 |
| Combined | 55.32 (9.39) | 45.55 (10.72) | -9.76 (5.69) | <0.001 | 55.58 (10.22) | 54.97 (10.43) | -0.61 (1.66) | 0.064 | <0.001 |
P<0.05 was significant. Data reported based on Mean (SD). aP value was obtained from paired t-test. bP value was obtained from ANCOVA adjusted for baseline
Table 5.
Mean and Standard Deviations of ADHD Scores According to Parent Report over Time for the Two Groups (Intervention vs. Control)
| Variable | Intervention group (n=36) |
Control group (n=36) |
P b | ||||||
|---|---|---|---|---|---|---|---|---|---|
| Baseline M (SD) | End (n=34) M (SD) | Change M (SD) | P a | Baseline M (SD) | End M (SD) | Change M (SD) | P a | ||
| Inattentive (IA) | 25.78 (6.76) | 21.05 (6.01) | -4.74 (3.97) | <0.001 | 25.38 (7.58) | 25.55 (7.53) | 0.16 (1.84) | 0.591 | <0.001 |
| Hyperactive-Impulsive (HI) | 27.02 (5.74) | 21.7 (6.34) | -5.32 (5.2) | <0.001 | 24.25 (6.95) | 23.98 (6.83) | -0.27 (1.72) | 0.056 | <0.001 |
| Combined | 52.82 (8.02) | 42.76 (10.49) | -10.05 (6.55) | <0.001 | 49.63 (8.26) | 49.13 (8.36) | -0.5 (2.46) | 0.232 | <0.001 |
P<0.05 was significant. Data reported based on Mean (SD). aP value was obtained from paired t-test. bP value was obtained from ANCOVA adjusted for baseline
Discussion
The present study aimed to the effect of educational intervention of parents and teachers on children with attention deficit hyperactivity disorder. For the first time in Iran, the present study examine whether the is the simultaneous educational intervention of parents and teachers effective on children with attention deficit hyperactivity disorder?
According to parent report, before the intervention, ADHD symptoms were not different in the two groups, but two months later in the experimental group, the disorder was significantly reduced in all aspects. The findings are similar to previous studies.[39,40] Two months after the intervention in the experimental group, the mean hyperactivity score was significantly reduced. Explaining the results of this study, it should be said that, the parents who do not parents who do not behave appropriately toward the hyperactive child, use negative behaviors toward children, which make them ineffective in controlling the child’s hyperactivity.[41] Also, two months after the intervention in the experimental group, the mean score of students’ inattention also increased. Contrary to this finding, no significant changes in students’ inattention score has been seen in previous studies.[41,42] The mean score of the students’ combined type (inattention and hyperactivity) also decreased. These findings are similar to previous studies.[43,44] The reason behind this could probably be a focus on parents and teacher training simultaneously could lead to a decrease in students’ inattention.
Comparison of the results of parents ‘knowledge, attitude, and practice regarding hyperactivity in children before and after the intervention showed that in the present study, two months after the educational intervention, parents’ knowledge, attitude, and practice in the intervention group increased. Several studies in Iran and other countries have emphasized the effect of parental interventions in reducing hyperactivity and provide the necessary information to parents for proper functioning of the hyperactive child.[39,45] Parents’ knowledge about ADHD makes them behave accurately toward the child and adjust their behavior according to the specific circumstances of the ADHD child with a positive attitude toward them, resulting in a reduction of impulsive and aggressive behaviors and improving the child’s attention.[46]
According to teachers’ reports, before the intervention, ADHD symptoms were not different in the two groups, but two months later in the experimental group, a significant decrease was seen in all subscales (inattention and hyperactivity). Similar to our study, numerous studies have shown the effect of teachers ‘educational intervention in reducing students’ disorder.[47,48,49] Because teachers interact with students on a daily basis, so, must have the skills to deal with inactive students in order to have a better and more lasting impact on children’s behavior.[50]
Comparison of teacher education results on hyperactivity in children before and after the intervention showed that in the present study, two months after the educational intervention, teacher knowledge, attitude, and practice in the intervention group increased. This finding is consistent with previous studies.[20,28,51] But, unlike the present study, there was no significant difference between before and after evaluations of teachers’ attitudes in a similar study in Saudi Arabia.[52]
In the present study, according to the parents and teachers, the mean score of students’ inattention after intervention significantly was decreased. Contrary to our study, numerous studies indicated that after educational interventions, the mean score of the inattention has decreased less than the rest of the parameters.[42,46] For example a study in Iran which compared the effectiveness of the use of parental and teacher behavior modification methods in reducing the symptoms of ADD and attention deficit disorder in elementary school students, revealed that after behavioral parent and teacher training there was no significant improvement in students’ inattention scores.[53] Researchers believe that inattention is more resistant to change because it has a stronger biological basis than other behavioral problems in children.[42,46] However, in our study, students’ inattention was significantly reduced. It seems that focus on parents and teacher training simultaneously could lead to a decrease in students’ inattention. In another word, because the child’s attention-related behaviors were controlled in a coordinated method, both at school and at home, which leads to reinforcing the child’s attention and reduces the inattention scores in students.
In our study, the intervention was found to be successful in reducing ADHD symptoms in the school setting based on the ratings of parents and teachers. Contrary to our results, in a previous study by Tamkeen in Pakistan after a behavioral parent, training there was a significant improvement in parent-reported ADHD symptoms, but teacher reports of symptoms and impairments generally did not show any improvement.[31]
Although in Iran schools are first-line providers of mental healthcare for students, most students with ADHD don’t take any formal school-based services to address their problems and complications. In addition, most of the services provided by school mental health providers commonly comprise of child-centered interventions that emphasize individual or small group counseling, without or with a limited engagement of parents and teachers. The present study supports the effectiveness and feasibility of behavioral parent and teacher training educations for children with ADHD applied in school settings as they significantly improve ADHD symptoms.
There are some limitations of this study. First, we measured only short-term effects of educational intervention, thus, sustainability of education effects requires further study with a long time follow-up. Second, this study did not measure academic performance. For a more accurate assessment of education effects, it is advisable to evaluate academic performance. Third, in the current research due to limited resources, this study could not measure other related items such as oppositional defiant disorder, peer conflict scale, and checklist of the symptom side effects parent variables (e.g., stress), and education acceptability. Future studies should include an expanded number of outcome measures.
Conclusion
In the present study, educational intervention of parents and teachers regarding ADHD disorder caused an improvement in the disorder symptoms in children. Therefore, it is necessary for parents and teachers to be trained simultaneously in order to see a better and more constant impact on children’s behavior and to reduce ADHD symptoms in all three aspects including inattention, impulsive-hyperactivity, and combination of both.
Ethical consideration
Research Deputy of Isfahan University of Medical Sciences provided ethical approval for the study (397796). Also, the Ethical Committee of Isfahan University of Medical Sciences approved the study proposal. (ID code: IR.MUI.RESEARCH.REC.1398.297). In addition, the Education Department of Isfahan City provided the required permission.
Financial support and sponsorship
The Research Deputy of Isfahan University of Medical Sciences provided the sources for this study.
Conflicts of interest
There are no conflicts of interest.
Acknowledgment
The authors like to express their appreciativeness to all parents and teachers participated in this study.
References
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