Attention deficit hyperactivity disorder (ADHD) is a chronic and impairing condition associated with a high lifetime risk of behavioral and learning dysfunctions. The maximum age at onset is 14 years, suggesting that diagnosis and treatment of this disorder in childhood are critical (Dakwar et al., 2014). ADHD is clinically significant because it is linked to severe functional impairment, comorbidities, and substantial economic burden on the healthcare system. Its symptoms include a lack of attention, hyperactivity, and impulsions (Dakwar et al., 2014). Pharmacologic agents, such as stimulants, are recommended as an efficacious first-line therapy for ADHD in childhood.
The refusal to use medication may be attributed to, among other factors, a perceived inefficacy of pharmacotherapy and social stigma. However, interventions, such as parent-mediated behavioral training and token reinforcement procedures, can help children manage ADHD symptoms (Hodgson, Hutchinson, & Denson, 2014). The proposed study aims to create awareness of the importance of interventions with ADHD among parents refusing to use medication.
Research Problem
Significance of the Problem
The refusal of ADHD medication could be due to psychological reasons. Behavioral interventions offer alternative evidence-based treatments for this disorder. However, attitudinal barriers, such as perceptions of misdiagnosis, may prevent parents from seeking therapy for their children. Partridge, Lucke, and Hall (2014) found that 78.3% of adults regard ADHD diagnosis in children as incorrect in most cases and are more likely to refuse the use of medication in treating this disorder. Thus, given the negative attitudes towards pharmacotherapy by parents, it is important to explore effective behavioral interventions for ADHD symptom management.
The misperceptions about ADHD diagnosis and limited use of behavioral modification strategies may be due to inadequate parental awareness and education on evidence-based choices. Most parents use the Internet for information about this disorder and its management (Sage et al., 2018). Educating the public on school-based and home-based interventions may lead to improved ADHD symptom management and outcomes. Therefore, it would be crucial to create awareness on teacher-, parent-, and computer-mediated behavioral strategies for ADHD treatment.
Benefits of the Research Project
The primary beneficiaries of this project will be school-age children, teachers, education administrators, and parents. Behavioral interventions can be used with ADHD as alternatives to pharmacotherapy. Through this project, parents will learn about home-based contingency management and behavioral tutoring strategies for reducing or preventing behavior problems. School-age children will acquire self-monitoring and self-management skills. Instructors and education administrators will benefit from reduced behavioral problems and classroom misbehavior. Adequate knowledge of school-based interventions will enable educators to be responsive to the learning needs of children with ADHD. As a result, they will ensure classroom conditions are conducive for ADHD students to succeed.
Literature Review
Treatment-seeking Behavior
ADHD is a prevalent childhood-onset disorder associated with multiple learning and behavioral difficulties. The recommended evidence-based treatments are both pharmacological and non-pharmacological. However, their use depends on perceived efficacy, side effects, and parental approval. Several stimulants and non-stimulant FDA-approved drugs can be used to treat ADHD (Mojtabai et al., 2011). Despite the efficacy of these medications, up to 55% of parents whose children are diagnosed with ADHD refuse pharmacological interventions for this condition (Dakwar et al., 2014). As a result, the delay from symptom onset to therapy is high – 10 to 28 years (Dakwar et al., 2014).
The refusal of ADHD medication may be attributed to several factors. Parents may be unaware of alternative therapies or they do not think ADHD requires intervention. Sage et al. (2018) found that up to 87% of parents search the Internet for basic information on ADHD and its remedies. Thus, clinician-led education on ADHD treatment is limited and has been replaced by online sources and schools.
Further, stimulants are shrouded in controversy because of potential side effects, such as tics and elevated risk of substance use disorder (Mojtabai et al., 2011). However, psychotropic drug formulations that are long-acting have been produced to counter these effects. Nevertheless, most parents still refuse medication because of social stigma and attitudinal barriers. According to Mojtabai et al. (2011), doubts about intervention efficacy, stigmatization, and cost, among others, can discourage parents from seeking treatment.
Social Stigma and Seeking Intervention
Stigma is a strong predictor of treatment-seeking behavior. The general perception is that ADHD children exhibit self-harm and violence to others (Partridge et al., 2014). Symptom recognition is also a challenge, as most parents cannot distinguish ADHD as a neurodevelopmental disorder that requires intervention (Partridge et al., 2014). They have to contend with criticism over their parenting styles and children’s misbehavior, which discourages them from going for ADHD assessment. The fear of stigmatization forces most parents not to seek treatment (Ahmed, Borst, Wei, & Aslani, 2017). Further, stress and self-blame represent common psychological states of parents after an ADHD diagnosis.
Parents may also refuse pharmacological treatment for their child because of the fear of the impact of stimulant drugs. Potential side effects, such as substance-use disorder, low self-esteem, and psychosocial dysfunction reinforce parental fear of medications (Ahmed et al., 2017). They may also fear that their ADHD children will experience learning difficulties in school. Negative views about a child’s educational performance also amount to a stigma that discourages parents from seeking treatment services (Ahmed et al., 2017).
Interventions for Children with ADHD
Contingency management programs can be used in school or home settings to change behavior. Behavioral interventions, such as cognitive behavior therapy, are the recommended treatments for ADHD, specifically for minors with “mild to moderate ADHD or symptoms not meeting the diagnostic criteria” (Veenman, Luman, & Oosterlaan, 2017, p. 2). A common home-based program is behavioral parent training to reinforce positive behaviors. School-based treatments may be proactive such as peer tutoring and instructional modification or reactive, for example, verbal reprimands, self-management, and token reinforcement procedures (Hodgson et al., 2014; Veenman et al., 2017). These interventions may be provided through mediators or directly to the minor.
Children can also receive cognitive training to reinforce neuro-developmental capabilities. Such programs train the working memory to increase attention and reduce hyperactivity (Catalá-López et al., 2015). Neuro-feedback, which involves sensors that monitor brain activity, has been used to manage impulses (Catalá-López et al., 2015). Dietary interventions and complementary medicine can also be used to treat ADHD in children in different settings.
Research Design
The research design selected for the proposed study is quasi-experimental. This approach will involve comparing the pre-and post-intervention knowledge of parents participating in an ADHD-intervention awareness program. They will receive structured, on-site training on home-based contingency management and school-based interventions.
Research Purpose Statement and Questions
The proposed quantitative study aims to address barriers to the use of interventions with ADHD by parents who have refused to use medications. In this regard, the project will create awareness on behavioral programs that can be used with ADHD children at home or school settings to this parental sample. Their knowledge of the interventions, ability to cope with stigma, and attitudes towards these treatments will be measured at baseline and after an educational intervention. Based on the review of studies on treatment-seeking behavior and social stigma, this research will test the following three hypotheses on a sample of medication-refusing parents with ADHD children.
- The post-test parental perceptions of the importance of ADHD behavioral interventions will be more favorable than baseline scores.
- There will be a significant improvement in the parents’ recognition of ADHD symptoms after the awareness program compared to baseline data.
- There will be a positive correlation between parental self-efficacy and the use of behavioral interventions.
Data Collection Plan
Participant Selection
The recruitment of parent participants with children diagnosed with ADHD to take part in the study will occur at Clinic ABC and Clinic XYZ. The rationale for using two different sites is to ensure a representative sample and improve external validity. A passive recruitment method will be used to recruit eligible participants. The inclusion criteria will be parents with ADHD children enrolled at the clinics, possessing a high school diploma and above, and refusing medication use. The invitation for participation in the study will be posted on the two clinics’ homepages and brochures. Those willing to participate will be contacted. Eligible parents will complete an informed consent form before participation.
Gaining Permission
Institutional approval will be secured from the university’s IRB before starting the study. Permission to research the two clinics will be sought from the management. The researcher will send a letter of intent to the board and hospital administrator of each facility to request and approval. Its content will include institutional affiliation, the nature of the study, target population, foreseeable risks, and measures to protect participating parents. It is expected that the management will grant the researcher permission to conduct the study and assist in developing a sampling frame and participant recruitment.
Data to be Collected
The first set of data that will be gathered will be the participants’ demographic characteristics. The researcher will collect the following information: age, sex, race, and educational level. Each parent will also provide details of his/her child, including gender, age, and ADHD-linked problems, and treatment history. The study will also obtain data on parental perceptions of ADHD behavioral interventions, symptom recognition, and self-efficacy in caring for children with this disorder.
Data Collection Instruments
Quantitative data will be collected using two different instruments. A demographic questionnaire will be employed to capture the personal details of the parents and those of their children. Thus, this tool will comprise two distinct sections.
A second structured questionnaire with closed questions rated on a five-point Likert-type scale will be used to collect data on the three variables: ADHD behavioral interventions, symptom recognition, and parental self-efficacy before and after an awareness program. It will be piloted to test and validate its content and face validity. In the first case, two reviewers will be sought to help assess the message of the questionnaire items. Subsequently, the instrument will be revised based on the reviewer’s advice. Face validity will involve a pilot study. This step will help evaluate the grammar, clarity, and relevance of the questions to the study.
Administration of Data Collection
The study will involve two data collection points: at baseline and the conclusion of an awareness program. First, the researcher will send a notification to eligible parents via e-mail and mail informing them to complete web-based questionnaires. Its content will include an introductory statement, details of the project, and assurances of confidentiality. Links to the demographic and study surveys will be provided.
A follow-up e-mail and letter will be sent to participants failing to respond to the invitation within one week. Parents will indicate their availability for a researcher-led three-day workshop at the clinics on parent-mediated behavioral interventions to prevent behavior problems in children with ADHD. Post-intervention data will be collected using a survey questionnaire similar to the one used at baseline.
Data Analysis and Interpretation Plan
Preparing Data for Analysis
Preliminary data handling procedures will involve scrutiny of the returned surveys for any errors and completeness. Those missing over one-third of the responses will not be analyzed. Outlier data points will be excluded to avoid measurement error. The utilization of a web-based survey will allow the researcher to validate the answers online. Valid quantitative data will be downloaded for further processing. The next step will involve importing the data into the SPSS software for statistical analysis. The researcher will ensure that this process is as accurate as possible. Mistakes will be avoided by counterchecking the data entered or edited against the survey forms.
Analyzing the Data
Data analysis will be performed using descriptive and inferential statistics. Therefore, the process will occur in two stages. In the descriptive analysis, the frequency and distribution of the participants’ demographic data will be done. The results will include the mean and median of their age, gender, race, and educational level. This procedure will also give the variance in parental perceptions of ADHD behavioral interventions, symptom recognition, and self-efficacy (dependent variables).
Inferential statistics (t-test) will be used to compare baseline and post-intervention data. The aim is to assess the impact of the awareness program on the intervention-seeking behavior of the participating parents. Chi-square tests will also be used to determine if there is a correlation between post-test outcomes and age, gender, or level of education. The response rate will also be computed.
Reporting Results
Respondents will be parents refusing medication use for their children with ADHD. Descriptive results will be presented first. They will be summarized in tables, percentages, and charts under the subheadings of parental age, gender, race, and educational level that will be organized by site. Significant group differences in demographic variables between the two samples will be reported. The researcher will also present baseline and post-intervention results in a table. Inferential tests (T-test and chi-square output) will be described after each of the three hypotheses. The report will highlight significant correlations between post-intervention measures and age, gender, or level of education.
Interpreting the Results
The proposed study aims to address barriers to seeking behavioral interventions for ADHD among parents refusing medication use through an awareness program. The independent variable will be the workshop, while the dependent ones will be parental perceptions of ADHD behavioral interventions, symptom recognition, and self-efficacy before and after the training. If the results will suggest an improvement in the first two measures, hypotheses 1 and 2 will not be rejected. A strong correlation between self-efficacy and intervention use will confirm hypothesis 3. The results will be compared to previous findings in the literature. Thus, the interpretation of data will involve a consideration of other studies.
Ethically and Culturally Relevant Considerations
A key ethical consideration for this project is maintaining confidentiality. Since this research involves human participants, their privacy and anonymity are critical. For example, a unique code will be assigned to each parent to protect his/her real identity. Through a passive recruitment method, the clinic managers will give identifiers – numbers or pseudonyms – to participants. Both the baseline and post-intervention surveys will be web-based to maintain the respondent’s anonymity. Demographic data will not include the parent or child’s name or zip code to protect participant privacy.
Another ethical measure will involve securing informed consent. The researcher will mail an information sheet highlighting the research’s aims, design, and benefits, and possible risks. This consent form will also inform potential participants of their roles and obligations in this study. It will indicate their right to withdraw from the project at any point. Parents signing and returning the consent forms will be deemed to have accepted to take part in the research.
Potential harm to respondents will be minimized through a short training period – three days. Further, parents who may not attend the workshop will have the option of receiving relevant materials via email. As such, participants will not experience more harm than they would in their daily lives. Cultural sensitivity will be ensured during data collection. Language differences exist in the study sites. For this reason, measures will be taken to address the linguistic diversity of the participants. For example, though the questionnaire will be primarily in English, non-English speakers will still receive this instrument in their preferred language. The participants will not be drawn from vulnerable populations. They will be addressed respectfully and accurately irrespective of culture, age, or sex.
Conclusion
ADHD is a childhood-onset disorder associated with significant functional impairment. This quantitative study will involve an awareness program to promote behavioral interventions as alternative therapies for ADHD. Samples drawn from two research sites – Clinic ABC and Clinic XYZ – will participate in a workshop and their post-test perceptions, symptom recognition knowledge, and parenting self-efficacy compared with baseline data.
Various challenges are anticipated at the research sites. First, gaining access to the clinics to conduct the study may be a problem due to patient confidentiality issues. ADHD is associated with stigma. As such, healthcare organizations may not want parents whose children have this disorder to participate in research. To meet this challenge, the researcher will provide assurances of confidentiality to the management and offer to use a passive recruitment method and unique identifiers and hold on-site awareness workshops.
Enlisting an adequate number of participants may also be a problem. The researcher will use two measures to address this challenge. First, the invitation letter will emphasize the benefits of the project to potential participants, such as it is an opportunity for parents to gain knowledge on home-based contingency management. Second, follow-ups will be made on all eligible participants to address their concerns and increase participation. Managing the logistics of the project is another potential challenge given that the study will be conducted at two research sites. To overcome this problem, the workshops in the two clinics will be held on separate dates.
References
Ahmed, R., Borst, J., Wei, Y. C., & Aslani, P. (2017). Parents’ perspectives about factors influencing adherence to pharmacotherapy for ADHD. Journal of Attention Disorders, 21(2), 91-99. Web.
Catalá-López, F., Hutton, B., Núñez-Beltrán, A., Mayhew, A. D., Page, M. J., Ridao, M., … Moher, D. (2015). The pharmacological and non-pharmacological treatment of attention deficit hyperactivity disorder in children and adolescents: Protocol for a systematic review and network meta-analysis of randomized controlled trials. Systematic Reviews, 4(19), 1-10. Web.
Dakwar, E., Levin, F. R., Olfson, M., Wang, S., Kerridge, B., & Blanco, C. (2014). First treatment contact for ADHD: Predictors of and gender differences in treatment seeking. Psychiatric Services, 65(12), 1465-1473. Web.
Hodgson, K., Hutchinson, A. D., & Denson, L. (2014). Nonpharmacological treatments for ADHD: A meta-analytic review. Journal of Attention Disorders, 18(4), 275-282. Web.
Mojtabai, R., Olfson, M., Sampson, N. A., Jin, R., Druss, B., Wang, P. S.,… Kessler, R. C. (2011). Barriers to mental health treatment: Results from the National Comorbidity Survey Replication. Psychological Medicine, 41(8), 1751-1761. Web.
Partridge, B., Lucke, J., & Hall, W. (2014). Over-diagnosed and over-treated: A survey of Australian public attitudes towards the acceptability of drug treatment for depression and ADHD. BMC Psychiatry, 14, 74. Web.
Sage, A., Carpenter, D., Sayner, R., Thomas, K., Mann, L., Sulzer, S.,… Sleath, B. (2018). Online information-seeking behaviors of parents of children with ADHD. Clinical Pediatrics, 57(1), 52-56. Web.
Veenman, B., Luman, M., & Oosterlaan, J. (2017). Further insight into the effectiveness of a behavioral teacher program targeting ADHD symptoms using actigraphy, classroom observations, and peer ratings. Frontiers in Psychology, 8(1157), 1-10. Web.