By Lauren Haack, Ph.D.
Department of Psychiatry and Behavioral Sciences
University of California, San Francisco
Attention-Deficit, Hyperactivity/Impulsivity Disorder (ADHD) is one of the most common mental health disorders impacting approximately 5% of children across cultures.1 Brain differences related to ADHD influence those affected in several ways.1,2 To begin, new or challenging tasks seem overwhelming, making it hard to map out a plan for completion and self-motivate initiation.3 In addition, individuals with ADHD have a tendency to over-perceive negative feedback and under-perceive positive feedback,2,4 which relates to difficulty regulating emotions.2 Unfortunately, as children with ADHD reach school age, they encounter more difficulties and more opportunities for critical rather than positive feedback from parents, teachers, and peers.2,5 As a result, ineffective patterns of interaction between children with ADHD and others in their lives can become entrenched, contributing to stress, confusion, and even hopelessness.4,5
Fortunately, behavioral ADHD treatments help parents/caregivers and teachers use strategies that have been found to be effective but can be difficult to put into place consistently without support.5,6 Three key goals for behavioral ADHD treatments can be thought of as the “3 C’s”
- Clarity – well-defined and reasonable expectations that children can achieve
- Coordination – communication between families and teachers to provide children a clear roadmap for success
- Celebration – frequent and specific praise, as well as rewards, when children meet expectations.
Consistent use of “3 C” strategies by parents/caregivers and teachers can help mend broken bonds, improve child functioning, and convey optimism and hope for all.5,6
Unfortunately, there are barriers across all stages of ADHD help-seeking that prevent youth in need from receiving treatments that work.7 Many barriers are especially pronounced for families from racial and ethnic minority groups.7,8
ADHD Help-Seeking Stages
Recognizing there is a problem that needs support
The first step in ADHD help-seeking involves recognizing there is a problem that needs support. Barriers in this stage include limited knowledge about ADHD, as well as differing beliefs about the causes of—and developmental expectations for—child behavior.7–10 For example, if one believes that impulsivity is just part of the typical childhood experience (“Boys will be boys; no big deal”) and they have never heard a biopsychosocial explanation for ADHD, they may be less likely to recognize a need for treatment even if the child’s behavior becomes impairing.
Deciding to seek help and selecting a service
If one does identify problematic child behaviors warranting support, they may progress to the next steps of deciding to seek help and selecting a service. A primary barrier here can be finding treatment in one’s native language.7,8 Additionally, given that families from racial and ethnic minority groups are disproportionately uninsured and financially strained in the United States, their decisions to seek help may be obstructed by out-of-pocket costs.7,8 There also may be hesitancy to seek treatment due to societal stigma and distrust, perceived lack of family support, fears about revealing undocumented status, and prior experiences with discrimination and racism by care providers.7–9
Utilizing the service selected
The final step in ADHD help-seeking is utilizing the service selected. Even if one can locate affordable treatment in their native language, they may have difficulty securing transportation, time off work, and/or child care, thus impeding consistent attendance.7,8 They also may lack genuine connection with providers or find that services focus on strategies which don’t feel relevant in their communities, which can lead to dissatisfaction, dropout, or poorer treatment outcomes.7–9
- A potential solution addressing many of the barriers to ADHD help-seeking outlined above is offering services for free in familiar and accessible settings, such as schools.5,11 Research supports the following recommendations when using this approach:
Redeploy school resources from ADHD practices with limited evidence (such as individual counseling) to treatments that work (such as behavioral parent/caregiver groups and classroom management)5,6,11
- Offer linguistically and culturally appropriate services whenever possible; for example, the Collaborative Life Skills (CLS) school-based program11 shows feasibility, acceptability, and effectiveness in Spanish with Latinx families in the U.S. and Mexico12,13
- Describe services using words that carry less stigma, such as “a program to improve youth attention and behavior” rather than “treatment for ADHD and related disorders”13
- Harness technology to improve service reach and feasibility; for example, offer groups via videoconference for those who can’t attend in-person14
- Faraone, S. V., Banaschewski, T., Coghill, D., Zheng, Y., Biederman, J., Bellgrove, M. A., Newcorn, J. H., Gignac, M., Al Saud, N. M., Manor, I., Rohde, L. A., Yang, L., Cortese, S., Almagor, D., Stein, M. A., Albatti, T. H., Aljoudi, H. F., Alqahtani, M. M. J., Asherson, P., … Wang, Y. (2021). The World Federation of ADHD International Consensus Statement: 208 Evidence-based Conclusions about the Disorder. Neuroscience & Biobehavioral Reviews. https://doi.org/10.1016/j.neubiorev.2021.01.022
- Shaw, P., Stringaris, A., Nigg, J., & Leibenluft, E. (2014). Emotion Dysregulation in Attention Deficit Hyperactivity Disorder. American Journal of Psychiatry, 171(3), 276–293.
- Sibley, M. H., Graziano, P. A., Ortiz, M., Rodriguez, L., & Coxe, S. (2019). Academic impairment among high school students with ADHD: The role of motivation and goal-directed executive functions. Journal of School Psychology, 77, 67–76. https://doi.org/10.1016/j.jsp.2019.10.005
- Babinski, D. E., Kujawa, A., Kessel, E. M., Arfer, K. B., & Klein, D. N. (2019). Sensitivity to Peer Feedback in Young Adolescents with Symptoms of ADHD: Examination of Neurophysiological and Self-Report Measures. Journal of Abnormal Child Psychology, 47(4), 605–617. https://doi.org/10.1007/s10802-018-0470-2
- Pfiffner, L. J., & Haack, L. M. (2014). Behavior Management for School-Aged Children with ADHD. Child and Adolescent Psychiatric Clinics of North America, 23(4), 731–746. https://doi.org/10.1016/j.chc.2014.05.014
- Friedman, L. M., & Pfiffner, L. J. (2020). Chapter 7—Behavioral interventions. In M. M. Martel (Ed.), The Clinical Guide to Assessment and Treatment of Childhood Learning and Attention Problems (pp. 149–169). Academic Press. https://doi.org/10.1016/B978-0-12-815755-8.00007-1
- Eiraldi, R. B., Mazzuca, L. B., Clarke, A. T., & Power, T. J. (2006). Service utilization among ethnic minority children with ADHD: A model of help-seeking behavior. Administration and Policy in Mental Health and Mental Health Services Research, 33, 607–622.
- Gerdes, A. C., Lawton, K. E., Haack, L. M., & Schneider, B. W. (2014). Latino Parental Help Seeking for Childhood ADHD. Administration and Policy in Mental Health and Mental Health Services Research, 41(4), 503–513. https://doi.org/10.1007/s10488-013-0487-3
- Araujo, E. A., Pfiffner, L., & Haack, L. M. (2017). Emotional, Social and Cultural Experiences of Latino Children with ADHD Symptoms and their Families. Journal of Child and Family Studies, 26(12), 3512–3524. https://doi.org/10.1007/s10826-017-0842-1
- Lawton, K. E., Gerdes, A. C., Haack, L. M., & Schneider, B. (2014). Acculturation, cultural values, and Latino parental beliefs about the etiology of ADHD. Administration and Policy in Mental Health, 41(2), 189–204. https://doi.org/10.1007/s10488-012-0447-3
- Pfiffner, L. J., Rooney, M., Haack, L., Villodas, M., Delucchi, K., & McBurnett, K. (2016). A Randomized Controlled Trial of a School-Implemented School–Home Intervention for Attention-Deficit/Hyperactivity Disorder Symptoms and Impairment. Journal of the American Academy of Child & Adolescent Psychiatry, 55(9), 762–770. https://doi.org/10.1016/j.jaac.2016.05.023
- Haack, L. M., Araujo, E. J., Delucchi, K., Beaulieu, A., & Pfiffner, L. (2019). The Collaborative Life Skills Program in Spanish (CLS-S): Pilot Investigation of Intervention Process, Outcomes, and Qualitative Feedback. Evidence-Based Practice in Child and Adolescent Mental Health, 4(1), 18–41. https://doi.org/10.1080/23794925.2018.1560236
- Haack, L. M., Araujo, E. A., Meza, J., Friedman, L. M., Spiess, M., Beltrán, D. K. A., Delucchi, K., Herladez, A. M., & Pfiffner, L. (2020). Can School Mental Health Providers Deliver Psychosocial Treatment Improving Youth Attention and Behavior in Mexico? A Pilot Randomized Controlled Trial of CLS-FUERTE: Journal of Attention Disorders. https://doi.org/10.1177/1087054720959698
- Haack, L. M., Lai, J., Guerrero, M. F. A., Valdez, M. E. U., Beltrán, D. K. A., Rivera, E. C. Z., Saldaña, D. M. L., García, K. D., Candil, E. M., Beltran, J. U. M., & Araujo, E. A. (2022, November). Adapting a Comprehensive ADHD Intervention and School Clinician Training Program for Fully Remote Delivery in Mexico: The CLS-R-FUERTE Program. In M. Dvorksy’s and L.M. Haack’s (Chairs) Optimizing Interventions for ADHD Using Technology: Designs to Improve Treatment Engagement and Implementation. Association for Behavioral and Cognitive Therapies Annual Convention, New York, NY,