Acceptability and expected changes in parental practices after an online behavioural parent program for ADHD during the Covid-19 pandemic

doi:10.21203/rs.3.rs-1830149/v2

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Research Article

Acceptability and expected changes in parental practices after an online behavioural parent program for ADHD during the Covid-19 pandemic

https://doi.org/10.21203/rs.3.rs-1830149/v2

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Background

Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder in children and adolescents, characterized by attention deficit, hyperactivity, and impulsivity. Treatments for this population should be multidisciplinary and must be initiated as soon as possible. Non-pharmacological interventions for ADHD include psychoeducation, parent behavioural training programs and school interventions and accommodations. In response to the COVID-19 pandemic, we developed an online version of a combined psychoeducation and behavioural training program to facilitate access to mental health treatment and ensure continuity of care. The study assessed the acceptability of this online parent training program, among parents and/or caretakers of children and adolescents with ADHD.

Methods

The program consisted of 10 online sessions over the course of 2 consecutive days (5 sessions a day). Satisfaction, usefulness and general comments about the program were assessed with open-ended questions and visual-analogous scales. Parents/caretakers’ use of strategies to manage behavioural problems was assessed using the Parenting and Family Adjustment Scales.

Results

A total of 206 parents participated in the online program and 175 of them completed the evaluation. Overall, participants were satisfied with the content of the program and found it beneficial for their child. The engagement was high and no major obstacles were identified to participation, except some internet connection issues. More than half of participants had already used some of the strategies included in the program. Despite this, some difficulties in implementing new strategies were observed.

Conclusions

Our study contributes to the growing body of papers evaluating online behavioral training program to improve their efficacy and content. With these measures, we hope to improve engagement in online psychoeducation and behavioural therapy programs. Future research evaluating online behavioural training programs should focus on ways to make them more accessible and adaptable to families’ obstacles.

Attention deficit hyperactivity disorder

lockdown

parental coping strategies

telehealth

Rationale

Attention deficit hyperactivity disorder (ADHD) is a frequent neurodevelopmental disorder in child and adolescent populations (1, 2). It is characterized by a triad of symptoms: attention deficit, hyperactivity, and impulsivity (3). According to the DSM-5 (3), the diagnosis can be confirmed when the symptoms are noticeable in various contexts and cause functional impairment. The prevalence of ADHD is estimated to be approximately 5% among school-aged children worldwide (4).

ADHD and its various clinical presentations (either predominantly attention deficit or both attention deficit and hyperactivity/impulsivity) cause marked functional impairment, leading to poor academic, professional, and personal outcomes (5). The majority of comorbid psychiatric disorders in this population is high, including learning disorders (specific learning disorders, developmental coordination disorder), externalizing disorders (oppositional defiant disorder, conduct disorder) and internalizing disorders (anxiety disorders, major depressive disorder and disruptive mood dysregulation disorder) (6). To maximize efficacy, treatment for children and/or adolescents with ADHD should be multidisciplinary and must be initiated as soon as possible (7).

Non-pharmacological interventions for ADHD include psychoeducation, parent behavioural training programs and school interventions and accommodations (8). Psychoeducation and behavioural training programs (BTPs) are usually delivered in a group format and are sometimes combined. A Cochrane review involving 284 children aged 5 to 18 years found that BTP improved child behaviour and reduced parental stress (9).

Recently, in response to the COVID-19 pandemic, practices of the child psychiatry department of the Montpellier University Hospital had to be adapted. With on-site groups posing an undeniable risk of SARS-CoV-2 infections and due to the sanitary restrictions in place, we developed an online version of a combined psychoeducation and BTP adapted from Barkley’s Parent Training Program (6) to facilitate access to mental health treatment and ensure continuity of care.

Objectives

In this study, our objective was to obtain participants’ feedback on the online Parent-BTP (P/BTP), exploring its acceptability by assessing parents’ satisfaction level and gathering their suggestions to improve both content and format. We also aimed to assess parenting strategies and motivation to change maladaptive strategies after completion of the program. The format of the study is exploratory without a specific a priori hypothesis.

Study Design

This was a survey study exploring the acceptability of the P/BTP held during the COVID-19 pandemic between February and May 2021. Participants took part in a 2-day training program. The link to the online questionnaire was distributed on the discussion forum towards the end of the sessions and was preceded by information about the aims and objectives of the study. Participation was anonymous and voluntary.

Study Population

Parents or legal representatives of children and adolescents with a diagnosis of ADHD according to the DSM-5 (3) diagnostic criteria who participated in the online P/BTP were asked to fill out an online survey. Parents were referred to the P/BTP through our ADHD outpatient consultation at the Child Psychiatry Department of Montpellier University Hospital (MPEA1, CHU Montpellier). The standard diagnostic procedure at our site consists of multidisciplinary assessments, including clinical interviews and parent and teacher questionnaires. Participation in the P/BTP is offered to parents or caretakers of all recently diagnosed patients or during follow-up for those who were not able to participate in previous on-site sessions. No exclusion criteria were specified.

Intervention

We developed an online P/BTP based on Barkley’s program for parents. This program consisted of 10 online sessions over the course of 2 consecutive days (5 sessions a day). The intervention was performed by a tandem of experienced clinicians (psychiatrists, psychologists, nurses or occupational therapists) through videoconference. One therapist led the sessions while the other monitored the chat and facilitated the discussion.

Outcome Measures

Data retrieval was performed anonymously via online forms designed with Formstack (Formstack, LCC – Fishers, Indiana, USA). This software was chosen because of its multiple personalization options, its ability to export data as Microsoft Excel files and the availability of technical support. Moreover, this website offers strong personal data protection features through encryption.

The questionnaire assessed different domains: 1) satisfaction / usefulness with the content of the program 2) satisfaction with the online format, 3) currently used parental strategies and specific questions related to strategies learned in the program 4) potential changes in parental strategies at the end of the program, and 5) suggestions for improvement of the program.

Satisfaction, usefulness and general comments about the program were assessed with open-ended questions and visual-analogous scales. Parents/caretakers’ use of strategies to manage behavioural problems was assessed using the Parenting and Family Adjustment Scales (PAFAS). The PAFAS is a 30-item self-report questionnaire for parents/caretakers that measures two domains of parent and family functioning related to child emotional and behavioural problems (10). PAFAS parenting practices consist of four factors: parental consistency, coercive discipline, positive encouragement and parent-child relationships. The PAFAS Family adjustment includes parental adjustment, family relationships and parental teamwork. Items on the PAFAS are rated on a 4-point scale and some are reverse scored. The PAFAS has shown good psychometric properties (10) and sensitivity to change (11). The scale has been used across different cultural contexts (12, 13) and the French translation has shown good internal consistency in a previous study (14).

Participants completed forms after two-day online BTP sessions, in February 2021 and May 2021. Links to the online forms were distributed on the chat at the end of the program.

Statistical and Qualitative Analysis

Descriptive statistics used Statistical quantitative analyses were performed using SPSS (IBM Corp. Released 2021. IBM SPSS Statistics Version for Windows, Version 28.0. Armonk, NY: IBM Corp).

Qualitative and textual data were analysed using NVivo version 12 (Windows 11 21H2 QSR International – Melbourne, Australia) and Microsoft Excel 365 (Windows 11 21H2, Microsoft Corporation – Redmond, WA – USA). Thematic analysis guided the data analysis. A multistage inductive coding process followed, where themes and subthemes were devised from the dataset. NVivo™ software was used for organizing and collating data. A strength of this method is that themes are continually added to depict complexities within the data, rather than reducing data into a minimal number of predetermined codes. Coding and themes were discussed with peers and project supervisors to improve reliability.

Descriptive statistics are presented as the means and standard deviations, and we used Pearson correlations coefficient with a threshold of p < 0,05 to investigate relations between parenting strategies and motivation to change.

Sample Characteristics

A total of 206 parents who participated in the online P/BTP received the evaluation questionnaire and 175 of them completed it.

The sample was distributed as follows: 121 mothers (69,1%), 22 fathers or stepfathers (12,6%) and in 32 cases both parents participated (18,3%).

The children with ADHD included 119 boys (68%) and 56 girls (32%). The mean age of the children was 9.5 years old (range between 5 and 20 years of age).

Feedback about program content

Five questions were provided in a format of Visual Analogue Scales ranging from 1 (not at all) to 10 (yes, absolutely).

Almost all (95,4%) participants thought their child was likely to benefit from their participation in the program. All participants but 1 were likely to recommend the program to other parents and 172 out of 175 participants (98,30%) believed that a similar program should be proposed to teachers.

A majority of parents (n = 120; 68,57%) were interested in participating in a more intensive BTP focusing on strategies to deal with problematic behaviour.

Feedback about the online format

When asked about their preferred format of delivery outside the context of any sanitary restrictions, 73 (41,7%) parents opted for an on-site program while 95 (54,3%) favoured an online format and 7 (4%) had no preference.

Parenting strategies

Parents’ usual strategies were assessed with the PAFAS based on the last four weeks prior to the program. PAFAS scores are shown in Table 1. Higher scores indicate lower positive parenting and family adjustment (e.g. lower levels of consistency, worse parent-child relationships.

Table 1

Min-Max, mean and SD of pafas parenting and family adjustment in our study sample.
	Minimum-Maximum	Mean	Standard Deviation
PAFAS Parenting
Parental Consistency	0–13	6.02	2.55
Coercive Parenting	0–15	6.49	3.45
Positive Encouragements	0–9	2.33	1.93
Parent-Child Relationship	0–14	5.03	2.81
PAFAS Family adjustment
Parental adjustment	0–15	6.27	3.04
Family relationships	0–12	3.59	2.66
Parental teamwork	0–9	2.94	2.52

For each item of assessing parenting strategies, we asked parents if they were likely to change their attitude after participation in the P/BTP program. For each responder, the number of parenting strategies likely to change ranged from 0–12 with a mean of 2.1 strategies (see Fig. 1).

A large proportion of parents (N = 75; 42.9%) did not consider changing any of their attitudes, 57 parents (32.6%) were likely to change 1 to 3 negative strategies and 43 parents (18,6%) were likely to change 4 strategies or more. The strategies most likely to change were the following: “I shout/get angry with my child when they misbehave”, “I follow through with a consequence (e.g. take away a toy) when my child misbehaves” and “If my child doesn’t do what they are told to do, I give in and do it myself”. The fewest changes were reported in items related to parents’ satisfaction with life, family support and quality of family relationships.

The number of strategies parents were likely to change was correlated with higher scores in PAFAS coercive parenting (r = 0.43; p < 0.001) and negative parent-child relationships (r = 0.27; p < 0.001).

The number of strategies parents were likely to change was correlated with the visual analogous score “gaining new information” through the program (r = 0.15; p < 0.048) and “utility of the program” (r = 0.15; p < 0.046), and negatively correlated with the item “number of strategies already implemented” (r = 0.25; p = 0.001).

Parental strategies were also assessed by questions regarding strategies directly trained in our P/BTP: task splitting, token economy, positive reinforcement, special moment and time-out. We asked whether parents already applied these different strategies before the program, those they considered implementing or intensifying after the program and those found the hardest to implement. The results are presented in Fig. 2.

Qualitative Analyses of Parental Suggestions

The following section describes the most recurrent themes and subthemes that emerged from textual thematic analysis. The two main themes were: 1) feedback and experiences around the online format and 2) feedback and experiences around content. Overall, feedback was positive, since most participants were satisfied with the content and online delivery method of the P/BTP (see Table 2).

Table 2

Satisfaction about P/BPT content rated with Visual Analogous Scales.
Item	Mean	Standard Deviation
Did you find this program useful?	8,75	1,84
Did this program change some misconceptions you previously had about ADHD?	7,48	2,78
Did this program provide information that was new to you about ADHD?	8,56	1,91
Have you had responses to your questions while participating in this program?	8,18	2,10
Did you already use some of the parenting strategies that were presented in the program?	5,97	3,01

Feedback and experiences around the online format

Parents reported increased accessibility due to online delivery since they did not need to use transportation means, especially if they were not based in Montpellier. Here are some examples of participants’ comments regarding accessibility: “It is very convenient because I live far away from Montpellier”, “It’s awesome because I have been able to take part in your program although I live in Nice. I am very grateful” and “Online delivery is truly great, I couldn’t have participated in a face-to-face program because I don’t have a driving licence. It’s perfect: I can participate from home”.

Despite the overall acceptance of the online format, some participants reported technical problems with this format, especially internet connection issues. Others emphasized that the high number of participants could lead to irrelevant comments in the chat. One parent reported “that there was a lot of participants, making the program harder to follow”, while another participant explained that: “the high number of participants discourages chat communication on experiences”.

Suggestions made by parents regarding these challenges included offering the training to a smaller group of participants, which in turn could reduce the number of irrelevant messages on the chat. Other participants suggested that only health care professionals should leave their video and microphone on, while one caretaker suggested that the training should “provide information on the delivery method and encourage non-talking participants to turn off the video and mic”. More suggestions included allowing participants to interact via chat with 2 different chat rooms: one for questions and one for sharing personal experiences.

Feedback and experiences around program content

Textual analysis of suggestions on program content allowed us to identify the following subthemes: adapting content to the child’s age, going more in-depth on certain concepts, receiving content before the program, popularizing the content, and adapting the program’s intensity to facilitate participation.

Adapting content to the child’s age

Some parents raised concerns about the child’s age and the appropriateness of the program to adolescents: “This program is not adapted to parents of adolescents. Most advice given applies to younger children. It would be better to create different groups according to the child’s age”. Participants suggested having two different groups: one for parents of children and one for parents of adolescents instead of a group covering all ages. Another participant suggested “separate the program into different subgroups by age class and the presence or absence of hyperactivity”.

Going more in-depth on certain concepts

Participants suggested the need to offer optional in-depth modules focusing on specific concepts, related to ADHD: “having different modules covering some issues more in depth”, “offering additional and shorter sessions on specific issues”, “adding a short session on tantrum management”, “adding content on panic attacks and anxiety linked to emotional dysregulation” and “adding more information about impulsivity and oppositional defiant disorder”. Another frequent piece of feedback was the need to focus on scheduling techniques if attention deficit was the main symptom as described by this parent: “we need modules to learn tools oriented towards managing attention deficit and its consequences such as poor scheduling skills and frequent oversight”.

Receiving content before the program

Some participants expressed their wish to receive slides beforehand to better follow on the chat and video: “it would be convenient if a link to download the slides beforehand was provided, allowing us to read and annotate it”. A prerecorded program was also suggested by most participants, allowing for viewing at any time and sharing the contents with teachers. One parent declared that “it would be a good thing to have a recording on hand because staying attentive for 6 hours is challenging”. Another one explained that “this program should definitely be offered to teachers allowing for better understanding and management of ADHD children at school.

Popularizing the content (e.g. simplifying the language to increase its understanding).

Participants suggested the use of a simpler lexicon and more detailed explanations about drug treatments. Information about nonpharmacological interventions was also requested. Some of the parents’ comments are as follows: “I liked the program as it was offered. My only suggestion would be to explain more lexicon specifically i.e., for newcomers”, “Information on risks and benefits of methylphenidate along with simplified psychopharmacological explanations would be useful”, “What brain cells does treatment act on?”, “Adding information on the role of the prefrontal cortex, the reward system and the effect of drug treatment on these components, possibly with illustration to facilitate understanding.” and “you only briefly talked about alternative medicine such as yoga, meditation and phytotherapy”.

Adapting the program to facilitate participation.

Some participants found that the program contained too much information to process in 2 days. Their experiences are illustrated by the following comments: “a 6-hour videoconference in a day is too much”, “way to dense, I feel tired” and “difficult to follow especially at the end when focusing on chat and health professionals at the same time is required”

Shorter sessions and longer breaks were suggested. Another proposition put forward by participants was to make a longer program with only one-half day session per day. For example, a parent suggested: “It would have been better to split sessions into 2- or 3-hour sessions, allowing for better sustained attention”.

Finally, feedback allowed us to consider that an additional session to answer questions and share experiences could be of interest. As stated in some comments: “I would need to talk about this program’s content in a month to adjust the way I implemented learnt strategies”, “It would be great to have access to reminders from time to time and to have the opportunity to discuss difficulties encountered implementing the content of the program” or “Is it possible to have a short feedback session at a later date to assess efficacy of implemented strategies?”.

In this study, we assessed the acceptability of the P/BTP, an online version of the Barkley’s Parents Training Program, among parents and/or caretakers of children and adolescents with ADHD. We also assessed pre-existing parental strategies and those that were reported to be implemented or intensified after completion of the program. Finally, we sought to evaluate the motivation to change non adaptive parental strategies at the end of the program.

With the rise of the digital age, research about online adaptations of the BTP is emerging (15, 16). These studies highlight the importance of an online alternative to face-to-face BTP where parent engagement may be challenged by logistical constraints (e.g., transportation, childcare, family schedule). Online BTP may overcome some of these barriers and increase access to BTP programs, while being effective on ADHD symptoms and behavioural disturbances (20, 21).

Regarding the online format, 54% of participants preferred online to direct delivery, whereas 42% favoured the opposite. Only 4% had no preference. This is in line with previous studies that reported increased parental satisfaction when using an online format (20). However, user feedback is mixed in more recent papers (16, 17). In our survey, online delivery was described as more convenient by some families, especially for those who have a child to attend to or who do not have access to easy transportation. However, participants needed to own a videoconferencing device, which may be out of reach for some families. Moreover, some participants might not be at ease with this new kind of delivery method. This can be partly mitigated by providing written instructions, recorded tutorials and a technical hotline. Providing participants with a digital copy of the slides as well as tools and working sheets can also ease the process of taking notes and completing the program. These documents could be made available beforehand.

A recurring request was to provide video and/or audio recordings of the sessions, thus allowing participants to watch the session when they had time and to pause and listen again to some parts. If this option is offered in future online BTPs, content provided by health care professionals could be recorded while leaving out confidential discussions. However, considering that the removal of such content will have to be processed afterwards, families would have to agree to being recorded and this could be another limiting factor. Therefore, audio or video classes preparing for the program could be prerecorded by health professionals and provided to parents after completion of the P/BTP.

Health care professionals should also consider implementing smaller group sessions by separating age groups (e.g., children and adolescents). During these sessions, techniques could be targeted to the child’s age and developmental needs and families could share their experience more easily, leading to better engagement and motivation regarding acquired skills and tools.

This P/BTP could be complemented, as reported, by specific optional more in-depth modules focusing on different ADHD symptoms. Parents’ feedback regarding the addition of specific modules was aimed at consolidating acquired strategies and learning new ones. Others suggested that these groups would be a great opportunity to focus on specific symptoms and/or comorbidities such as impulsivity or oppositional defiant disorder. Finally, another piece of feedback was to focus on techniques targeting attention deficit rather than impulsivity or behavioural problems for those whose attention difficulties were the most prominent.

Overall, participants in our study were satisfied with the content of the program. Most participants reported that the P/BTP was useful in providing them with new information about ADHD and allowing them to shake preconceived ideas. A better understanding of ADHD helps parents to consider ADHD-related problem behaviours as the consequence of differences in the sensitivity to the contingencies present in their children’s environment rather than deliberate misbehaviour or parental incompetence (18). This psychoeducational component included in most P/BTP for ADHD is considered a first step towards an optimization of the environment to the children’s specific needs and towards parental empowerment. The general positive feedback about our program is encouraging because, other studies of BTPs noticed that the more parents have a positive attitude towards the program, the greater they are involved and likely to implement positive strategies (19). More specifically, another study about BTP satisfaction found an association between parental satisfaction and positive behavioral attitudes towards their children (12).

Parental strategies were assessed using two different approaches: 1) a broad assessment of parental attitudes using a questionnaire and 2) specific questions directed towards the strategies specifically trained in our online P/BTP. In addition, we aimed to identify which strategies were already used and which ones were considered difficult to implement.

The PAFAS scores with the highest values indicating dysfunctional parenting or adjustment were found for consistent parenting, coercive parenting and parental adjustment. Positive encouragement was the dimension with the lowest scores. This pattern was also found in a previous study in children with ADHD and irritability (22), indicating the consistency of parental attitudes in similar clinical samples. A majority (51,2%) of participants declared motivation to change negative strategies or parental attitudes as assessed by the PAFAS after completion of the program.

The strategies most likely to change were those related to negative and inconsistent parenting with shouting and getting angry in the top-ranking position. Parents’ satisfaction with life, family support and quality of family relationships were considered least likely to change. These changes are consistent with the global objectives of online P/BTPs that are not specifically aimed at improving global family functioning but rather at reducing harmful parental strategies and developing skills. Our results seem to indicate that parents are more likely to reduce negative parenting than implement new skills.

The number of strategies likely to change was positively correlated with coercive parenting, negative parent-child relationships and the VA scales “utility of the program” and “gaining new information” through the program. However, a large proportion of parents did not consider changing strategies. Regarding the negative association between the number of strategies likely to change and the number of strategies already used, parents who were already familiar with positive parenting attitudes were probably less in need of modifying their attitudes.

More than half of the participants in our study had already used some of the strategies included in the online BTP. The use of positive reinforcement was cited as the most frequent strategy used before participation in the program followed by task-splitting and providing a special moment. Token economy and time out were the least frequently used and were also considered the most difficult to implement after the completion of the P/BTP. The differences between the declared use of positive reinforcement and the use of token economy might indicate that parents consider positive reinforcement as a general strategy of providing positive feedback without structured and enhanced reinforcement strategies using tokens or equivalents. This is also consistent with the PAFAS profile where positive encouragements were the positive strategy most frequently used.

Most parents considered implementing or intensifying positive parental strategies presented in the P/BTP, except for time-out with only half of the sample showing motivation to use or intensify this strategy. While we did not specifically explore what kind of difficulties in implementation were apprehended by parents, some participants suggested the addition of a follow-up session a few months later. This could allow us to problem-solve the difficulties encountered when implementing or intensifying strategies as reported previously (20). Indeed, most of the participants in our study were interested in an extension of the program focused on strategies to manage behavioural problems. We also need to consider that some parents may have ADHD with potential learning issues or dysfunctional reinforcement processing, thus necessitating the further consolidation of positive parental skills.

Factors that could increase parental engagement and motivation regarding BTPs have been identified (19, 21). A qualitative study by Smith et al., 2014 on the experiences of parents and health care professionals during parent training programs found the following factors to be associated with positive change: parental self-efficacy, support of other parents, convenient schedules, location of the program and ability to learn and maintain new skills over time.

Strengths and Limitations

Our study design has a number of strengths such as the sample size and the high participation rate. It allowed us to assess the satisfaction and acceptability of our online P/BTP and to gain useful insights into improvements in content and format. It also allowed us to gather information on potential changes in parental strategies postintervention. However, the generalization of these data is limited by the lack of socio demographic and clinical information and by the fact that, inherently, participants were required to have a computer or smartphone connected to the internet to participate.

While telehealth platforms can be convenient for both patients and health care professionals, they can also come off as impersonal and potentially decrease participants’ engagement (23). Our program differs from those offered on platforms because it was moderated in real time by trained clinicians and offers a chat feature to facilitate questions and answers.

We only assessed potential changes in parental strategies and we have no data supporting the continuation (or lack thereof) of these effects in the long term and in different contexts. In addition, our study has the limitations of online and parent-rated questionnaires without blinding or extensive experiential assessment as in qualitative interviews. Similarly, we did not have a control group or direct observation of children’s behaviour. Our results should therefore be considered preliminary and not indicative of the efficacy of our online P/BTP.

Clinical & Research Implications

One difficulty consistently reported by previous studies on BTP was to determine factors impacting participation in the program (24). Our study, exploring a new form of delivery, could provide information as to whether this new form of delivery can increase participation, even though further research is needed to generalize our results. A trial comparing online vs. face-to-face BTP in a larger population could give us better insight into the advantages and inconveniences of online delivery, preferably with blinded evaluation of changes via, e.g., at-home assessment by health care professionals or via teachers.

Special attention should be devoted to engagement and motivation to change among parents in the case of online delivery. Indeed, as previously stated, facilitating communication between participants in this setting probably necessitates the implementation of specific strategies such as the use of a chat. It could also be useful to compare engagement and motivation data between online and face-to-face deliveries.

Our study contributes to the growing body of papers evaluating online BTPs to improve their efficacy and content (25). Overall, no major obstacles were identified to participation, and engagement was high. Despite this, some difficulties in implementing new strategies were observed. As a result, future research evaluating online BTP programs should focus on ways to make them more accessible and on adapting them to families’ obstacles. With these measures, we hope to improve engagement in online BTP and the related motivation to change.

ADHD, Attention Deficit Hyperactivity Disorder, BTP, Behavioural Training Programs.

Acknowledgements

We gratefully acknowledge the parents who took the time to complete the questionnaire and give their feedback.

Competing interests

The author(s) declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Authors’ contributions

MR, HK, EF, DP-O contributed to the redaction, data analysis and interpretation of the data under supervision of HK. NF and JN contributed to the design and the realisation of the program. DP-O conceptualized and designed the questionnaire. All authors reviewed and approved the submitted version of the manuscript.

Availability of data and materials

The questionnaires and the datasets generated during the current study are available on request from the corresponding author (EF) on reasonable request.

Ethics approval and consent to participate

Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements.

Consent for publication

Not applicable

Funding

The author(s) declare that they have not received any funding for this work.

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No competing interests reported.

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Acceptability and expected changes in parental practices after an online behavioural parent program for ADHD during the Covid-19 pandemic

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