BCCHR's Ask an Expert Series
We asked an expert about attention deficit hyperactivity disorder (ADHD), her two latest studies that focus on parents and helpful resources for caregivers.
ADHD is one of the most common psychiatric disorders of childhood and typically persists through adolescence and into adulthood. ADHD affects an estimated five to nine per cent of school-age children and four percent of adults. That means in every classroom, two kids would have ADHD, whether they’re diagnosed or not.
ADHD usually causes difficulties with a child or youth's functioning at school, at home, in extra-curricular activities and when interacting with friends.
Research strongly supports a combination of genetics and neurobiology as the cause of ADHD, in most cases.
Dr. Janet Mah is a psychologist and investigator at BC Children’s Hospital and a clinical assistant professor of psychiatry at the University of British Columbia who studies parenting contributors to treatment engagement and adherence.
We caught up with Dr. Mah, asked her about ADHD, her two most recently published studies and resources she recommends.
Q: What is ADHD?
ADHD is a neurodevelopmental disorder with two broad categories of symptoms. One is attention difficulties, such as a child that doesn’t seem to pay attention when you’re speaking to them, has difficulty sustaining focused attention on tasks that require a lot of mental effort, does not follow through with multiple-step directions or tasks, is forgetful or loses things.
The other category is hyperactive or impulsive symptoms. These kids are constantly on the go and unable to stay seated when they’re expected to. There’s also verbal hyperactivity and verbal impulsivity. These kids talk nonstop, and blurt out answers, interrupt and don’t wait their turn.
Sometimes ADHD is kind of a misnomer because you can have attention difficulty without hyperactivity or impulsivity. Also, individuals with ADHD can hyperfocus on things of interest, like video games, reading or Lego. So, ADHD is not just about attention deficit, but more like attention inconsistent.
Q: Does ADHD present differently in boys and girls
Research shows there’s about a 2:1 ratio; more boys than girls have ADHD. Sometimes girls with ADHD, or those with the predominantly inattentive presentation with less of the outward signs of hyperactivity, might be overlooked because they’re not outwardly disruptive, but they are still missing details, making careless mistakes and not following through with instructions.
Q: What distinguishes ADHD from “normal” inattentiveness and restlessness?
Because we all have difficulties paying attention when we’re bored or tired, we assess how much it’s impairing one’s life in respect to age/developmental level expectations. We generally try not to diagnose ADHD before the age of six because a preschooler would have all the symptoms of ADHD and it’s totally normal that they can’t focus or stay seated for prolonged periods of time.
Q: How is ADHD typically diagnosed?
ADHD can be diagnosed through family physicians, pediatricians, psychologists and psychiatrists. Your first line would be going to your family doctor. Depending on expertise, they might send you to a pediatrician, and depending on complexity, they might also refer to a psychiatrist or psychologist. An assessment typically involves a clinical interview with parents/guardians, rating scales for caregivers and teachers, and review of report cards and other relevant documents.
Q: What are the most effective treatments for ADHD?
There are two main evidenced-based interventions for ADHD; using both in combination tends to be best.
The first would be long-acting stimulant medication. These are medications that target the neurotransmitters in the prefrontal cortex of the brain, which is primarily responsible for executive functioning, which includes difficulties such as inhibiting your responses, shifting your attention from one thing to another, emotional control, time management and organizing.
Behavioural parent training is the second treatment. Parents and teachers are taught how to accommodate, instruct and create an environment to support a child with ADHD by using visual timers and transition warnings, breaking tasks into smaller parts, allowing movement breaks or fidgets and giving appropriate choices of how (not if) to do tasks. They are taught to try to catch times when children are behaving well, as opposed to only catching times when they’re misbehaving, and to plan incentives to reward children with ADHD for target behaviours like raising their hand before speaking, or completing homework or chores.
Q: Tell me about your study on parents’ attitudes towards medication. What did you find and why is that significant?
While stimulant medications are one of the most effective first-line treatments for ADHD – hundreds of studies have found stimulant medications to improve ADHD symptoms in 70 to 80 per cent of children shortly after starting treatment – many parents feel uncomfortable about giving their children prescription drugs.
We examined how parents’ beliefs about ADHD and ADHD medications affected medication use for their kids. We considered parents’ knowledge about ADHD, treatment attitudes and level of stigma to gauge how well researchers could predict the uptake and continuation of medication.
The study revealed that parents who are more knowledgeable about ADHD and hold fewer negative beliefs about ADHD and stimulant medications were more likely to start and continue medication as prescribed for their kids.
This highlights that we need to assess for parents’ beliefs – not just the child’s ADHD symptoms – and then target education to meet the parents where they’re at. We need to provide more education about ADHD and also address all parents’ concerns about their treatments, and then do a better job of reducing stigma.
Q: Why did you decide to study the effect of incorporating mindfulness into behavioural training for parents?
There’s years and years of solid research about behaviour parent training as a great evidence-based intervention for ADHD, but we’ve also recognized that those strategies work best when parents are consistent and when parents are calm, and we know in real life that parenting is not so easy. We have our own emotional triggers, we’re tired, we’re busy and nobody is a perfect parent. It’s really easy to fall into repeated patterns of overreacting, getting upset, or giving up altogether. We wanted to try addressing the emotional support for parents while they’re implementing these behavioural management strategies.
Q: What did you do in your mindfulness-enhanced parent training study and what did you find?
We pitted this enhanced mindfulness parent training against gold-standard parent training, to see how much more adding mindfulness would help. We found that both groups helped parents feel more confident in their parenting, as well as helped their kids improve in their ADHD difficulties. But parents in the mindfulness-enhanced group had additional improvements in their parenting strategies and in their own regulation skills, which is exactly what we were hoping for: that by using mindfulness, you’re better able to be less reactive, more regulated, and follow through better with your parenting strategies.
Q: What resources do you recommend to parents?
- For behaviour management: Rolling With ADHD online program. It’s a free, eight-week online program developed by psychologists at BC Children’s.
- For mindfulness: Apps to explore include Headspace and Insight Timer.
- For medication: At the Kelty Mental Health Resource Centre at BC Children’s, click on “Medications & Therapy” and “ADHD Medications.”
- For schools and families: Centre for ADHD Awareness Canada