Promote-Parents Program adapted for guardians of children and adolescents with ADHD

Abstract

Parental educational practices act on the behavioral repertoire of children. This study aimed to verify the effects of the adapted Promote-Parents program on the behavioral repertoire of children and adolescents diagnosed with ADHD and their primary caregivers. Seven schoolchildren and their caregivers participated in the study, and they were evaluated before and after the intervention using the Roteiro de Entrevista de Habilidades Sociais Educativas Parentais (RE-HSE-P, Parental Educational Social Skills Interview Script), the Conners Scale, and the Social Skills Rating System (SSRS-BR). There was an increase in skillful behaviors, a reduction in behavior problems and ADHD symptomatology among the children/adolescents, a decrease in negative educational practices, and an increase in educational social skills among the caregivers. It was concluded that the program generated positive effects, in addition to being of low cost.

Keywords
Attention-Deficit/Hyperactivity Disorder; children; adolescents; parental educational practices; intervention

Resumo

As práticas educativas parentais atuam sobre o repertório comportamental dos filhos. O objetivo deste trabalho é verificar os efeitos do programa Promove-Pais adaptado ao repertório comportamental de crianças e adolescentes diagnosticados com TDAH e de sua cuidadora principal. Participaram sete pessoas em período escolar e suas respectivas cuidadoras, avaliados antes e após a intervenção por meio do Roteiro de Entrevista de Habilidades Sociais Educativas Parentais (RE-HSE-P), Escala de Conners e Social Skills Rating System (SSRS-BR). Observou-se aumento em comportamentos habilidosos, redução de problemas de comportamento e sintomatologia de TDAH nas crianças/adolescentes e redução de práticas educativas negativas e aumento de habilidades sociais educativas nas cuidadoras. Conclui-se que o programa gerou efeitos positivos, além de ter baixo custo.

Palavras-chave
Transtorno de Déficit de Atenção e Hiperatividade; crianças; adolescentes; práticas educativas parentais; intervenção

Resumen

Las prácticas educativas parentales influyen en el repertorio comportamental de los hijos. El objetivo de este trabajo fue verificar los efectos del Programa Promove-Pais adaptado al repertorio comportamental de niños y adolescentes diagnosticados con trastorno por déficit de atención con hiperactividad (TDAH) y de su cuidadora principal. Participaron siete escolares y sus cuidadores; quienes fueron evaluados antes y después de la intervención mediante un Guion de Entrevista de Habilidades Socioeducativas Parentales (RE- HSE-P), la escala de Conners y el Sistema de Calificación de Habilidades Sociales (SSRS-BR). Se observó un aumento de las conductas hábiles, una reducción de los problemas de conducta y de los síntomas de TDAH en los niños/adolescentes, y una reducción de las prácticas educativas negativas y un aumento de las habilidades socioeducativas en las cuidadoras. Se concluye que el programa generó efectos positivos, además de ser bajo coste.

Palabras clave
Trastorno por Déficit de Atención con Hiperactividad; niños; adolescentes; prácticas educativas parentales; intervención

Attention-Deficit/Hyperactivity Disorder (ADHD) is a multicausal neurobehavioral disorder characterized by persistent patterns of inattention, impulsivity, and hyperactivity, present in two different contexts (home and school), beginning in childhood and remaining in adulthood (American Psychiatric Association [APA, 2014]; Du Paul et al., 2019; Paiano et al., 2019). Studies in the field consider ADHD predictive of impairments in children's mental health and social and academic development (APA, 2014; Posner et al., 2020), with a high risk of the development of comorbidities throughout life, such as mood and conduct changes and substance abuse (Storebø et al., 2018; 2019; Willis et al., 2019). The estimated prevalence among schoolchildren with ADHD is from 3% to 8% of the population (Barbarini, 2020; Brasil, 2022; Posner et al., 2020), with a higher incidence among boys, about 2:1 in children and 6:1 in adults (APA, 2014). Considering the significant numbers that indicate that a portion of the child population has ADHD, there is a need for debates and clashes regarding the diagnosis and treatment. The increase in diagnosed cases, medication prescriptions, and legal proceedings that subsidize rights in education and the work environment places ADHD under suspicion (Caliman, 2008; Silva & Batista, 2020), given that errors in its diagnosis and subsequent treatment may occur. In this direction, the study by Abrahão and Elias (2021) identified that of 43 children enrolled in public schools with ADHD medical reports in their records, only three met the criteria according to the ADHD symptom screening scale, considering the multi-informer evaluation. To avoid errors in this regard, authors have indicated multimodal evaluations, which are carried out by multidisciplinary teams using different techniques and informers (Abrahão & Elias, 2021; Barkley, 2002; Beltrame et al., 2019; Caliman, 2008; Moýses, 2013; Pelham et al., 2016), the criteria of which are based on scientific evidence (Brasil, 2022; Fabiano et al., 2021; French et al., 2019; Posner et al., 2020). Currently, combined treatment (psychological and medication) is recommended, including family, teachers, and peers, in addition to individual care with the child/adolescent (Barkley, 2002; Brasil, 2022; Braga et al., 2022; Fabiano et al., 2019; 2021; Posner et al., 2020), starting with assistance to the schoolchild and guidance to the contexts (family and schoolchildren), with the addition of medication being a complementary step if necessary (Pelham et al., 2016).

It is also noteworthy that, in addition to the issues of failures in diagnosis, treatment, and medication use, there is a discussion worldwide and in Brazil about the very existence of the disorder, with the biologization of bodies to the detriment of social-historical processes being questioned (Beltrame et al., 2019; Depathologize, 2016; Moysés & Collares, 2013). Nowadays, when the neoliberal system prevails, it must be considered that being within the norm is a condition, acting within modern society, i.e., a disciplinary society; while individualizing, normalization makes the individuals comparable to each other, dividing them into groups (Silva & Henning, 2014; Veiga-Neto, 2000). Within this larger context, political, economic, and social-historical issues that govern people are considered; pathologization and medicalization need to be thought of from this perspective, and in the Brazilian scenario, the movement against the medicalization of schoolchildren is evident (Conselho Federal de Psicologia [CFP], 2015; Depatologiza, 2016; Moysés & Collares, 2013).

The importance is highlighted of issues related to the different ecological systems that impact the development of an individual from micro to macro systems, i.e., from educational practices to issues of public and cultural policies, which may act as risk factors (e.g., negative educational practices, stigmas, pathologization, difficulties in the school and medical systems, excessive medicalization, diagnostic errors) or protective factors (e.g., positive educational practices, educational policies, pedagogical strategies), which act in the school experiences and subjective constitution of students with ADHD (Abrahão, 2021; Abrahão & Elias, 2022). Law 14254/21 stands out, as it provides for comprehensive monitoring of students with ADHD, dyslexia, and learning disorders, focusing on early identification, diagnosis, educational support in the education network, and therapeutic support in the health network, with it being up to public and private education networks, health services, and the family to guarantee the care and development of these students (Brasil, 2021). Although this law is an advance in guaranteeing the rights of this population, care must be taken so that it is effective and does not increase a stigma narrative, especially in the school context.

It is acknowledged that children with ADHD need educational practices that consider the presence of characteristic behavioral patterns (difficulties in interpersonal relationships with adults and peers), attention difficulties, impulsivity, among others, which predict risks of school exclusion (Barkley, 2002; Gwerman et al., 2016; Abrahão et al., 2022) and impact family relationships (Benczik & Casella, 2015; Breaux & Harvey, 2018; Duh-Leong et al., 2020; Johnston, 1996; D Rezende et al., 2019). The family interactions of parents with children with ADHD are characterized by conflicts, resulting in disharmony and discord, impacting the quality of life of all involved (Breaux & Harvey, 2018; Johnston, 1996; Duh-Leong et al., 2020; Weels, 2000). The mental health of family members may be affected, with signs of depression, low self-esteem, feelings of failure and incompetence regarding the role of parents, little satisfaction with the involvement in parental responsibilities compared to other parents (Johnston, 1996), difficulties in parental practices due to stress levels, problems in establishing rules and limits, and difficulties in manifesting affection and communication (Rezende et al., 2019) being commonplace.

Educational practices are strategies used by parents to develop socially accepted behaviors and stimulate independence, autonomy, and responsibility in their children, i.e., they influence the behavioral development of children; how parents employ such practices (e.g., frequency, intensity, quality) defines the parental style (Gomide, 2003). Parental practices are divided into two categories: negative and positive. Positive practices involve positive monitoring (proper use of attention) and moral behavior (promotes conditions for developing virtues). In turn, negative educational practices include neglect (parents without responsiveness), negative monitoring (stressful supervision), inconsistent punishment (punishment according to one's mood), relaxed disciplining (attitudes of threats and non-compliance with what was agreed and boundaries), and physical abuse (Gomide, 2006; Andrade, 2015).

Rielly et al. (2006) conducted a study verifying the educational practices used by parents evaluated by children with ADHD. The results showed that parents had more negative practices (such as inconsistent disciplining) than positive ones, more negative responses, and little opportunity for positive interactions inside and outside the family environment. The literature has pointed out that the perception by adolescents of an authoritarian parental style is associated with greater expression of aggressiveness on the part of parents (De La Torre-Cruz et al., 2014). The stricter parental style found in the adolescents' responses is characterized by a tendency of guardians to express more criticism and less acceptance, communication, and affection to their children (González et al., 2014). In the same direction, other studies have found an association between negative parental practices and ADHD (Pires et al., 2012), and ADHD of the inattentive subtype (Haack et al., 2016).

In contrast, some family educational practices favor the improvement of the main symptoms of ADHD, functioning as protective factors for children and adolescents. Ray et al. (2017) pointed out that the involvement of parents in the school routine and tasks was a potentiating factor of healthy social functioning among children with ADHD. Bhide et al. (2017) found that parental support was positively related to the prosocial behavior and responsibility of children with ADHD according to the evaluation by parents and teachers. These studies highlight and corroborate the importance of family insertion as a planning possibility in interventions and educational and social action (Silva & Batista, 2020).

Within the theoretical field of social skills, positive educational practices are called educational social skills (ESSs)(Del Prette & Del Prette, 1999): attitudes adopted intentionally to promote the development and learning of others (Bolsoni-Silva & Loureiro, 2021). In this study, it is hypothesized that ESSs may be an important instrument for improving relationships between parents and children with ADHD. ESSs are divided as follows: (a) Parental Educational Social Skills for Communicating; (b) Parental Educational Social Skills for Expressing Feelings and Coping; (c) Parental Educational Social Skills for Establishing Boundaries (Bolsoni-Silva & Loureiro, 2021). Brazilian studies have shown a positive effect regarding interventions for the development of parental educational social skills, improving the behavioral repertoire of children with ADHD (Ferreira, Ayalla et al., 2016; Rocha et al., 2013).

Justino and Bolsoni-Silva (2022) described the social interactions established between family members (mothers and children) and between teachers and students with ADHD indicators and evaluated the educational social skills of mothers and teachers and the social skills and behavior problems of the children. The results indicated more behavioral difficulties at school than in the family, even though teachers were more skilled than the mothers, which may be explained by the excessive use of negative practices and the fact that the teachers set boundaries more skillfully.

Promoting social skills aims to teach specific behaviors, which are practiced and integrated into the behavioral repertoire of an individual. In this scenario, the evaluation for the subsequent promotion of these skills proves central to fostering behaviors relevant to the studied context, considering their sociocultural characteristics. In Brazil, only the RE-HSE-P instrument (Bolsoni-Silva et al., 2016) is standardized for evaluating parental ESSs (Vieira-Santos et al., 2018). Studies using the RE-HSE-P have identified positive correlations between negative practices and behavior problems and between a child's social skills and ESS (Assis & Bolsoni-Silva, 2020; Campos et al., 2019; Santos & Wachelke, 2019; Rovaris & Bolsoni-Silva, 2020). Negative correlations were identified between behavior problems and ESS (Assis & Bolsoni-Silva, 2020), children's social skills and negative practices, and children's behavior problems and social skills (Assis & Bolsoni-Silva, 2020; Santos & Wachelke, 2019; Rovaris & Bolsoni-Silva, 2020). These results indicate that using the RE-HSE-P proved effective in measuring interactions between parents and children (Fogaça & Bolsoni-Silva, 2018), showing, above all, the impact of ESS on children's behaviors.

In Brazil, the Promote-Parents Program (Fogaça & Bolsoni-Silva, 2018), aimed at teaching parental ESSs and reducing behavior problems in children, presented relevant findings. Results after the application of the Promote-Parents Program in Brazil indicated a reduction in the frequencies of behavior problems for clinical and non-clinical participants (Bolsoni-Silva, Silveira, & Ribeiro, 2008), a reduction in internalizing problems (Tozze & Bolsoni-Silva, 2018), and both behavior problems (Kanamota, Bolsoni-Silva, & Kanamota, 2017). Bolsoni-Silva et al. (2008) noted in the follow-up evaluation ESS improvement in communication, expressiveness, and consistency. Other studies identified that the means of positive parental practices were higher than negative practices after the intervention. Improvements were also identified in children's social skills after the evaluation (Kanamota et al., 2017; Tozze & Bolsoni-Silva, 2018).

Although the Promote-Parents Program (Fogaça & Bolsoni-Silva, 2018) showed promising results, it had not yet been applied to the legal guardians of children/adolescents with ADHD. There is a shortage of programs to promote social skills for this population at the national level in Brazil (Abrahão, Elias, Zerbini, & D'Ávila, 2020; Abrahão & Elias, 2021). Given this context, the Promote-Parents Program was adopted in the present study, with some adaptations to meet the behavioral management of children and adolescents with ADHD. Thus, the objective was to verify the effects of the adapted Promote-Parents Program on the behavioral repertoire of children and adolescents diagnosed with ADHD and their primary caregivers.

Method

This is pre-experimental research (Cozby & Bates, 2014) with pre- and post-intervention measures.

Participants

Seven guardians (one grandmother and six mothers) participated in the intervention and three in the post-intervention phase, and their demographic data are shown in Table 1. This study is the continuation of another conducted in 2018, which focused on characterizing the sample of students with ADHD (Abrahão, 2021). Thus, 11 guardians who participated then were invited to participate in the intervention, of which seven accepted the invitation. The four participants who withdrew from the intervention during the process claimed health issues and a lack of family support. The inclusion criterion was to be the legal guardian of a child or adolescent with a medical report of ADHD with the Municipal Department of Education.

Table 1
Demographic data on the participants (guardians, children, and adolescents), types of behavior problems, and treatment

Participants	Age	Marital status	Education level	Degree of relatedness	Behavior problems	Treatment for ADHD
P1	39	married	Complete secondary education	mother
C1	11	single	Incomplete elementary school	son	Internalizing/externalizing	Medication Ritalin
P2	66	widowed	Incomplete elementary school	Grandmother/legal guardian
A2	12	single	Incomplete elementary school	granddaughter	Internalizing/externalizing	none
P3	47	married	Complete secondary education	mother
A3	13	single	Incomplete elementary school	daughter	Internalizing/externalizing	none

• Note: P = Participants/legal guardians; C = child; A = adolescent.

Materials and instruments

• Promote-Parents (Fogaça & Bolsoni-Silva, 2018) is a program that seeks to promote educational social skills to prevent or remedy behavior problems and boost parental and child social competence. The instrument enables the stimulation of the occurrence of skilled behaviors in communication, affection, and consistency by the parents, favoring the reduction of behavioral problems in their children, as well as the promotion of their social skills.

• Information Booklet (Bolsoni-Silva et al., 2006): composed of themes related to difficulties generally encountered in parent-child interactions, it presents examples of conflicting situations and solutions and serves as a model of expected behaviors for the guardians.

• RE-HSE-P / Parental Educational Social Skills Interview Script (Bolsoni-Silva et al., 2016). This instrument aims to evaluate the interactions between parents and children through the survey and characterization of positive educational practices (ESS), negative practices, contextual variables, social skills, and complaints of behavior problems presented by children (from one to 12 years old). This instrument also allows for verifying the parental consistency in conducting parental practices and sociodemographic variables. It presented values (Cronbach's Alpha) for all items of the instrument (80 items = 0.649) and without the context variable (65 items = 0.666). It has two factors: Positive total (educational social skills, social skills, and context variables) and Negative total (behavior problems and negative practices). The instrument showed test-retest stability and differentiated preschoolers from schoolchildren, children with and without behavior problems, and children with and without language and hearing disorders.

• Social Skills Rating System / Inventory of Social Skills, Behavior Problems, and Academic Competence(SSRS-BR): version for parents and children (Del Prette et al., 2016). The version for parents features two scales for parents to rate their children for Social Skills and problematic behaviors. It presented a reliability value (Cronbach's alpha) of 0.85 on the social skills scale and 0.84 for behavior problems. The version for children consists of self-assessment, composed of the social skills scale with a reliability of 0.73.

• Conners Scale (CPTRS) – version for parents (Gaião & Barbosa, 1998). The reduced version of the scale, which measures oppositional behaviors, cognitive problems/inattention, hyperactivity, anti-social behavior, and the ADHD index, was used. The internal consistency index was 0.79%, with the following Cronbach's alpha values: Factor 1 (Hyperactivity = 0.83), Factor 2 (Fears/Somatizations = 0.74), Factor 3 (Perseverance/Perfectionism = 0.67), and Factor 4 (Thefts/Anti-social behavior = 0.62).

Data collection procedures

After the approval of the Ethics Committee (information removed), the consent of the legal guardians was obtained through the ICF, and the Term of Assent was applied to the children and adolescents. The following instruments were applied in the pre- and post-intervention phase: RE-HSE-P (individually) and SSRS and Conners Scale (in a group) with the legal guardians; the SSRS in a group at a psychology clinic with the children or adolescents.

After the initial evaluation, the intervention was initiated with the adapted Promote-Parents applied to the guardians. In the intervention, five adaptations were made to the Promote-Parents Program (Fogaça & Bolsoni-Silva, 2018) under the supervision of the coauthors to meet the specific needs of managing difficulties identified among children and adolescents with ADHD, as characterized in a previous study, in addition to the indications of the literature of the field.

Regarding the adaptations to the Program, the first was to teach the guardians the "token economy" technique in a theoretical-experiential manner, given that they would apply it with their child or adolescent. The activity was carried out in the initial 30 minutes; the guardians were reinforced with happy or sad tokens (emojis) according to their compliance with the group's operating rules, as previously agreed. The second adaptation was the dialogical establishment of rules such as "participate", "secrecy", "respect the other", "wait your turn to speak", "punctuality", and "read the booklet at home". The third adaptation consisted of conducting two themes in each meeting, so the 14 sessions proposed by the Promote-Parents Program were compiled into seven sessions of one hour each. The sequence of sessions of the Promote-Parents Program (Fogaça & Bolsoni-Silva, 2018) in the reduced/adapted version was organized as follows: Session 1. Introduce oneself, initiate and maintain conversations, and ask questions; Session 2. Express positive feelings, praise, give and receive positive feedback, thank, and know fundamental human rights; Session 3. Express and listen to opinions and skilled and unskilled behavior; Session 6. Establish boundaries: attitudes of parents that hamper establishing boundaries, and Establish boundaries: ignore problem behaviors, consequence socially skilled behaviors, pay attention, express affection; Session 7. Establish boundaries: ignore problem behaviors, consequence socially skilled behaviors, pay attention, express affection.

The fourth adaptation involved the teaching of strategies for routine organization and reinforcement of appropriate behaviors; at this time, the rules and behaviors of the child/adolescent desired by the guardians were discussed; type of reinforcer (e.g., playing, games, desserts, food, gifts) and day of the week when the reinforcer would be delivered; the difficulties in managing the rules and necessary changes were also discussed; thus, the guardians put into practice the token economy technique developed in a group in the family context. The fifth adaptation was to introduce theoretical-experiential classes focused on presenting information about ADHD and behavioral management guidelines. The themes of the theoretical-experiential classes were based on authors in the field, such as Barkley (2002), Döpfner et al. (2016), and Du Paul and Stoner (2007), and discussed together with the guardians, as proposed by the collaborative model of Webster-Stratton and Herbert (1993), when they asked questions about the subjects and shared their experiences. The themes of the theoretical-experiential classes discussed in the meetings were organized as follows: Session 1 – Teaching of the token economy strategy; Session 2 – Information on the diagnosis of ADHD and expected difficulties; Session 3 – Types of treatments; Session 4 – Teaching of a strategy to increase a child's self-regulation; Session 5 – Teaching and discussion of forms of self-care; Session 6 – Discussion of principles for mothers and fathers of children with ADHD; Session 7 – Teaching of strategies to encourage friendships among children/adolescents.

The intervention was conducted in two stages. The first stage (first hour), held in the seven meetings, involved the development of the token economy technique, the discussion on the organization of the routines of the children and adolescents, and the presentation of the theoretical-experiential class. In the second stage (second hour), the sequence proposed in the Promote-Parents Program (Fogaça & Bolsoni-Silva, 2018) was applied according to the manual with the support and discussion of the Information Booklet (Bolsoni-Silva et al., 2006), which was read by the participants at home and the topics were discussed at the meetings. The homework tasks proposed by the program and the organization of the weekly routine were monitored by the first author, who wrote feedback on the task sheets, returned them, and discussed the difficulties with the group at the next meeting.

It is noteworthy that, to the participating guardians who did not have caregivers for the children/adolescents during the intervention period, support was offered, with a psychologist accompanying the children and adolescents in another room, performing recreational activities.

Data analysis procedure

The data obtained using the instruments at the two evaluation moments considering the overall scores were tabulated, and the pre-and post-intervention phases were compared.

Results

The results are presented in the following order: RE-HSE-P, SSRS (version for guardians and children/adolescents), and Conners Scale (evaluated by guardians); thus, the tables present pre- and post-intervention measures.

Table 2 shows the results according to the RE-HSE-P, regarding the overall scores in a diversity of interactions, namely in the pre-intervention phase (participants P1, P2, P3, P4, P5, P6, and P7) and the post-intervention phase (participants P1, P2, and P3).

Table 2
Scores and classification of participants according to the RE-HSE-P in a diversity of interactions, pre- and post-intervention

Encoding			Diversity of interactions
	P1		P2		P3		P4		P5			P6			P7
	Pre-int	Post-int	Pre-int	Post-int	Pre-int	Post-int	Pre-int	Post-int	Pre-int	Post-int	Pre-int		Post-int	Pre-int		Post-int
P-ESSs	11NC	13NC	4C	9B	7C	14NC	7C	-	7C	-	11NC		-	9B		-
SS	9NC	12NC	10NC	23NC	9NC	20NC	9NC	-	9NC	-	12NC		-	7B		-
CTX	15NC	18NC	20NC	17NC	11B	21NC	8C	-	15NC	-	16NC		-	11B		-
NEG PR	11C	3NC	15C	2NC	5NC	4NC	10C	-	10C	-	5NC		-	7C		-
PROB	8L	7NC	11C	2NC	8L	2NC	7NC	-	6NC	-	1NC		-	8L		-
MCNS NEGPR	3	2	-	-	3	2	3	-	2	-	4		-	2		-
MCNS P-ESSs	3	4	-	-	2	4	2	-	2	-	0		-	2		-
Pos Total	38NC	47NC	36NC	51NC	32NC	60NC	31NC	-	35NC	-	42NC		-	30NC		-
Neg Total	22C	12NC	28C	5NC	15C	8NC	20C	-	20C	-	8NC		-	20C		-

• Note: Pre-intervention phase; Post-intervention phase; Clinical (C), Borderline (B), and Non-Clinical (NC) of the RE-HSE-P obtained by the guardians in the categories of Parental Educational Social Skills (P-ESSs), Social Skills (SS), Context (CTX), Negative Practices (NEG PR), Children's behavior problems (PROB), Marital Consistency-Negative Practices (MCNS NEGPR), Marital Consistency-Parental Educational Social Skills (MCNS P-ESSs), Positive Total (Pos Total), Negative Total (Neg Total); P = participants/guardians.

In the pre-intervention, four participants were classified as clinical for Parental Educational Social Skills (P-ESSs), one as borderline, and two were deemed normal. The Social Skills (SSs) of the children/adolescents were classified as normal by six participants and as borderline by one. Regarding the diversity of interactions in the context, five participants had scores classified as normal, one clinical, and two as borderline. Concerning the negative practices of the participants, they were considered clinical for five participants and normal for two. The behavior problems of the children and adolescents were classified as clinical by one participant, borderline by three, and normal by three. The positive total was classified as normal by all participants, and the negative total was considered clinical by six participants (P1, P2, P3, P4, P4, and P7) and normal by one (P6).

In the post-intervention phase, there was an increase for all participants who completed the intervention (P1, P2, and P3) in the diversity of interactions for the P-ESSs, with P2 going from the clinical level to borderline and P3 from clinical to normal, the SSs (P1, P2, and P3), the context (P1, P2, and P3), and the positive total (P1, P2, and P3). Regarding the diversity of negative aspect interactions, there was a decrease in negative practices (P1, P2, and P3), with P1 and P2 going from the clinical level of negative practices to the non-clinical. For the guardians who completed the intervention, it was observed that the item of marital consistency-negative practices decreased for P1 and P3, while the marital consistency regarding the parental educational social skills used by the guardians also increased for P1 and P3 (because she was a widow, participant P2 did not score in this item). There was a decrease in behavior problems among the children/adolescents, with P1 and P3 going from the borderline classification to normal and P2 from the clinical level to normal. In the negative total, the three concluding participants went from clinical to normal.

Table 3
Scores of the SSRS answered by the guardians, children, and adolescents pre- and post-intervention

Encoding			Phases
	P1		P2		P3
	Pre-int	Post-int	Pre-int	Post-int	Pre-int	Post-int
Guardians
Social skills total	53	57	42	58	45	74
Responsibility	10	9	5	11	4	18
Self-control	11	14	10	11	9	18
Affectivity/cooperation	14	13	14	17	14	20
Social resourcefulness	8	9	5	8	8	10
Civility	10	12	8	11	10	15
Behavior problems total	15	15	11	6	20	19
Externalizing Internalizing	10 5	10 5	6 5	3 3	12 8	7 7
Children and adolescents
	C1		A2		A3
Social skills total	34	30	22	28	25	30
Empathy	10	10	7	5	8	10
Responsibility	10	10	6	8	6	6
Self-control/civility	10	10	6	10	7	8
Assertiveness	4	10	3	5	4	6

• Note: Pre-intervention phase; Post-intervention phase; P = participants/guardians; C = child; A = adolescent.

Table 3 shows the scores obtained according to the SSRS instrument answered by the guardians, indicating the skilled behaviors and behavior problems present the children or adolescents with ADHD. One may observe an increase in social skills (SSs) considering the SS subclasses of self-control, social resourcefulness, and civility; there was an increase in responsibility and affectivity/cooperation according to P2 and P3. Regarding behavior problems, there was a decrease for P2 and P3 and maintenance of the pre-intervention scores for P1; for externalizing and internalizing behavior problems, there was a decrease for P2 and P3.

Table 3 also shows the results obtained in the SSRS according to the self-assessment of the children and adolescents. For the total in SSs, an increase for two participants and a decrease for one was observed. In the empathy subclass, there was an increase for one, a decrease for another, and maintenance for another; in responsibility, there was an increase for one and maintenance for two; in self-control and civility, there was an increase for two and maintenance for one; and in assertiveness, there was an increase for the three participants.

Table 4
Scores for the Conners Scale answered by the guardians, pre- and post-intervention

Encoding			Phases
	P1		P2		P3
	Pre-int	Post-int	Pre-int	Post-int	Pre-int	Post-int
Total	26	24	22	20	49	35
Hyperactivity	9	9	3	7	18	11
Fears/somatizations	3	3	4	5	9	9
Perseverance/ perfectionism	7	8	10	3	17	9
Thefts/anti-social behavior	0	0	0	0	0	0

• Note: Pre-intervention phase; Post-intervention phase; P = participants/guardians; C = child; A = adolescent.

Table 4 shows the results from the Conners Scale according to the guardians. It is possible to observe a decrease in the total points for ADHD for P1, P2, and P3; in hyperactivity, there was a decrease for P3, an increase for P2, and maintenance of scores for P1; in fears and somatization, there was an increase for P2 and maintenance for P1 and P2; in perseverance and perfectionism, there was a decrease for P2 and P3 and an increase for P1; in theft and anti-social conduct there was maintenance of scores for the three participants.

Discussion

This study aimed to describe the effects of the adapted Promote-Parents Program regarding the educational practices of legal guardians and skilled and problematic behaviors of children and adolescents with ADHD. Significant results were obtained using the RE-HSE-P (Bolsoni-Silva, Loureiro, & Marturano, 2016), an instrument that evaluates parental educational social skills, negative parental practices, and complaints of behavior problems and social skills of children. An increase in the diversity of positive interactions was observed for all participants who completed the intervention, which is a positive point given the frequent conflicting family relationships that occur in the presence of a child with ADHD (Benczik & Casella, 2015; Johnston, 1996; Leitch et al., 2019; Duh-Leong et al., 2020; Breaux & Harvey, 2018); similar results were found by studies that conducted interventions for parents of children with behavior problems (Assis & Bolsoni-Silva, 2020; Bolsoni-Silva et al., 2008; Kanamota et al., 2017), an accentuated characteristic in this population (Abrahão & Elias, 2021) that may influence the misdiagnosis, requiring training and the adoption of scientific criteria to make a diagnosis (Brasil, 2022; Posner et al., 2020).

The increase in parental social skills indicates that the legal guardians (mothers and grandmother) developed positive educational practices (e.g., communicating, praising, establishing boundaries, monitoring, and expressing affection and criticism appropriately), culminating in the increase in the social skills of the children/adolescents and in various contextual subjects in this interaction, which has also been reported by other authors (Assis & Bolsoni-Silva, 2020; Bolsoni-Silva et al., 2016; Kanamota et al., 2017; Rovaris & Bolsoni-Silva, 2020), leading to the lower occurrence of family conflicts and difficulties and issues in marital relationships, given the increase in the marital consistency P-ESSs item and decrease in negative practices in this dyad.

There was also a decrease in negative parental practices for participants P1, P2, and P3, who went from the clinical level of negative practices to the non-clinical level, so one may infer that the lower emission of negative practices culminated in a decrease in behavioral problems among the children/adolescents, who went from the borderline classification to the non-clinical. Similar results were found in studies that showed a decrease in negative educational practices after interventions (Assis & Bolsoni-Silva, 2020; Bolsoni-Silva et al., 2016; Kanamota et al., 2017; Rovaris & Bolsoni-Silva, 2020). Improvements in behavior problems after interventions directed at mothers of children with ADHD have also been reported (Ferreira et al., 2016; Rocha et al., 2013). Evolutions in the social skills of children resulting from interventions with guardians whose children had behavior problems have been reported by several Brazilian studies (Kanamota et al., 2017; Tozze, 2016) and in international studies aimed at children and adolescents with ADHD (Coghill et al., 2021; Yvonne et al., 2019).

According to the SSRS, an instrument that evaluates the children's social skills (SS), answered by the guardians, there was an increase in total SS and the subclasses of self-control, social resourcefulness, and civility for all participants, and there was an increase in responsibility and affectivity/cooperation according to P2 and P3. These results reinforce the gains obtained after the intervention for the children as well, which was also verified by the RE-HSE-P, indicating that the instruments were complementary. Similar results in improved practices and increased skilled behaviors among children with ADHD were found in two Brazilian studies focusing on teaching ESSs to mothers (Ferreira et al., 2016; Rocha, 2013).

Regarding externalizing and internalizing behavior problems, there was a decrease for adolescents A2 and A3 according to the reports of their guardians. These data extend the discussion by De La Torre-Cruz et al. (2014), evidencing that the improvement of educational practices associated with the absence of an authoritarian style culminated in a decrease in externalizing behaviors.

For child C1, there was maintenance of the behavior problems according to the SSRS reported by their mother, so it was inferred that they may be maintained by aspects related to parental practices, even though the mother benefited from the intervention, presenting a considerable increase in positive practices and a decrease in her negative practices, in addition to the child having increased his total SS, social resourcefulness, self-control, and civility according to his mother's report and his assertiveness according to his self-report. It is assumed that this participant improved less because he had the highest ADHD scores of the three; although the scores decreased in the final evaluation, this reduction still left him with a score higher than the baseline of the other two participants. In this regard, we consider that the intervention achieved its objective since we focused on developing positive behavioral repertoires in the interaction between parents and children (Assis & Bolsoni-Silva, 2020; Rovaris & Bolsoni-Silva, 2020). It is suggested that prolonged care with this mother, child, and family could improve the reported difficulties.

Regarding the self-assessment of SS and behavior problems of the children or adolescents in the SSRS, an increase in total SS was observed for adolescents A2 and A3 and a decrease for child C1. Thus, there is an agreement between the assessments of increased SS for mothers/guardians for the adolescents. However, the same was not observed for C1, which may be related, for example, to the presence of behavior problems that, when present in family interactions, may be reinforced, influencing the self-concept regarding their abilities of diminished characteristics (different from their mother's report). In this sense, observing this interactional dyad (mother and child) could express important variables of understanding. The negative self-assessment reported by students with ADHD compared to the report of their parents was identified by Abrahão and Elias (2021).

There was also an increase in self-control/civility and assertiveness for the adolescent participants (A2 and A3) according to their self-report, and this may be associated with the improvement of parental practices, given that, as they communicated, the guardians established boundaries and rules, offered feedback and affection, and, above all, by positively reinforcing the behaviors of the children/adolescents, they improved the interpersonal interactions, developing a welcoming environment, even to receive eventual oppositions (assertiveness) from them.

Another important variable studied in this work involved verifying ADHD symptomatology according to the Conners Scale answered by the guardians. A decrease in the total attributed to ADHD was identified, so the performed intervention increased parental educational practices and positively impacted the improvement of general ADHD symptoms of the children/adolescents. This statement is supported by studies that found that negative parenting practices predict symptoms of the disorder (Haack et al., 2016; Pires et al., 2012).

The proposal of psychological intervention developed in this study is in line with studies that indicate multimodal treatments (Fabiano et al., 2021; Pelham et al., 2016; Storebø et al., 2019), emphasizing care for schoolchildren with ADHD and guidance to contexts (family and school), thus contributing to bridge this gap present in the Brazilian context. In addition, this study cooperates as a treatment modality with potential execution in school environments by psychologists and social workers as advocated by Law 14254/21, either with students or especially with educators (mothers/ fathers/guardians and teachers), in the promotion of educational social skills that are essential for the development of children and adolescents with ADHD.

A last point to be highlighted and discussed involves the withdrawal of guardians before the intervention was concluded. Although they reported health problems and a lack of family support to stay, this showed a trend in the field reported by Ferreira et al. (2016) and in the literature review by Fabiano et al. (2009), authors who also found this behavior among the participants, this being a significant limitation for research with this focus and reaffirming a cultural pattern concerning the function and responsibilization of women for the "caring". These data show the importance of intervention designs that seek to meet the personal demands of the participants, taking into account strategies for the engagement of other family members who can support the realization of the process.

Conclusion

The results revealed the positive effect of the adapted Promote-Parents Program both on the guardians, with the increase of positive educational practices and decrease of negative practices, and on the children and adolescents, with the increase of social skills and decrease of ADHD symptoms and behavior problems. The evaluation of the behavioral repertoire of the participants through different instruments proved to be a relevant point when contributing to bridging the gap in the literature. The applicability of the program in groups is a promising strategy for low-cost care in mental health services and in the school context, collaborating for the school inclusion of students with ADHD and the relationships established among peers and educators.

As for the limits, there is the small number of participants who completed the intervention, the non-participation of the fathers or other supporting family members, and the absence of a comparison group. It is recommended that future studies involve teachers as evaluators, which may reveal the impact of parental ESSs on school interactions and performance, in addition to inserting them into interventions to enhance and maintain the gains obtained. We conclude by emphasizing the need to know and consider in interventions, both in promotion and prevention programs, specific characteristics of the microsystems in which participants participate, as well as sociocultural issues of the macrosystem that impact them.

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• Responsible editors:
  Associate Editor: César Leite https://orcid.org/0000-0001-8889-750.

• Editor-in-Chief: Silvio Gallo https://orcid.org/0000-0003-2221-5160.

Publication Dates

• Publication in this collection
  07 Oct 2024
• Date of issue
  2024

History

• Received
  04 May 2021
• Reviewed
  14 June 2023
• Accepted
  30 Nov 2023