Patient Education and Counseling 68 (2007) 23–28

www.elsevier.com/locate/pateducou

Educating and counseling of parents of children with

attention-deficit hyperactivity disorder
Ahmad Ghanizadeh *
Division of Child and Adolescent Psychiatry, Department of Psychiatry, Hafez Hospital, Shiraz University of Medical Sciences, Iran
Received 15 December 2006; received in revised form 15 March 2007; accepted 21 March 2007

Abstract
Objective: This study surveys the parents’ knowledge and attitude about attention-deficit hyperactivity disorder (ADHD), barriers to enrolment for
treatment, parents’ source of information, reason for delay in treatment, and the first person who suggests the diagnosis of ADHD.
Method: The subjects of the study were the 119 parents and their children with ADHD. The parents and their children were interviewed and the
mothers completed a self-reported questionnaire about ADHD.
Results: The knowledge about ADHD was relatively low. Half of them did not agree that ADHD is due to biological and genetic vulnerabilities
and causation. Fifty-two percent of all the parents considered ADHD to be the result of parental spoiling. Only 6.2% reported that ADHD relate
difficulties would persist for the whole life. About 40% of the respondents considered it as a sign of child independency. The main source of
knowledge about ADHD was radio and TV. There were about 1.5 years between the time that the parents were suspected to the ADHD and the time
they referred for the first time. The most common reason for the delay was lack of knowledge about where or whom they should refer to. Teachers
were the first one who suggested the diagnosis of ADHD in most of the cases.
Conclusion: Knowledge about ADHD is low and barriers of referral are not usually overcome.
Practice implications: Educating and counseling of the parents should be directed toward emphasizing it as a biological problem, with concerns
about its course. Also, targeting of the barriers in delaying the referral is an important issue. Medical personnel, especially GPs should be more
informed about ADHD and play more active role in the treatment process.
# 2007 Elsevier Ireland Ltd. All rights reserved.

Keywords: ADHD; Parent’s report; Knowledge; Attitude; Barriers; Information sources; Farsi version of K-SADS; Iran

1. Introduction attitudes toward ADHD are extremely limited [6,7]. The

ADHD is the most common child and adolescent psychiatric
disorder. Its core symptoms are hyperactivity, inattention and
impulsiveness. Beliefs and attitudes of parents have some
implications for their willingness to seek and respond to mental
health services for ADHD children and it is a cultural value
orientation [1]. In addition, it can affect how they evaluate
and report their child’s behavior [2]. Furthermore, the parents’
knowledge of ADHD plays a significant role in their
participation in treatments [3]. Acculturation played a role in
Latino mothers’ perceptions of the hyperactivity aspects of
ADHD [4]. The acceptable level of activity for children is set by
cultural expectations [5]. Studies of parents’ knowledge and
* Tel.: +98 711 627 93 19; fax: +98 711 627 93 19.
E-mail addresses: ghanizad@sina.tums.ac.ir, ghanizadeha@hotmail.com.
0738-3991/$ – see front matter # 2007 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.pec.2007.03.021
previous study is based on presenting case vignettes of
hyperactivity (not ADHD) to mothers and taking their views.
As the authors mentioned, the mothers’ answers may not reflect
their actual behavior. In addition, they did not examine the
mothers’ views on management and course of the behavior
problems [6]. African–American parents are less likely than
white parents to have heard of ADHD, feel knowledgeable
about ADHD, or receive information from their physician about
ADHD [8]. Most of the parents of ADHD children are reluctant
to consider their child’s difficulties as an illness [9]. Parent
management training of ADHD children has a positive effect on
the parents’ general mental health [10].
If Iranian parents of ADHD children are aware of their
children’s problems that are less consistent with scientific
research, they may be less likely to accept proper mental health
services. Therefore, ADHD children will be less likely to have
been referred to mental health services by family, or the
24 A. Ghanizadeh / Patient Education and Counseling 68 (2007) 23–28
families may be less willing to enroll and follow up treatment.
In other words, to care for children with ADHD, their behavior
must be understood within the context of their parents’ beliefs
and its related perceptions.
There was not found any study from Asia about the
knowledge and attitude of parents with a child diagnosed as
ADHD about ADHD. If the Iranian parents identified the
child’s behavior as problematic, would they discuss it with their
child’s primary health care provider? This study starts to survey
Iranian mothers’ views of ADHD.
2. Method
2.1. Study design
This was a cross-sectional study of parents of 119 children
with ADHD.
2.2. Subjects and setting
The study population was 119 ADHD children, consecutive
outpatients of the only Child and Adolescent Psychiatry Clinic
affiliated to Shiraz University of Medical Sciences at Shiraz,
one of the largest cities in Iran. The individuals were drawn
from general referrals to the outpatient setting dealing with
child and adolescent psychiatric and psychological problems.
The children and their parents were interviewed. In addition,
the parents of children diagnosed with ADHD were asked to
complete a self-administered survey.
The interviews were performed during the first visits of the
patients to the clinic. The inclusive criteria were child age
range of 5–15 years old and having a diagnosis of ADHD. The
exclusive criteria were child full-scale estimated IQ score less
than 80, suffering from a chronic medical condition, and the
parents’ illiteracy. Only three of the eligible subjects refused
to take part in the study because it was time consuming and
three other parents did not take part because they were
illiterate.
Diagnostic assessment was the K-SADS Farsi version by
face-to-face interview with children and adolescents and their
parents (over 90% of the parents were mothers). The K-SADS
Farsi version is a reliable, respondent-based instrument
that provides diagnostic data on psychiatric disorders. It is
the only diagnostic instrument based on the standard
psychiatric diagnosis that has been translated into Farsi. The
Farsi version of K-SADS used in the current study has been
shown to have good validity and reliability. The test-rest
reliability for ADHD is 0.84. In addition, it has a good
sensitivity and specifity for ADHD diagnosis [11,12].
2.3. The knowledge and attitude questionnaire
In addition to demographic characteristics (educational
level of parents and children, type of parents’ occupation,
fathers’ age, mothers’ age, and income), the self-administered
questionnaire asked parents to privately record their child’s age,
gender, age when they first became concerned with their child’s
behavior. The second part of the questionnaire was regarding
knowledge, attitude and source of acquired information about
ADHD. It has been used in a study in Iran and has sufficient
validity and reliability [13]. The reliability of the questionnaire
in this study was 0.90.
The patients and their parents were informed and their
consents were obtained to participate in the study. It was
stressed that the information collected would be confidential,
and would be used for analysis in writing an article in order to
improve the life of children with ADHD and their families by
increasing the knowledge of family. The study was conducted
according to the Good Clinical Practice Guidelines, in
accordance with the Declaration of Helsinki, 1975, as revised
in 2000 and approved by the University. The data were analyzed
by using SPSS-10 for Windows statistical package.
3. Results
The subjects of the study were 119 child and adolescents
with ADHD and 119 parents of them. The number of boys was
100 (84%). More than 73% of the parents were mothers. The
age range of the children was 5–15 years old (mean = 8.4,
S.D. = 2.5). The mean of mothers’ age was 32.6 (S.D. = 6.3).
About 85% of the mothers were housekeeper. Mothers’
education level range was 5–18 and the mean was 11.4
educational years. The fathers’ education level range was 4–18
and the mean was 11.3 educational years. The mean of the
fathers’ age was 38.8 (S.D. = 5.8). 58.8% of the children were
the first child of family and 22.7% were the second child. About
40% of the children were the only child of the family.
Less than half of the parents reported that ADHD was due
to biological and genetic vulnerabilities. About 40% of them
think that ADHD symptoms were sings of curiosity or high
intelligence (Table 1). However, near two thirds of the
mothers agreed that it was a serious problem and nearly all of
them believed that it would not improve spontaneously and
emphasized the necessity for treatment of their children. In
addition, a minority of them believed that it was a life long
condition. The parents reported that the mean age that
children with ADHD should improve is 16.5 years (range of
12–21).
About half of them said that poor parenting practices and
parental spoiling is the cause of ADHD. A minority of them
believed that sugar was a reason for this problem.
About one-third believed that it increased the risk of truancy
and about half them believed the children were at a higher risk
of delinquency. The minority of the mothers reported that the
same discipline and rules used for all children should be applied
to ADHD children. More than 90% believed that these children
require psychological support but only 40% said that they need
specially trained educators at school.
14.4% of the mothers reported that ADHD childrens’ IQ was
lower than that of non-ADHD children. 45.9% reported that
their IQ is similar to peers and 39.6% believed that the
childrens’ IQ is more than that of their peers. Half of the
mothers thought that educational achievements of these
children would be less than that of non-ADHD peers.
 A. Ghanizadeh / Patient Education and Counseling 68 (2007) 23–28 25

Table 1
Knowledge and attitude of the parents of children with ADHD about ADHD
Statements % Answer code
ADHD is due to biological and genetic vulnerabilities 47.7 True
ADHD is a singe of child independency 10.4 True
ADHD is a singe of curiosity 40.9 True
ADHD is a singe of a bright intelligence 38.4 true
ADHD is a serious problem 73.3 True
ADHD will be improved spontaneously 2.6 True
ADHD can be caused by poor parenting practices and parental spoiling 52.2 False
They are at a higher risk of truancy and escaping 35.3 True
ADHD related difficulties persist for whole life 6.1 True
ADHD children should receive a special education setting and this would be more favorable than mainstream 78.4 True
ADHD children have a high risk for becoming delinquent as teenagers 54.4 True
ADHD children’ IQ is more than that of non-ADHD children 39.6 –
ADHD children need psychological support 93.2 True
Specially trained educators should teach these ADHD children 40 True
The same discipline and rules used for all children should be applied to ADHD children 18.3 True
Educators should be aware from ADHD and ADHD children in the class 92.3 True
ADHD children experience more difficulties in their relations with their classmates 67.3 True
Educational achievement of ADHD children will be less than that of non-ADHD peers 50.5 True
ADHD children experience more difficulties in their relations with their family members 60 True
ADHD students should receive less homework than others should 20.9 True
ADHD students should be examined orally 22.9 True
ADHD can be treated and managed with proper medication 60.4 True
ADHD can often be caused by sugar or food additives 11.3 True

About 77.3% of the mothers have already heard about
ADHD and about 70% self-rated their information about
ADHD as very low or unknown. The most common sources of
the mothers’ information are depicted in Fig. 1.
The mean age of the child that the parents were suspected
for the first time that their child have behavioral difficulty or
ADHD was 5.3 (S.D. = 2.09) years old. However, the first
time they referred for assessing their child was 6.96
(S.D. = 2.3) years old. In other words, the children were
referred for assessment 1.6 years later than when they were
suspected. The most common reason for this delay was
that they did not know where or whom they should refer to
Fig. 2.
Family members, friends and school psychologist were the
three most common sources of advice for refries to Child and
Adolescent Psychiatry Clinic (Table 2). In one-third of the
cases, the teachers were the first individual who suggests the
diagnosis (Fig. 3).

Fig. 1. Mothers’ source of information about ADHD.

26 A. Ghanizadeh / Patient Education and Counseling 68 (2007) 23–28

Fig. 2. The reasons reported by mothers for their delay in referring for assessment of the child.

Table 2 4. Discussion and conclusion

The source of advice for refries to child and adolescent psychiatry clinic for
assessment of the child’s behavior
4.1. Discussion
Adviser of the parents for assessment of the child n %
Teacher 9 8.9 The most striking finding of this study is that most of the
Family members 29 28.7 parents have not sufficient information about ADHD. Although
Pediatrician 9 8.9 most of the parents have already heard of ADHD, they feel that
Relatives 14 13.9
they are unaware about it. These might show high rates of
School psychologist 17 16.8
Friends 18 17.8 unmet ADHD treatment needs among the children even in those
Speech therapist 1 1.0 who already referred by their parents.
Psychiatrist 4 4.0 Most of them do not believe that there is a biological and
genetic vulnerability. It means that they did not take on a

Fig. 3. Who first suggests the diagnosis of ADHD?.

 A. Ghanizadeh / Patient Education and Counseling 68 (2007) 23–28
biomedical meaning. Most of them thought that ADHD could be
caused by poor parenting practices and parental spoiling. It might
make parents feel extremely guilty for their behavior. When they
finally learn about ADHD, they might not feel guilty [7].
About only two-third of them believe that ADHD can be
treated and managed with proper medication. It shows that
many of them do not believe that it is an illness. Another
interesting finding was that only about 6% of the parents believe
that ADHD symptoms would persist for the whole life.
Meanwhile, many studies demonstrate that in about 40–70% of
children the ADHD symptom persists into adulthood [14]. It
seems that the parents maintain a sense of optimism.
One-third of the parents do not think that ADHD children
experience more difficulties in their relations with their
classmates. On the other hand, the relationship with peers is
an important factor in the prognosis of ADHD and social
disabilities are negative markers in the outcome [15,16].
Meanwhile, it is estimated that 95% of ADHD students
experience academic under-achievement [17]. Only half of the
current study parents reported that educational achievement of
ADHD children will be less than that of non-ADHD peers.
One of the most interesting findings is that near half of the
parents were not aware about where and whom they should
refer to for treatment. This barrier is considered as one of the
most common reasons expressed by the parents for delay in
assessment. On the other hand, the radio and TV were the most
common sources of their information about ADHD. It might be
concluded that providing information about ADHD is not
sufficient and the references for assessing and treating of theses
children should be announced in mass media. Most of the
patents have information about ADHD from TVand radio, even
more than that of the medical personnel or other resources. A
prior study showed that 39.4% of the parents of ADHD received
explanation/information from professionals [18]. It might show
that the main source of information for the parents in Iran is
very different from those of others, or it is possible that other
sources such as medical personnel have very low information
about ADHD. This indicates that these personnel should take a
more active role in the education of the community.
Economical factors and fear from stigmatization did not play
any major role in delay for treatment. Of course, it can be
explained by the method of sampling which included clinical
cases. To assess the role of these two factors, a community-
based study is necessary.
There was found a delay between the time of suspicion about
ADHD by parents and their referral. It is very important
because a delay in the diagnosis of ADHD can be the cause of
the development of serious social problems [19]. The mean age
of the child when the parents were suspected for the first time
about their child’s ADHD was 5.3. This mean age is very
similar to another study which reported that the first age of
presenting symptoms was 5.2 years [18]. It is interesting that
the first time that they referred for assessing of their child was
about 1.5 years later.
The most common individuals who first suggested diagnosis
of ADHD were the teachers and the family members. The
percentage for psychologist or GPs or pediatricians was much
27
lower than that of the teachers. In a prior study, the teachers
were most likely to be first to suggest the diagnosis of ADHD
(46.4%), followed by parents (30.2%) [20]. This result might
show that GPs should be more informed about ADHD. In
addition, it shows the teachers’ recommendations play a very
important role in the diagnosis or treatment of ADHD.
Meanwhile, the previous study showed that the knowledge of
teachers in Iran about ADHD was found to be very low [13].
4.2. Limitations
The responding mothers were those who referred to the
clinic and probably less likely to consider attention-deficit
hyperactivity disorder (ADHD) behavior as a normal (or
expected) compared to general population mothers. In addition,
the mothers had probably greater interest in discussing the
boys’ behaviors with their physician than those who had not
referred. In addition, it is possible that those who have the most
severe degree of ADHD were referring to the clinic. Knowledge
and attitude of other parents in different phases of treatment
process could vary considerably with those who are in the
stages of identification, diagnosis, and management. It is
possible that in view of the mothers in community, ADHD is
considered normal and the mothers would not seek physician’s
advice about the behavior. Of course, the focus of the current
study is studying the parents who already referred to the clinic.
Studies of parents’ view of ADHD children about ADHD are
very limited and this study can be a beginning point for this
matter. Finally, it did not survey if the primary health provider
did not encourage further referral.
Community sample studies are necessary for a better
understanding of cultural variation for the criteria for ADHD.
In addition, more studies are necessary to understand why other
mothers do not seek treatment for a child with ADHD.
4.3. Conclusion
There is an emergency need to improve the insight of the
parents of ADHD children, parents’ conception of the problem,
its cause, its effect on behavior and education, its impact on social
relationships and its outcomes. Comprehensive training in
ADHD is very necessary for the parents. It is the starting point for
better diagnosis, management, and treatment of these children.
4.4. Practice implication
Providing information about ADHD is not sufficient and the
references for assessing and treating of these children should be
announced in mass media. Medical personnel should take a
more active role in the education of people; especially GPs
should be more informed about ADHD.
References
[1] Chavira V, Lopez SR, Blacher J, Shapiro J. Latina mothers’ attributions,
emotions, and reactions to the problem behaviors of their children with
developmental disabilities. J Child Psychol Psyc 2000;41:245–52.
28 A. Ghanizadeh / Patient Education and Counseling 68 (2007) 23–28
[2] Livingston R. Cultural issues in diagnosis and treatment of ADHD. J Am
Acad Child Adol Psych 1999;38:1591–4.
[3] Corkum P, Rimer P, Schachar R. Parental knowledge of attention-deficit
hyperactivity disorder and opinions of treatment options: impact on
enrollment and adherence to a 12-month treatment trial. Can J Psychiat
1999;44:1043–8.
[4] Schmitz M, Velez M. Latino cultural differences in maternal assessments
of attention deficit/hyperactivity symptoms in children. Hispanic J Behav
Sci 2003;25:110–22.
[5] Pachter LM, Dworkin PH. Maternal expectations about normal child
development in 4 cultural groups. Arch Pediat Adol Med 1997;151:
1144–50.
[6] Gidwani PP, Opitz GM, Perrin JM. Mothers’ views on hyperactivity: a
cross-cultural perspective. J Dev Behav Pediatr 2006;27:121–6.
[7] Perry CE, Hatton D, Kendall J. Latino parents’ accounts of attention
deficit hyperactivity disorder. J Transcult Nurs 2005;16:312–21.
[8] Bussing R, Schoenberg NE, Perwien AR. Knowledge and information
about ADHD: evidence of cultural differences among African–American
and white parents. Soc Sci Med 1998;46:919–28.
[9] Wilcox CE, Washburn R, Patel V. Seeking help for attention deficit
hyperactivity disorder in developing countries: A study of parental expla-
natory models in Goa, India. Soc Sci Med 2007 [Epub ahead of print].
[10] Ghanizadeh A, Shahrivar FZ. The Effect of Parent Management Training
on children with attention deficit hyperactivity disorder. J Child Adoles
Ment Health 2005;17:31–4.
[11] Kaufman J, Birmaher B, Brent D, Rao U, Flynn C, Moreci P, Williamson D,
Ryan N. Schedule for affective disorders and schizophrenia for school-age
children-present and lifetime version (K-SADS-PL): initial reliability and
validity data. J Am Acad Child Adol Psych 1997;36:980–8.
[12] Ghanizadeh A, Mohammadi MR, Yazdanshenas A. Psychometric proper-
ties of the Farsi translation of the Kiddie Schedule for Affective Disorders
and Schizophrenia-Present and Lifetime Version. BMC Psychiatr
2006;6:10.
[13] Ghanizadeh A, Bahredar MJ, Moeini SR. Knowledge and attitudes
towards attention deficit hyperactivity disorder among elementary school
teachers. Patient Educ Couns 2006;63:84–8.
[14] Mannuzza S, Klein RG, Moulton 3rd JL. Persistence of attention-deficit/
hyperactivity disorder into adulthood: what have we learned from the
prospective follow-up studies? J Atten Disord 2003;7:93–100.
[15] Bagwell CL, Molina BS, Pelham Jr WE, Hoza B. ADHD and problems in
peers relations: predictors from childhood to adolescence. J Am Acad
Child Adoc Psych 2001;40:1285–92.
[16] Greene RW, Biederman J, Faraone SV, Ouellette CA, Penn C, Griffin SM.
Toward a new psychometric definition of social disability in children with
ADHD. J Am Acad Child Psych 1996;35:571–8.
[17] Barkley RA. Attention-deficit/hyperactivity disorder: a handbook for
diagnosis and treatment.. New York: Guilford Press; 1990.
[18] Brook U, Boaz M. Attention deficit and hyperactivity disorder/learning
disabilities (ADHD/LD): parental characterization and perception. Patient
Educ Couns 2005;57:96–100.
[19] Tsai CH, Gau SF. Long-term outcome studies of hyperactive children:
literature review. Kaohsiung J Med Sci 1999;15:307–14.
[20] Sax L, Kautz KJ. Who first suggests the diagnosis of attention-deficit/
hyperactivity disorder? Ann Fam Med 2003;1:171–4.