
==== Front
J Educ Health Promot
J Educ Health Promot
JEHP
J Edu Health Promot
Journal of Education and Health Promotion
2277-9531
2319-6440
Wolters Kluwer - Medknow India

JEHP-13-53
10.4103/jehp.jehp_1816_22
Original Article
Educational intervention of parents and teachers for children with attention deficit hyperactivity disorder
Hosseinnia Maede
Mazaheri Maryam Amidi 1
Heydari Zahra 2
PHD Student, Student Research Committee and Health Education and Health Promotion Group, Faculty of Health, Isfahan University of Medical Sciences, Isfahan, Iran
1 Department of Health Education and Promotion, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran
2 Department of Biostatistics, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran
Address for correspondence: Dr. Maryam Amidi Mzaheri, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran. E-mail: maryamamidi@hlth.mui.ac.ir
2024
26 2 2024
13 5322 12 2022
10 3 2023
Copyright: © 2024 Journal of Education and Health Promotion
2024
https://creativecommons.org/licenses/by-nc-sa/4.0/ This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
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.

ADHD
education
intervention
Iran
parents
student
teachers
==== Body
pmcIntroduction

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.[678] 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.[1213] 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.[171819]

Parent training is one of the important behavioral treatments for children with ADHD.[2021] Numerous studies have found parental education as one of the most effective methods in the treatment and control of ADHD.[222324] 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.[1320] 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.[1330] 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).[3031] 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.[333435] 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.[3940] 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.[4142] The mean score of the students’ combined type (inattention and hyperactivity) also decreased. These findings are similar to previous studies.[4344] 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.[3945] 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.[474849] 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.[202851] 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.[4246] 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.[4246] 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.
==== Refs
References

1. Cabral MDI Liu S Soares N Attention-deficit/hyperactivity disorder: Diagnostic criteria, epidemiology, risk factors and evaluation in youth Transl Pediatr 2020 9 Suppl 1 S104 13 32206588
2. Reale L Bonati M ADHD prevalence estimates in Italian children and adolescents: A methodological issue Ital J Pediatr 2018 44 108. 30185215
3. Epstein JN Loren RE Changes in the definition of ADHD in DSM-5: Subtle but important Neuropsychiatry 2013 3 455. 24644516
4. Evans S Ling M Hill B Rinehart N Austin D Sciberras E Systematic review of meditation-based interventions for children with ADHD Eur Child Adolesc Psychiatry 2018 27 9 27 28547119
5. Mohammadi MR Zarafshan H Khaleghi A Ahmadi N Hooshyari Z Mostafavi SA , Prevalence of ADHD and its comorbidities in a population-based sample J Atten Disord 2021 25 1058 67 31833803
6. Narad ME Garner AA Peugh JL Tamm L Antonini TN Kingery KM , Parent-teacher agreement on ADHD symptoms across development Psychol Assess 2015 27 239 48 25222436
7. Safavi P Ganji F Bidad A Prevalence of attention-deficit hyperactivity disorder in students and needs modification of mental health services in Shahrekord, Iran in 2013 J Clin Diagn Res 2016 10 LC25 8 doi: 10.7860/JCDR/2016/14481.7671 27190839
8. Adeboye M , Attention deficit hyperactivity disorder in ilorin: Screening with the conner’s teachers’ rating scale 2018 10 33 41
9. Hakim Shooshtari M Shariati B Kamalzadeh L Naserbakht M Tayefi B Taban M The prevalence of attention deficit hyperactivity disorder in Iran: An updated systematic review Med J Islam Repub Iran 2021 35 8 doi: 10.47176/mjiri. 35.8 33996659
10. Yadegari N Sayehmiri K Azodi MZ Sayehmiri F Modara F The prevalence of attention deficient hyperactivity disorder among Iranian children: A meta-analysis Iran J Psychiatry Behav Sci 2018 12 doi: 10.5812/ijpbs. 8990
11. Garreta E Jimeno T Servera M Analysis of the effectiveness of a training program for parents of children with ADHD in a hospital environment Actas espanolas de psiquiatria 2018 46 21 8 29417978
12. Espases US Analysis of the effectiveness of a training program for parents of children with ADHD in a hospital environment Actas Esp Psiquiatr 2018 46 21 8 29417978
13. Hosseinnia M Mazaheri MA Heidari Z Knowledge, attitude, and behavior of elementary teachers regarding attention deficit hyperactivity disorder J Educ Health Promot 2020 9 120. 32642476
14. Khademi M Rajeziesfahani S Noorbakhsh S Panaghi L Davari-Ashtiani R Razjouyan K , Knowledge and attitude of primary school teachers in Tehran/Iran towards ADHD and SLD Glob J Health Sci 2016 8 141 9
15. Khodabakhshi Koolaee A , The effect of positive parenting program training in mothers of children with attention deficit hyperactivity on reducing children’s externalizing behavior problems 2015 17
16. Alfageer HH Alfageer H Al Queflie S Masud N Al Harthy N Alogayyel N , Knowledge and attitude of male primary school teachers about attention deficit and hyperactivity disorder in Riyadh, Saudi Arabia J Nat Sci Biol Med 2018 9 257 62
17. Mulholland SM Cumming TM Jung JY Teacher attitudes towards students who exhibit ADHD-type behaviours Australas J Spec Educ 2015 39 15 36
18. Coles EK Pelham WE Fabiano GA Gnagy EM Burrows-MacLean L Wymbs BT , Randomized trial of first-line behavioral intervention to reduce need for medication in children with ADHD J Clin Child Adolesc Psychol 2020 49 673 87 31411903
19. Schechter JC Kollins SH Adaptations to behavioral parent training for children with ADHD: Promoting access, engagement, and treatment effectiveness ADHD Rep 2019 27 1 6 10, 11, 12. doi: 10.1521/adhd. 2019.27.1.1
20. Latouche AP Gascoigne M In-service training for increasing teachers’ ADHD knowledge and self-efficacy J Atten Disord 2019 23 270 81 28494656
21. van der Oord S Tripp G How to improve behavioral parent and teacher training for children with ADHD: Integrating empirical research on learning and motivation into treatment Clin Child Fam Psychol Rev 2020 23 577 604 32968886
22. Dekkers TJ Hornstra R van der Oord S Luman M Hoekstra PJ Groenman AP , Meta-analysis: Which components of parent training work for children with attention-deficit/hyperactivity disorder? J Am Acad Child Adolesc Psychiatry 2022 61 478 94 34224837
23. Chen YC Hwang-Gu SL Ni HC Liang SH Lin HY Lin CF , Relationship between parenting stress and informant discrepancies on symptoms of ADHD/ODD and internalizing behaviors in preschool children PLoS One 2017 12 e0183467 doi: 10.1371/journal.pone. 0183467 29016602
24. Yao A Shimada K Kasaba R Tomoda A Beneficial effects of behavioral parent training on inhibitory control in children with attention-deficit/hyperactivity disorder: A small-scale randomized controlled trial Front Psychiatry 2022 Apr 27 13 859249 doi: 10.3389/fpsyt. 2022.859249 35573335
25. Nawabzada S Steiner NJ Lodha P Karia S Prevalence of ADHD in children and knowledge and attitude of parents about ADHD in a tertiary hospital in Mumbai, Maharashtra, India 2021 Available from: https://hsrc.himmelfarb.gwu.edu/cgi/viewcontent.cgi?article=1037 and context=gw_research_showcase
26. Bhide S Sciberras E Anderson V Hazell P Nicholson JM Association between parenting style and socio-emotional and academic functioning in children with and without ADHD: A community-based study J Atten Disord 2019 23 463 74 27474160
27. Menikdiwela KR Vojtova V Attention-deficit/hyperactivity disorder through Sri Lankan primary school teachers’ eyes J Educ Pract 2017 8 4 10
28. Lasisi D Ani C Lasebikan V Sheikh L Omigbodun O Effect of attention-deficit-hyperactivity-disorder training program on the knowledge and attitudes of primary school teachers in Kaduna, North West Nigeria Child Adolesc Psychiatry Ment Health 2017 11 15 doi: 10.1186/s13034-017-0153-8 28331540
29. Lewis E Including a Pupil with Attention Deficit Hyperactivity Disorder: Exploring Teachers Perspectives 2018
30. Amiri S Noorazar SG Fakhari A Darounkolaee AG Gharehgoz AB Knowledge and attitudes of preschool teachers regarding attention deficit hyperactivity disorder Iran J Pediatr 2017 27 doi: 10.5812/ijp. 3834
31. Malik TA Rooney M Chronis-Tuscano A Tariq N Preliminary efficacy of a behavioral parent training program for children with ADHD in Pakistan J Atten Disord 2017 21 390 404 24621459
32. Barkley RA Poillion MJ Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment Behav Disord 1994 19 150 2
33. Sprafkin J Gadow KD Nolan EE The utility of a DSM-IV-referenced screening instrument for attention-deficit/hyperactivity disorder J Emot Behav Disord 2001 9 182 91
34. Mattison RE Gadow KD Sprafkin J Nolan EE Schneider J A DSM-IV- referenced teacher rating scale for use in clinical management J Am Acad Child Adolesc Psychiatry 2003 42 442 9 12649631
35. Gadow KD Sprafkin J Salisbury H Schneider J Loney J Further validity evidence for the teacher version of the child symptom lnventory-4 Sch Psychol Q 2004 19 50 71
36. Mohammad Esmaeel E Adaptation and standardization of child symptom inventory-4 (CSI-4) J Except Child 2007 7 79 96
37. Barkley RA Treating ADHD in Children and Adolescents Guilford Publications 2022
38. Barkley RA Classroom accommodations for children with ADHD ADHD Rep 2008 16 7 10
39. Loren RE Vaughn AJ Langberg JM Cyran JE Proano-Raps T Smolyansky BH , Effects of an 8-session behavioral parent training group for parents of children with ADHD on child impairment and parenting confidence J Atten Disord 2015 19 158 66 23599209
40. Booster GD Mautone JA Nissley-Tsiopinis J Van Dyke D Power TJ Reductions in negative parenting practices mediate the effect of a family–school intervention for children with attention deficit hyperactivity disorder School Psychol Rev 2016 45 192 208
41. Pordel H Mahmood Lilo M Tajvar A Hejazipor M Effectiveness of children’s management skills training in decrease of attention deficit hyperactivity disorder Thoughts Behav Clin Psychol 2012 7 67 76
42. Zwi M Jones H Thorgaard C York A Dennis JA Parent training interventions for attention deficit hyperactivity disorder (ADHD) in children aged 5 to 18 years Cochrane Database Syst Rev 2011 2011 CD003018 doi: 10.1002/14651858.CD003018.pub3 22161373
43. Khanduri V Effectiveness of Educating Parents of Children with Attention Deficit Hyperactivity Disorder (ADHD) on Children’s Behavioral Issues and the Stress Experienced by Parents: An Integrative Review 2017
44. Raghibi M Fouladi S Bakhshani NM Parent training and behavior therapy on behaviors of children with attention deficit-hyperactivity disorder Health Scope 2014 3 e15418.
45. Malekshah SH Alizadeh H Pezeshk S Soheili F The effectiveness of Adlerian parent training on executive functions in children with attention deficit/hyperactivity disorder Adv Cogn Sci 2017 18 88 98
46. Pasha R The effectiveness of parents’ behavior modification on the degree of hyperactive children’s unpleasant behavior Knowl Res Appl Psychol 2017 17 90 8
47. Moldavsky M Sayal K Knowledge and attitudes about attention-deficit/hyperactivity disorder (ADHD) and its treatment: The views of children, adolescents, parents, teachers and healthcare professionals Curr Psychiatry Rep 2013 15 377 doi: 10.1007/s11920-013-0377-0 23881709
48. Staff AI van den Hoofdakker BJ van der Oord S Hornstra R Hoekstra PJ Twisk JWR , Effectiveness of specific techniques in behavioral teacher training for childhood ADHD: A randomized controlled microtrial J Clin Child Adolesc Psychol 2021 50 763 79 33471581
49. Ward RJ Bristow SJ Kovshoff H Cortese S Kreppner J The effects of ADHD teacher training programs on teachers and pupils: A systematic review and meta-analysis J Atten Disord 2022 26 225 44 33331193
50. Al-Omari H Al-Motlaq MA Al-Modallal H Knowledge of and attitude towards attention-deficit hyperactivity disorder among primary school teachers in Jordan Child Care Pract 2015 21 128 39
51. Aguiar AP Kieling RR Costa AC Chardosim N Dorneles BV Almeida MR , Increasing teachers’ knowledge about ADHD and learning disorders: An investigation on the role of a psychoeducational intervention J Atten Disord 2014 18 691 8 22851210
52. Aldawodi M Alfageer H Al Queflie S Masud N Al Harthy N Alogayyel N , Knowledge and attitude of male primary school teachers about attention deficit and hyperactivity disorder in Riyadh, Saudi Arabia J Nat Sci Biol Med 2018 9 257 62
53. Shaban S Baba M Mohd Noah S Wan Jaafar WM School-based multi-component intervention. Symptoms of Iranian ADHD children Asian Soc Sci 2015 11 212.
