Introduction 
Attention-deficit/hyperactivity disorder (ADHD) is one of the most widespread psychological and neurological disorders during childhood, which has been the focus of many researchers. This disorder is characterized by repetitive episodes of hyperactivity, impulsiveness, and inattention which often begin before the age of seven and are more severe than can be attributed to average growth. In the USA, ADHD affects the life of 3.5% to 5% of children [1]. Furthermore, it is more prevalent in male children, and, in some cases, the hyperactivity disappears, but attention deficit and impulsiveness remain. Accordingly, the academic achievement of these people is less than other normal people [2]. This disorder could damage normal functions such as academic achievement, school behavior, family interaction, and peer communication. As a result, these children may be rejected by their peers and society [3]. For these reasons, finding effective treatments and strategies to prevent the aggravation of these children’s problems is one of the main goals of research in this field.
Among the various treatments, the effect of sensory integration therapy has already been analyzed and proven [4]. This therapy includes controlled sensory stimuli in the context of self-controlled and significant activities to improve some behavioral, motor, educational, and oral functions and skills of children (especially children with learning disabilities, autism, and attention deficit hyperactivity disorder).
Various pharmacological, cognitive, behavioral, combinatory, and complementary therapies are used to treat children with ADHD. Sensory integration is one of these therapies. Sensory integration therapy includes controlled sensory stimuli in the framework of self-directed and meaningful activities that cause an adaptive response. In addition, the therapy acts through the integration of sensory inputs of some behavioral, motor, academic, and language functions and skills of children [5]. The integration of different sensory information increases the ability of the children in sensory-motor and perceptual-motor functions. As a result, it empowers the child in different aspects. Sensory integration helps the children’s control power which consequently gives their nervous system the ability to change and keep the stimulation level necessary for the development of abilities, such as paying attention to homework, controlling impulses, increasing failure tolerance, and balancing emotions [6].
In the Rathod et al. study, the results showed that sensory integration therapy by itself and in combination with cognitive-behavioral therapy had a significant effect on reducing ADHD symptoms based on Conner’s scale [7]. Similarly, Ebrahimi et al. conducted a study entitled “the effect of sensory integration with an emphasis on deep and superficial senses on the academic progress of 6- to 12-year-old-children with ADHD in Semnan City.” In this study, 32 students diagnosed with ADHD were chosen and divided into the intervention and control groups (each with 16 members). The results indicated that sensory integration with an emphasis on deep and superficial senses affects the academic achievement of students with ADHD [8]. 
Peterson et al. (2018) conducted a study entitled “Providing Sensory Diet by California Occupational Therapists.” The results show that a sensory diet in children with ADHD has positive effects on reducing abnormal behaviors, increasing domains of attention, and the level of mental retention [9]. 
Rahmani et al. examined the effect of sensory integration therapy in reducing ADHD symptoms. The study results show that children who received sensory integration therapy reported a significant improvement in their primary ADHD symptoms compared with the control group [10]. Similarly, Sahoo et al. established that sensory diet therapy based on sensory integration theory significantly affected the functional behavior of ADHD children [6]. 
Amrovan, in the results of her dissertation entitled “The effectiveness of sensory integration on executive actions of children with attention deficit hyperactivity disorder,” argued that the performance of the experimental group significantly improved compared to the control group in the components of response inhibition, sustained attention, and working memory [11]. Ebrahimi et al. examined the effect of sensory-motor integration activities on the symptoms of ADHD. Such activities reduced attention deficit, hyperactivity, and impulsivity in the participants [8]. 
Considering the high prevalence of ADHD in school children and its consequent problems in different aspects of their personal and social life, the importance of early intervention in these cases, the effectiveness of sensory integration therapy in improving different functions of children, and finally, a few studies on the effect of sensory integration therapy on improving the symptoms in ADHD patients, we intended to answer whether planning a family-based sensory diet can be effective on ADHD symptoms of these children. 
Materials and Methods 
The present study is applied research in terms of purpose and quasi-experimental in terms of methodology with a Pretest-Posttest design. The study’s statistical population included all children with ADHD aged 6-12 years living in Tehran City, Iran, who were referred to Hasti, Bahar, and Masir Sabz treatment clinics during the last quarter of 2020. The samples were selected by convenience sampling after confirming their ADHD criteria by performing Conners’ test (1973) and meeting other inclusion criteria.
The participants’ parents were then subjected to 12 sessions of comprehensive family-centered program training; after the program, the Posttest was performed, and the results were statistically analyzed (Table 1). 


Contents of the Family-based Sensory Diet
The therapist implemented this program for 1 month, 3 sessions per week, and each session lasted 45 minutes. In this program, the parents were guided towards activities stimulating vestibular, deep, tactile, visual, and auditory senses to maintain the children’s focus and organized consciousness.
The summary of the sensory diet practices given to the participants was as follows.
In each therapy session, 5 to 6 exercises were practiced with the children; as each child progressed, other exercises were applied, or their difficulty increased in subsequent sessions. At the end of the intervention, the subjects underwent the Posttest.
Study tools 
Wechsler’s Intelligence Scale for Children:
In the present study, we used the fourth edition of Wechsler’s intelligence scale for children, published in 2003. In this edition, total intelligence and four different intelligence subscales are measured, including verbal comprehension (similarities, words, comprehension, general information, verbal deduction), cognitive deduction (designing with squares, visual concepts, visual deduction, and completion of images), active memory (the breadth of figures, sequence of letters, numbers and calculation completion) and speed of processing (cryptography, symbolization, complementary line drawing). Sadeghi, Rabeei, and Abedi analyzed the validity and reliability of the fourth edition of Wechsler’s intelligence scale. The results of the validity between this scale and Raven’s progressive matrices showed a significant correlation between the two scales. The validity of the test was calculated by two methods of halving and retesting, during which the validity of the subscales with the retest was obtained from 0.80 to 0.88, and the validity coefficients of the halving were from 0.83 to 0.91. 
Conners’ Questionnaire 
The Conners’ scale measures attention deficit, hyperactivity, and impulsiveness. It is one of the common tools used for measuring children’s behavior based on a dimensional classification system. It contains various behavioral questionnaires designed for children. Connors introduced a 93-item scale in 1973. Then a short form of this scale with 48 items was introduced by Goyt, Connors, and Elvish in 1978. Conners’ classification scale was first designed to evaluate the effect of stimulant drugs on children with ADHD and to distinguish these children from normal children. Today, a modified questionnaire consisting of 27 items is used to diagnose children with ADHD. The reliability coefficient of the retest for the total score is 0.58, the Cronbach alpha coefficient for the total score is 0.73, and its validity is 0.84, which measures three factors of oppositional behavior, hyperactivity, and attention deficit. The range of scores for each question varies from 0 to 3 as follows: 0) not true at all (never), 1) only slightly true (occasionally), 2) relatively true (often), and 3) absolutely true (very high).
Results 
According to Table 2, there were 9 mothers with a diploma, 14 with bachelor’s, and 7 with master’s or higher degrees.


According to Table 3, there were 16 employed mothers and 14 homemakers.


According to Table 4, 9 students were between 6 to 8 years old, 11 were between 8 and 10 years old, and 10 were between 10 and 12 years old.


The first hypothesis was that a family-based sensory diet program is effective for the attention deficit of ADHD children.
Based on the Table 5, since F1,27=56.932 achieved a significant level (0.000) less than 0.05, the test hypothesis is accepted, and we can conclude that sessions of family-based sensory diet program have been effective on attention deficit of ADHD children.


The second hypothesis was that a family-based sensory diet program is effective on the hyperactivity of children with ADHD.
Based on Table 6 and Table 7, since F 1, 27=64775 achieved a significant level (0.000) less than 0.05, the second test hypothesis is accepted, and we can conclude that sessions of family-based sensory diet program have been effective on reducing hyperactivity in children with ADHD.




Discussion
We used the analysis of covariance to test the research hypothesis, i.e., the family-based sensory diet program is effective on attention deficit and hyperactivity of children with ADHD.
Based on the results (regarding the first hypothesis), there is a significant difference between Pretest and Posttest scores of the attention deficit in the subjects. In other words, the family-based sensory diet program reduces attention deficit symptoms of children with ADHD. 
The results of this study are consistent with the finding of Niklasson et al. and Vandenberg, which showed the effect of using sensory stimulation on attention functions of ADHD children [12, 13]. Also, the above results are consistent with the results of the study conducted by Salamati et al., who examined the effect of sensory stimulation in the form of atrial stimulation in children with ADHD. Hence, its effectiveness on the attention and auditory abilities of these children was proved [14]. The effect of sensory integration therapy in improving attention deficit of ADHD children does not agree with the study conducted by Ghareh Baghi et al., in which the effect of sensory stimuli on attention function of children with learning disorders was analyzed [15]. This difference might be because, in the above study, deep sensory stimulation was used in the form of only a vest and saddle in occupational therapy sessions. According to the sensory integration principles based on a combination of three proximal sensory systems, this effectiveness is disapproved. Moreover, the lack of enough samples in their study can be another reason for such disapproval.
In explaining this finding, one can say that these problems, along with attention deficit hyperactivity disorder, like disability in motor functions, attention deficit, learning disorder, aggression, educational problems, motor arousal, and apathy, are worth paying attention to [16, 17]. The problems in sensory integration like unfit physical condition, weak visual responses, and unnatural muscular consistency affect body scheme and bilateral and coordinated use of body members. These problems are due to weak processing and integration of received data from a deep vestibular sense. This weakness in processing the information can cause motor aversion or motor fear, reduction in motor range, reduction in domains of attention, and a lack of emotional stability. Additionally, some problems may also be observed in their tactile system. The outcome of all these problems are reactions we will see in therapy sessions: low concentration, irritability, unmotivated, and unorganized behaviors [17].
Hyperactivity is one of the more prominent problems of children with ADHD in whom the brain function is problematic in different aspects, and disorder in the right hemisphere and its injury, basic brain complex, and also prefrontal cortex can cause a reduction in motor functions and hyperactivity. On the other hand, the thalamus is effective in the integration of sensory input data, which, based on the definition by Ayres, sensory integration is the theory of the relationship between the brain and behavior. Dolin et al. believed that this process provides the basis for accurate sensory cognition and, consequently, appropriate motor reactions [8]. A sensory diet that improves the central nervous system in processing the information can improve these children’s symptoms, which can be reduced to a high level through early diagnosis and appropriate intervention methods for treating this disorder [18].
Based on the results (regarding the second hypothesis), there is a significant difference between the Pretest and Posttest hyperactivity scores in the test group. In other words, a family-based sensory diet program reduces the hyperactivity of children with ADHD. 
The results of the current study were consistent with a study by Batara et al. That examined the effectiveness of sensory stimulation on improving ADHD symptoms [19]. The results showed that sensory stimulation significantly affects three main symptoms of ADHD [19]. Besides, these results are consistent with the results of the study by Ebrahimi on the effectiveness of sensory integration therapy on attention deficiency and hyperactivity of children with ADHD [4].
To explain the effect of sensory integration therapy on children with AHDH, we can say that attention deficit is one of the most obvious and biggest problems of these children. Attention deficit causes children to have problems in controlling different stimuli and responding to merely one of these stimuli in an inappropriate way. The integration of deep and vestibular senses affects the function of the upper levels of the brain, which are responsible for excellent processes such as attention, and improves the organization of children’s senses receiving from the environment and stimuli. So that the spatial and temporal aspects of sensory processing data are processed, interpreted, related, and incorporated. Then, the brain chooses, improves, controls, and compares the data and integrates them in a flexible and changeable sample [4]. 
Ethical Considerations
Compliance with ethical guidelines
This study was extracted from PhD dissertation. An ethical approval was obtained from the Ethics Committee of Islamic Azad University, Science and Research Branch (Code: IR.IAU.SRB.REC.1400.155). Prior to study, written and verbal consent was obtained from the participants and they were assured of the confidentiality of their information. Iranian Registry of Clinical Trials (IRCT): IRCT20220214054020N1.

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors. 

Authors' contributions
All authors equally contributed to preparing this article.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
We express our deepest gratitude to the children and their families who participated in the study and all those who assisted us in conducting this study.


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