Design
This quasi-experimental study with a randomized control group was conducted in Isfahan province of Iran, in the autumn of 2019. Fifty-four primary school teachers were assigned to an intervention group (n = 27) and a control group (n = 27).
Participants
In this research, we used a multi-stage sampling method, where initially, one of the five Education Offices in Isfahan (Office 3) was randomly selected; afterwards, 12 elementary schools were randomly chosen from a list of elementary schools in that area (six public primary and six private schools). Three public and three private primary schools were randomly assigned as the intervention group and three public and three private primary schools were considered as the control group.
In the selected schools of both groups, all students with a definitive diagnosis of ADHD were identified based on their medical records, and their teachers were invited to participate in the study. Interested teachers were assessed for inclusion criteria (71 teachers). Ultimately, based on the inclusion criteria, eligible teachers (58 teachers) participated in the study as either intervention (n=31) or control (n=27) groups.
To participate in this study, teachers were required to meet the following inclusion criteria: (a) willingness to participate and (b) having at least two years of work experience as a schoolteacher. They were excluded from the study if they did not attend more than one session of training.
Procedure
The study was approved by the by the Research Deputy of Isfahan University of Medical Sciences (397796). In addition, The Ethics Committee of Isfahan University of Medical Sciences approved the study proposal (ID code: IR.MUI.RESEARCH.REC.1398.297). The required permission was obtained from the Education Department of Isfahan City. Participation was voluntary in the study, and prior to entering the study, the selected teachers provided written consent, and the study goals were delineated for them. Eligible teachers in the selected schools (of both groups) attended a single 30-minute assessment session to complete the assessment tools before the intervention. The training sessions were provided only for the teachers in the intervention group. Following two months, participants in both groups once again completed the questionnaires.
Measures
A self-reported questionnaire, developed by the researchers, was used for data collection. This questionnaire was developed based on a literature review to evaluate teachers' knowledge, attitudes, and behaviors to support children with ADHD (2, 9, 15, 16, 20, 22).
An expert panel, selected based on their qualifications and experience in health education, psychology, and ADHD, specified the face validity and content validity of the questionnaires.
The opinions of the experts resulted in minor modifications in the wording of several items. In addition, the expert panel indicated that the means CVI (item relevance) was acceptable for the questionnaires and their subscales. Finally, the questionnaire was tested in a classroom setting with 10 elementary school teachers, where they assessed the difficulty and understandability of the questionnaire. This tool had two main parts:
1- The demographic information checklist, including age, years of experience as a primary school teacher, education level, marital status, and prior participation in training workshops on ADHD.
2- The Teacher’s ADHD Knowledge, Attitude, and Behavior Scale. This scale comprises36 items and 3 subscales. Using 12 items, the first subscale measured the teacher’s general Knowledge on ADHD. The answers were designated as “true”, “false”, or “don't know”. Correct answers were given '2', incorrect answers were assigned '0', and don't know responses were considered as '1'. Examples of these items are as follows: attention deficit disorder only improves with medication, or children diagnosed with ADHD usually behave thoughtlessly. The correct answers were summed into a knowledge score where higher scores indicated a better knowledge of ADHD (range 0–36, α =0.89).
Using 12 items, the second subscale assessed teachers’ beliefs and attitudes about ADHD, scored based on a three-point Likert scale (disagree= 1, no idea= 2, and agree=3).
The answers were summed to reach an ADHD attitude score, where higher scores indicated a more positive attitude (range 12–36, α = 0.94). Here are some example items: I think it takes more time for students diagnosed with ADHD to do their classroom exercises or I think students diagnosed with ADHD need more support than their peers.
The third subscale consisted of 12 items to investigate teachers’ behaviors and strategies for managing ADHD children in the classroom. In the beginning of the subscale, the teachers were given a short scenario displaying the typical behavioral problems of an ADHD student in regular classrooms. Each item asked them questions on the strategies commonly recommended for use with ADHD students. For instance, reinforcement, organizing classroom/curriculum, negative consequences, emotional support, and planned ignoring. Teachers indicated their responses to items using a four-point Likert scale ranging from 1 (never) to 4 (most of the time). The answers were summed to generate a behavior score with higher scores indicating more support and better behaviors and strategies for managing children with ADHD. (range 12–48, α =0.95).
Intervention:
Based on an extensive review of relevant literature, the intervention was developed as a six-session training only for the teachers in the intervention group. The Classroom Accommodations for Children with ADHD (23) was selected by researchers as an intervention design framework.
Skilled and trained educators in the field of ADHD delivered conducted every session. Every session, presented in lecture format, ran lasted for 45 minutes to 1 hour (including a 10-min break) and it was presented in lecture format. Additionally, role‑playing and, and active participation in-group discussion were used employed as supportive activities in the intervention. The participants were encouraged to share their comments and questions during the presentation. In each session, two trained facilitators encouraged teachers to explore, discuss, and practice learned managing strategies. Via in-group work, teachers were provided with a good opportunity to hear others' experiences and share similar teaching and managing experiences with each other. They were able to modify their approaches to different classroom situations and receive confirmation and support for their individual practices to become more confident and effective. The contents of the sessions are as follows:
Session 1: defining ADHD: the symptoms and diagnosis, ADHD etiology and epidemiology, short-term and long-term consequences of ADHD, manifestations in the classroom, and common treatment strategies.
Session 2: the main principles to be considered in regard to the planning and management of programs for ADHD students.
Session 3: the main behavior strategies that must be taken used by the teacher to increase incentives, for example, increase increasing praise, approval, and appreciation of student’s good behavior and work performance.
Session 4: self-awareness training to display students’ work productivity on a daily chart or graph on the public.
Session 5: fundamental methods and measures for making rules and time clearer for ADHD students.
Session 6: The possible punishment methods in case of necessity. Moreover, a summary of medications used for ADHD treatment was provided to point out the effect of probably side effects such as stomachaches, insomnia, reduced appetite, growth problems, and irritability.
Statistical analysis
Because the teachers were randomly assigned to two groups, possible differences could still exist. Teachers’ age, years of experience, level of education, marital status, and prior training workshops on ADHD and student’s sex and school type (private or public) were compared between the 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 knowledge, attitudes, and behaviors before and after the intervention.
Analysis of covariance (ANCOVA) was applied to examine the effect of educational intervention. 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; also, pre-intervention scores were set as covariates and controlled for.
Statistical analyses were performed by the 20th version of the Statistical Package for the Social Sciences (SPSS) for Windows, with p ≤ .05 as the significance level.