Effectiveness of a Multimodal Intervention on Social Climate (School and Family) and Performance in Mathematics of Children with Attention Deﬁcit/Hyperactivity Disorder

: This study analyzes the differential efﬁcacy of a multimodal versus pharmacological intervention in isolation to improve the social climate (school and family) and the performance in mathematics of a sample of 20 children with ADHD aged 7 to 9 years. The multimodal intervention was based on a training program for 20 parents and 20 teachers in the management of ADHD during a school year, in combination with stimulant medication. The results evidenced the superiority of the multimodal intervention compared to the isolated pharmacological intervention to improve various variables of the family climate (Cohesion; Expressiveness; Autonomy and Control), of the school climate (Help; Tasks; Competitiveness; Organization, Clarity and Control), as well as their academic performance in the curricular area of mathematics. Our ﬁndings support the need to intervene in the signiﬁcant contexts in which children with ADHD develop in order to improve their quality of life.

In the same vein, a review found that 70% of studies found a negative association between ADHD diagnosis and mathematical skills [11]. Inattention is the ADHD symptom most strongly associated with difficulties in mathematics, which means that attentional processing is especially relevant to mathematical skills [12][13][14].
On the other hand, although research indicates that the origin of the disorder is neurobiological, environmental factors are fundamental in the evolution of symptomatology and the associated comorbidity. We can clearly see, then, the importance of taking into account the most significant contexts for socialization of children with ADHD, their family and their school, as well as the climates generated in both contexts [15].
The family setting plays a fundamental modulating role on the biological predisposition to ADHD, influencing the way in which the symptomatology is understood and managed by the family [16]. Several studies have indicated that parents of children with ADHD show lower educational involvement, lower expectations of their children, a less This study has been designed with the objective of analyzing the effects of a multimodal and multicomponential intervention (medication plus intervention with parents and teachers) on: - The school climate and family climate of a group of children with ADHD (multimodal group) compared to a group of children who only received stimulant medication (control group). - The mathematical performance of students with ADHD in the multimodal group compared to children in the control group.

Participants
This study included three samples (n = 100): a group of pupils with ADHD (n = 20), their parents (n = 40) and their teachers (two teachers per child, n = 40). All participants gave their informed consent to participate in the study. This research was carried out in accordance with the Declaration of Helsinki and the protocol was approved by the Ethics Committee of Abat Oliba University, CEU Universities (007).
All students received stimulant medication during the research, but none of them nor their teachers or parents were participating in any other ADHD intervention at the start of the study. Teachers and parents of the multimodal group participated in psychoeducational training, while the teachers and parent of the control group did not receive training (waitlist group, medication only). Once the study was finished, the teachers and parents in the control group were offered to participate in a training on ADHD management.

Sample of Children
The sample of 20 children was divided into two non-randomly assigned groups, based on practical criteria: one group receiving medication alone (control group), and the other group receiving the multimodal intervention (experimental group).
The characteristics of the children who participated in the study are shown in Table 1. Children in the control group had an average age of 7.6 years, with a predominance of boys over girls (8/2). All of them had a diagnosis of ADHD of the combined subtype. The average age of the 10 children in the experimental group was 7.8 years, with males predominating over females in this case also (9/1). Of these children, 8 were diagnosed with ADHD of the combined subtype, one with inattentive subtype and one with hyperactiveimpulsive subtype.

Sample of Parents
Twenty fathers and twenty mothers of the children described above participated in the study. Half of the pairs were in the control group and half in the multimodal group. In Table 2 we can see the socio-demographic characteristics of the parents.

Sample of Teachers
Forty teachers (two teachers per student) also participated in the study. Table 3 shows the socio-demographic and career characteristics of the teachers for each group of children.

Measures
In order to assess the social climate of the children, this study used Social Climate Scales: Family and School by Moos, Moos and Trickett [81]. The School Social Climate Scale (SSCS) (see Figure 1) assesses the social climate in the classroom, student-teacher and student-student relationships and the organizational structure of the classroom. It consists of 90 items grouped into 9 subscales, which in turn are included in four scales (relationships, self-realization, stability and change).
The Family Social Climate Scale (FSCS) (see Figure 2) assesses the socio-environmental characteristics and interpersonal relationships in the family, the developmental aspects that are most important in the family and its basic structure. It comprises 90 items integrated into 10 subscales, which are grouped into three scales (relationships, development and stability).
Moreover, we evaluated the academic performance of the children through the final grade they obtained in the subject of mathematics of the Primary School, on a scale of 0 to 10, where from 5 was considered approved. In other words, the final score that the children obtained from the exams and other activities of mathematics throughout the entire academic year, and that their teachers provided us. The children's mathematical skills included in the curriculum of these courses were evaluated: add and subtract with carried; begin with multiplication as addition of equal addends; know the concept of division as distribution or partition in equal parts; solve simple problems related to everyday situations and objects, in whose resolution a single operation is required, and this is an addition or a subtraction; know the concept of measurement as a comparison of two magnitudes, taking one of them as a unit; use natural measures referring to length, weight and capacity; and start using conventional measures.

Procedure
As mentioned above, all children in our total sample were taking stimulant medication, and parents and teachers in the multimodal group also participated in a long-term (one full school year) psychoeducational training programme in ADHD management.

Teacher Training Programme
The programme for teachers consisted of 17 meetings of two hours, on a fortnightly basis. They attended a total of 34 h of training at the school, with a high attendance (98%).

Parent Training Programme
The parent training program was conducted during 9 sessions of two hours, once a month. The times were adapted to parents' preferences and their attendance was very high (97%). The program was adapted from other empirically validated programs [27,37].

Statistical Analyses
A quasi-experimental mixed design (intra-and inter-group) was carried out, in which we collected pre-and post-treatment data. For statistical analyses, SPSS-27.0 software was used, with a confidence interval of 0.05 or less.
First, descriptive statistics were used to establish the sociodemographic characteristics of the samples, and the means and standard deviations of the various measurements.
Moreover, to carry out inter-group and intra-group comparisons, nonparametric tests were applied because parametric conditions were not satisfied (sample size was less than 30). The Wilcoxon test was used to perform comparisons between related samples (intragroup) between the pretreatment and posttreatment phases. Independent inter-group comparisons, that is, between the control and multimodal groups, were carry out in both phases using the Mann-Whitney U test.
The effect size was calculated using r, according to the adaptation to non-parametric tests, that is, the value of Z/the square root of N, where N is the sum of the scores with which the Wilcoxon Z has been obtained. Effect size values using r, are interpreted as: 0 to 0.4 being small, 0.4 to 0.6 being medium, and >0.6 large.

Results
We present below the results for social climate (school and family) and academic performance in mathematics obtained by each group, as well as the comparison between the two groups.

School Climate
As can be seen in Table 5, the control group improved in the post-test only in the variable Support, that is, degree of help and concern of the teacher for his students. On the other hand, the multimodal group (see Table 6) improved after the intervention in almost all variables related to school climate (7 variables out of 9): Relationships (Engagement and Support, that is, the degree to which students participate in the class activities and degree of help and concern of the teacher for his students); Self-realization (Tasks and Competitiveness, that is, the degree of importance that the teacher gives to the students completing the tasks and to their effort during their completion); Stability (Organization, Clarity and Control, that is, the degree to which the teacher gives importance to the organization in carrying out the tasks, to the establishment of clear rules and to the application of consequences when these rules are not followed).
Finally, when we compare both groups in the post-test phase (see Table 7), we observe statistically significant differences in favour of the multimodal group, compared to the control group, in 8 of the 9 variables analyzed: Relationships (Engagement, Affiliation and Support); Self-actualization (Tasks and Competitiveness); Stability (Organization, Clarity and Control). Although the superiority of the multimodal group in terms of school climate can be confirmed in only 6 of these 8 variables, given that in two of the Relationship dimensions (Engagement and Affiliation), the multimodal group already had a significantly higher score than the control group in the pretest phase (see Table 8).

Family Climate
The control group did not improve significantly in the post-test in any variable. In the dimensions of Relationships (Cohesion, that is, degree to which family members help each other) and Stability (Control, that is, degree to which the family follows agreed rules) it worsened when compared to the pre-test, and in the rest of the variables it remained the same (see Table 9). The multimodal group improved in seven of the ten dimensions (see Table 10): Relationships (Cohesion, Expressiveness and Conflict, that is, the degree to which the family helps each other and express their emotions, including anger); Development (Autonomy and Social-Recreative, that is, the degree to which family members are self-sufficient and make their own decisions, and they participate in social activities); and Stability (Organization and Control, that is, the degree of importance given by the family to a clear organization when planning family activities and responsibilities, and the degree to which they follow agreed rules). Finally, the comparison between the two groups in the post-test in terms of family climate showed statistically significant differences in favour of the multimodal group in 6 of the 10 variables (see Table 11): Relationships (Cohesion and Expressiveness); Development (Autonomy and Social-Recreative); and Stability (Organization and Control). However, in reality the superiority of the multimodal group can only be demonstrated in 4 of these 6 variables, given that in the pretest phase the multimodal group already had significantly higher scores than the control group in the Development (Social-Recreative) and Stability (Control) variables (see Table 12).

Academic Performance in Mathematics
Children's academic performance in the curricular area of mathematics in the pretest phase was similar and there were no statistically significant differences between the multimodal and control groups (see Table 13); however, in the post-test phase a statistically significant improvement was observed in the multimodal group compared to the control (see Table 14).

Discussion
Our data indicated that multimodal intervention combining psychoeducational training for parents and teachers with medication was shown to be significantly more effective than the use of medication alone in improving the school and family climate of children with ADHD, as well as their academic performance in mathematics.
In the school context, it was observed that the pupils in the control group, whose teachers did not participate in the psychoeducational training, did not improve their level of involvement in class, their level of friendship with each other or the degree of collaboration they offered each other in their tasks.
These results are consistent with other research that has found that medication improves core ADHD symptoms reasonably well, but when used as the sole treatment does not produce improvements in ADHD-associated problems such as peer relations [74,75,87,88].
Continuing with the data from our study, we found statistically significant improvements in the control group in the subscale "support", which assesses the degree of communication between the teacher and the students and the trust placed in them. This result could be due to the trust that teachers tend to place in treatment, whatever its modality [89].
The multimodal group experienced a very significant improvement in the overall classroom climate after participation in the training. A more detailed analysis of the data makes clear the positive developments in several variables. In terms of the quality of "relationships", teachers noted a statistically significant increase in the extent to which pupils were integrated in the class, supported each other, showed more interest in class activities and participated more in discussions. They also felt that it significantly improved their communication with and trust in their students.
These findings are most likely related to the continued effort of the group of teachers, who, accompanied by the group leader in the sessions, shared and applied different strategies to improve the quality of their relationships and positive communication with their students. Specifically, over the course of five sessions, we worked on different ways of improving self-esteem, positively motivating behavioural change in students, and fostering communication skills and confidence among them.
Our data are in agreement with those reported by Van der Oord, Prins, Oosterlaan & Emmelkamp [90], who also found improvements in the social skills of children with ADHD following their participation in a multi-modal, multi-componential intervention, in line with teachers' estimates.
In terms of "self-realization", teachers who participated in the training perceived a statistically significant decrease in the importance they placed on the completion of scheduled tasks, placing less emphasis on results and more on processes, as well as spending more time discussing things not directly related to the topic. They also perceived a statistically significant increase in the importance they placed on student effort in the completion of tasks. Again, we can link these results to the specific content addressed in the teacher training sessions in our study.
In relation to the "stability" of the group-class, teachers also perceived a statistically significant improvement after the intervention. Specifically, in the importance that teachers placed on order, organization and good manners in carrying out tasks, as well as to following clear rules and making pupils aware of the consequences of non-compliance. Again, our results are related to the five sessions of training on these topics in the intervention programme.
In terms of their degree of innovation or "change" in their approach to school activities, there was no statistically significant improvement after the multimodal intervention. These results may be related to the fact that this group of teachers was already quite creative in the use of new technologies and techniques to promote student creativity, as well as the fact that this content was not worked on very much in the sessions.
Finally, the comparison between the effectiveness of multimodal and pharmacological intervention in isolation allows us to conclude that the multimodal intervention is clearly superior in improving the school climate perceived by teachers for most of the variables an-alyzed ("relationships": support; "self-realization": tasks and competitiveness; "stability": organization, clarity and control).
Similarly, we also found a statistically significant increase in academic performance in mathematics in the multimodal intervention group of children in the post-test phase, compared to the children in the medication-only group.
These data are consistent with other studies that have also demonstrated the superiority of a multimodal intervention with parents and teachers on academic performance and school difficulties compared to medication used in isolation [79,[91][92][93][94]. For example, Langberg et al. [91] found that in the MTA study only participants who received the behavioural treatment (behavioural group and multimodal group) made sustained improvements in their academic difficulties in comparison to routine community care.
Other studies have also shown that pharmacological treatment produced slight and short-lived improvements in academic performance, which may be mainly due to the reduction of the core symptoms of the disorder in the short term [87,93,94].
On the other hand, our results regarding the family context also allow us to conclude that there were statistically significant improvements in the multimodal group, showing clear superiority of this group when compared to the control group. Moreover, in the control group, not only was there no improvement in family climate, but there was even a significant worsening in the degree to which family members helped each other ("cohesion") and in the degree to which family life adhered to established rules and procedures ("control").
Previous studies also found that pharmacological intervention in isolation was insufficient to improve the family functioning of children with ADHD [87,95].
These findings are especially relevant if we take into account the fact that a family climate with low levels of cohesion, affection and support hinders the development of certain social skills in children, such as the ability to identify non-violent solutions to social difficulties [96,97].
Furthermore, research on protective and resilience factors, increasingly studied in the field of childhood and adolescent onset disorders, has shown that adequate family structuring is associated with individuals being better able to overcome difficulties and may be associated with a lower risk or a more favourable prognosis in these children [98][99][100].
Continuing with our study, the data indicated that in the multimodal intervention group there was a significant improvement in the family climate of these children, both in "relationships" and in the "development" and "stability" of the family. Specifically, the degree to which family members are empathetic and supportive of each other, and to which family members are encouraged to express their emotions. These results are related to the effort devoted during various sessions of the training programme to improving communication skills in families.
With regard to the personal development of the family, there was also a significant improvement following the training in the degree to which family members are selfconfident, self-reliant and make their own decisions and in the degree of participation in social and recreational activities.
However, our programme was not effective in increasing the degree of family interest in political, social, intellectual or cultural activities, nor the importance placed on ethical and religious practices and values; possibly because the intervention programme did not include among its objectives the enhancement of these activities or values.
In terms of family stability, parents saw a statistically significant increase both in the importance given to organization in planning family activities and responsibilities, and in the degree to which family life adheres to established rules and procedures. Again, we can find a clear link between these results and the contents of some thematic blocks developed in the intervention programme for parents.
Our findings are consistent with those of one of the best studies to date on the efficacy of various treatment modalities for ADHD: the MTA [74,75]. This study also found that multimodal treatment led to improvements in parent-child relationships, as well as a reduction in harshness and inefficacy in parents' treatment of their children. This intervention helped families to educate their children with ADHD more effectively and to make the necessary accommodations in their lives to improve family functioning.
Finally, in our study, the comparison between both intervention groups in the post-test in terms of family climate also showed statistically significant differences in favour of the multimodal group in almost half of the variables analysed ("relationships": cohesion and expressiveness; "development": autonomy; and "stability": organization).
Again, our data are consistent with the results of the MTA study [74,75], which found that pharmacological treatment implemented as the sole treatment did not produce improvements in family relationships compared to multimodal intervention.

Conclusions
Our results allow us to conclude that multimodal treatment is superior to pharmacological treatment used in isolation in improving the social climate (school and family) and the academic performance in mathematics of children with ADHD in primary school.
However, our study has some limitations that need to be taken into account for future research on the subject. One is that the small sample size has led us to use non-parametric data analysis tests, which may have less discriminant power. Another important limitation is that we have not been able to collect follow-up data, which would have allowed us to obtain information on the long-term effectiveness of the interventions. Finally, our study could be difficult to replicate because the intervention programs that we have implemented are not published and are based on other manualized programs.
Despite these limitations, our findings have important implications for educational practice, especially the importance of intervening in the most significant socialization contexts of children with ADHD (home and school) to improve their quality of life and that of the people they live with on a daily basis. Funding: This research was funded by Plan Nacional I+D+I del Ministerio de Economía y Competitividad. Gobierno de España, grant number EDU2012-31402.

Institutional Review Board Statement:
The study was conducted in accordance with the Declaration of Helsinki, and approved by the Ethics Committee of Universitat Abat Oliba CEU (protocol code 007, 2 June 2022).

Informed Consent Statement:
Informed consent was obtained from all subjects involved in the study.

Conflicts of Interest:
The authors declared no potential conflict of interest with respect to the research, authorship, and/or publication of this article.