Gaps and gains in parents’ mental health literacy: A cross-cultural comparison on attention-deficit/hyperactivity disorder

Abstract

The aim of this study was to compare the knowledge and beliefs about attention-deficit/hyperactivity disorder (ADHD) between first-generation Chinese Canadian and European Canadian parents, and to evaluate the efficacy of an existing translated ADHD information resource to improve their ADHD literacy. A community sample of 28 first-generation Chinese Canadian and 28 European Canadian parents of elementary school-aged children completed questionnaires measuring ADHD knowledge, treatment attitudes and perceived stigma, both before and after reading an informational pamphlet about ADHD. Compared with European Canadian parents, Chinese Canadian parents initially had less knowledge and more stigma about ADHD but had greater increases in knowledge and medication acceptability after passive psychoeducation. For both groups, passive psychoeducation increased ADHD stigma, but did not impact the already high acceptability for parent training intervention. Passive psychoeducation can improve mental health literacy among ethnic minority groups, but further work needs to tailor resources to address specific gaps in mental health literacy and recognize the need for concurrent stigma-reduction methods.

Keywords

ADHD mental health literacy stigma Chinese parents

Introduction

Mental health conditions affect one in seven individuals across the world and are the third leading cause of global non-communicable disease burden (Ritchie & Roser, 2018). Although evidence-based mental health treatments and supports are available, mental health services are greatly underutilized among ethnic minority groups (Lê Cook et al., 2017). In fact, a series of meta-analyses of 130 studies (Smith & Trimble, 2016) showed that Asian Americans are 51% less likely to use mental health services than European Americans, with the Asian population having the greatest rates of mental health underutilization among other ethnic groups (e.g. African Americans and Hispanics/Latinx are 21% and 25% less likely than European Americans to use mental health services). Specifically, Chinese populations around the world have been shown to have lower mental health literacy and mental health service usage (Loo et al., 2012; Wong et al., 2017). The same pattern of underutilization has also been found with Asian Americans and Chinese Canadians (Chiu et al., 2018; Yang et al., 2019). A. W. Chen et al. (2009) make a case for culture as the defining factor for Chinese Canadians’ underutilization of mental health services, rather than the ‘healthy immigrant effect’ or lack of English language abilities. They suggest that it is a strong Chinese cultural orientation that deters Chinese Canadians from seeking mental health help (e.g. different presentation of symptoms, lack of recognition, incompatible treatment methods, stigma).

Mental health underutilization by Chinese families also impacts the outcomes of their children, including those who have attention-deficit/hyperactivity disorder (ADHD). ADHD is characterized by a persistent pattern of inattention and/or excessive hyperactivity/impulsivity that is associated with significant academic, social and behavioural impairments. ADHD occurs in approximately 3–7% of school-aged children, and this rate is similar across ethnicities around the world (Faraone et al., 2003; Wang et al., 2017). Symptoms and impairment can last into adolescence and adulthood (Sibley et al., 2017; Swanson et al., 2017). However, the struggles of Chinese children with ADHD may be underreported by their parents, and evidence-based treatments for ADHD (e.g. stimulant medication and behavioural parent training) may not be sought out by Chinese parents, owing to concerns about stigma or alternative beliefs about the underlying causes (Pham, 2013). Given the negative and long-term consequences associated with undiagnosed and untreated childhood ADHD (Hamed et al., 2015), it is imperative to better understand and reduce the service gap for Chinese families with children in this population.

Models on cultural influences in ADHD/mental health

Eiraldi et al. (2006) proposed a model of help-seeking behaviour for ethnic minority parents whose children have ADHD. This model shows four stages of help-seeking that families progress through in order: (a) problem recognition, (b) decision to seek help, (c) service selection and (d) service utilization. Moreover, there are several variables that contribute to each stage, such as (a) disorder and family profile, (b) predisposing characteristics, (c) community barriers and facilitators and (d) service promotors and categories. There is recognition that some variables are fixed (e.g. demographics), while other variables are amenable to change at differing levels (e.g. coordination of care relates to public health policy, economic and access factors relate to healthcare administration, and assessment and treatment relate to the direct service). Slobodin and Masalha (2020) reviewed cultural factors in problem recognition, service access and utilization for ADHD; however, the majority of the studies reviewed pertained to African American or Hispanic populations, with none specific to Chinese families. Na et al. (2016) identified a culturally responsive framework for mental health literacy among East Asian populations that addressed four key components: (a) knowledge and recognition of mental illness, (b) beliefs about causes of mental illness, (c) attitudes about treatment and help-seeking and (d) self-help strategies. Their review focused primarily on depression and/or psychosis. Previous research has found lower levels of ADHD literacy among ethnic minority populations, such as African Americans (Bussing et al., 2007, 2012) and Latinx populations (Pham et al., 2010). Next, we highlight the literature on ADHD among Chinese pertaining to these four components of mental health literacy.

Mental health literacy about ADHD among Chinese

Knowledge and recognition

A cross-cultural study showed lower levels of problem recognition and endorsement of professional help-seeking across a variety of mental health conditions, among Chinese and Malaysian populations compared with European populations, with only 35% correct identification of ADHD in Hong Kong (Loo et al., 2012). In China, Huang et al. (2012) found that fewer than 40% of Chinese parents were aware of ADHD, and Yin et al. (2020) found that many Chinese individuals have poor mental health knowledge broadly, including unfamiliarity with the causes, treatments and prevention of mental illnesses. In mainland China, 52% of participants correctly identified ADHD, but the authors noted that a high correct identification rate may not be equivalent to a high level of mental health literacy about ADHD, because the accurate knowledge about ADHD, stigma and treatment attitudes for ADHD were not addressed (Gong & Furnham, 2014). Compared with European Americans, Chinese populations from China appear to be more sensitive to hyperactive behaviours than inattention symptoms in children (Norvilitis & Fang, 2005). This is reflected in the common term that the Chinese use to refer to ADHD (過度活躍症), which translates to ‘over-active’ or ‘much movement’ disorder, and highlights how disruptive behaviours are not acceptable amid the Chinese cultural beliefs of maintaining social harmony (Alban-Metcalfe et al., 2002).

Beliefs about causes

Parental attributions, or beliefs about the causes of behaviour, have been studied as an important factor in families of children with ADHD and other mental health conditions (Kil et al., 2021). Simply having a diagnostic label of ADHD can affect parents’ beliefs, such that both European Canadian and first-generation Chinese Canadian mothers view the child with ADHD and their parent as less responsible for problem behaviours compared with when a child does not have ADHD (Mah & Johnston, 2007). Although both Chinese and American samples endorsed neurobiological causes, Chinese populations in China were more likely to believe that ADHD reflects poor parenting and/or poor child effort (Norvilitis & Fang, 2005).

Treatments attitudes and stigma

There are cultural differences in treatment attitudes towards the two evidence-based interventions for ADHD, namely medication and behavioural parent training. Huang et al. (2012) found that more than 60% of Chinese parents in mainland China did not accept stimulant medication treatment for child ADHD, and research shows that traditional Chinese medicine such as herbal treatments are used as much or more often than stimulant medications (Hinshaw et al., 2011). With regards to behavioural parent training, Chinese caregivers in both mainland China and in America endorse the high acceptability of positive reinforcement strategies (e.g. contingent praise and responsive play), but lower acceptability of punishment strategies (e.g. time-out) (Ho et al., 2012; J. Yu et al., 2011).

A review of the literature on stigma in ADHD (Mueller et al., 2012) suggests that there is considerable stigma associated with the disorder, and parents of children with ADHD in both the US (Mikami et al., 2015) and Taiwan (Chang et al., 2020) experience affiliate stigma; that is, they perceive others’ negative attitudes towards them because of their child's mental illness. Parents with higher affiliate stigma are more likely to have negative attitudes towards their child's ADHD diagnosis and evidence-based treatments, and have negative parenting practices and child outcomes. Yin et al. (2020) found that in China, mental health knowledge was negatively associated with stigma, with many Chinese participants believing that others would hold a negative attitude towards those with mental health disorders, particularly in close personal relationships. This is consistent with findings of negative public attitudes towards mental illness in China (Liu et al., 2016), which are associated with underlying cultural and philosophical beliefs such as moralizing or blaming the individual for mental illness (Lam et al., 2010). In particular, Taiwanese parents of children with ADHD who reported greater stigma were those with unfavourable attitudes towards ADHD diagnosis and treatment (Chang et al., 2020) and greater depressive symptoms (Y.-L. Chen et al., 2021).

Self-help and psychoeducation

The internet is a key source of health-related information that parents across the world use (Kubb & Foran, 2020), with more than 80% of American parents (Sage et al., 2017) and more than 95% of Chinese parents in China searching the internet for ADHD information (X. H. Yu et al., 2019). Chinese families in China preferred the internet as an information source owing to convenience of access (e.g. easy and free), and most sought out ADHD-related information with the desire for better care for their children and to check ADHD symptoms (X. H. Yu et al., 2019). Nevertheless, more than 75% of these Chinese parents continued to struggle with decisional conflict regarding ADHD treatment, because more than 60% reported finding wrong/misleading information (X. H. Yu et al., 2019). This points to the limitations of online information that significantly impact help-seeking behaviours, and suggests the importance of evaluating and tailoring mental health literacy resources to target gaps among culturally diverse families.

Psychoeducation, or the approach to informing patients and families about their illness (e.g. ADHD) and its treatment, improves parent/teacher/child knowledge about ADHD, medication adherence and ADHD symptoms (Dahl et al., 2020). There are many approaches to psychoeducation, ranging from passive forms that do not require action from the recipient (e.g. written material online or on paper), to active forms that requires the recipient to do homework or exercises (e.g. as a part of a treatment programme) (Donker et al., 2009). Passive psychoeducation materials about ADHD tend to have patterns of conflicting messages, including cultural differences in aetiological explanations (e.g. American and British materials focus on neurobiological causes, whereas Dutch and Hungarian materials are more diverse, including biological and environmental factors such as parenting and family stress; van Langen et al., 2022). Findings across the world show that increased mental health literacy and belief in neurobiological causes of schizophrenia and depression had no effect or increased public stigma and desire for social distance from people with mental illness in Germany, Turkey, Russia and Mongolia (Angermeyer & Matschinger, 2005; Dietrich et al., 2004). However, few studies have examined the effectiveness of psychoeducation for different cultural groups, including those who have not yet initiated help-seeking with mental health professionals. In Hong Kong, Chinese caregivers of patients with psychosis found a psychoeducation website to be helpful for increasing knowledge, resources and support (Chan et al., 2016). Similarly, in Hong Kong, Chinese patients with schizophrenia who participated in a nurse-led psychoeducation programme had greater improvements in mental health, insights into treatment and illness, and hospitalization rates compared with a control group (Chien & Leung, 2013). In the US, Chinese immigrant parents rated a school-based psychoeducational session about mental health in adolescence as less acceptable and perceived it to be less effective than Latinx participants (Rao et al., 2024). Among African American adults, increases in mental health knowledge were associated with increases in willingness to seek help from mental health services, particularly for specific knowledge about schizophrenia compared with specific knowledge about depression (Pederson et al., 2023). There are no known studies to date regarding the impact of psychoeducation about ADHD on stigma and help-seeking among Chinese populations.

In sum, culture impacts all components of ADHD literacy (knowledge, treatment attitudes, stigma and self-help), and we seek to understand the cultural differences in each, and the interplay among them, between first-generation Chinese Canadian and mainstream populations, to inform efforts to improve ADHD literacy and mental health promotion.

Current study

This study aims to address gaps in our understanding of first-generation Chinese Canadian parents’ ADHD literacy. Specifically, we compare current knowledge, treatment attitudes and perceived stigma about ADHD between a community sample of first-generation Chinese Canadian parents and European Canadian parents. Furthermore, we evaluate the efficacy of an existing ADHD informational resource (which was not developed with cultural sensitivity in mind) by comparing parental knowledge, treatment attitudes and stigma before and after passive psychoeducation among these cultural groups. Based on previous literature, we hypothesize that at baseline, first-generation Chinese Canadian parents will report less knowledge about ADHD, lower willingness to seek treatment and higher levels of perceived stigma in comparison with European Canadian parents. Previous literature lacks consistent information about the impact of psychoeducation on stigma and treatment beliefs, with different studies showing that increased knowledge or mental health literacy can be associated with increased help-seeking willingness (Pederson et al., 2023) or decisional conflict about treatment (Yin et al., 2020), as well as decreased (Yin et al., 2020) or increased stigma (Dietrich et al., 2004). We predict that after reading the passive ADHD resource, first-generation Chinese Canadian parents will report increased ADHD knowledge, but may continue to have less-positive attitudes towards treatment and more perceived stigma in comparison with European Canadian parents. Results will inform ways to target culturally specific gaps in ADHD literacy to better develop psychoeducational resources tailored to first-generation Chinese Canadian populations.

Methods

Participants

Thirty first-generation Chinese Canadian parents, and 30 European Canadian parents, of children aged 6–12 years were recruited from community organizations (e.g. community centres, libraries, playgrounds, parent support groups) in Metro Vancouver, British Columbia, Canada. First-generation Chinese Canadian parents were classified as those who were born in mainland China, Hong Kong or Taiwan, and have immigrated to Canada as an adult. European Canadian parents were classified as those who are of western European descent, and either born in Canada or born in western Europe and moved to Canada before 18 years of age. Parents with children who were already diagnosed with a mental health disorder were excluded from this study because they have prior exposure and engagement with mental health services that likely have changed their knowledge and attitudes compared with parents in the community.

One participant was excluded from each group owing to ineligible ethnicity and one additional participant was excluded from each group owing to incomplete forms. The final analysed sample consisted of 56 participants. See Table 1 for demographic details for both groups.

Table 1.

Demographic characteristics of sample (N = 56).

Variable	Euro-Canadian(n = 28)	First generation Chinese Canadian(n = 28)
Variable	Mean (Standard Deviation)	Mean (Standard Deviation)
Mean parent age (years)	42.96 (5.02)	40.79 (4.89)
Parent female gender	18 (64.3%)	20 (71.4%)
Mean child age (years)	8.57 (1.62)	7.52 (1.43)
Child male gender	22 (78.6%)	14 (48.3%)
Number of children	2.32 (1.39)	1.72 (0.70)
Married/common-law	23 (82.1%)	29 (100%)
College degree education	23 (82.1%)	16 (55.2%)
Employed	22 (78.6%)	19 (65.5%)
Hollingshead SES (range 8–66)	48.86 (13.20)	50.98 (8.21)
Acculturation (range 1–9) Mean mainstream identification score Mean heritage identification score	7.31 (1.16) 6.79 (1.17)	6.20 (0.86) 7.31 (1.02)
Mean child ADHD symptoms score	15.00 (8.17)	13.93 (8.79)
Mean impression management score (range 1–7)	4.85 (1.14)	5.52 (0.89)

ADHD: attention-deficit/hyperactivity disorder; SES: socioeconomic status.

Measures

Knowledge of Attention Deficit Disorders Scale

The Knowledge of Attention Deficit Disorders Scale (KADDS; Sciutto et al., 2000) is a 36-item measure of factual knowledge about ADHD across three domains: symptoms and diagnosis, treatment and associated features. Participants were asked to indicate whether the statement was true (scored as 1), false or whether they did not know (each scored as 0). The total score was used in this study, with mean scores closer to 1.00 indicating more accurate knowledge about ADHD. Internal consistency was high (Cronbach's alpha = .87).

ADHD Knowledge and Opinion Survey-Modified

The ADHD Knowledge and Opinion Survey-Modified (AKOS-M; Bennett et al., 1996) was used to measure treatment attitudes about two evidenced-based treatments for ADHD (medication and parent training). The first section regarding knowledge of ADHD, and the subscale items regarding feasibility of using parent training were not included in this study. This measure was modified from the original in two additional ways: (a) the specific term ‘parent training’ was used instead of the general term of ‘counseling’, and (b) two items about time constraints were removed because we felt it related more to feasibility rather than acceptability of treatment. The modified version used in our study consisted of 12 items, rated on a 6-point Likert scale, with higher scores reflecting greater willingness to use the ADHD treatment. Internal consistencies were high (Cronbach's alpha = .85 and.81 for medication and parent training subscales, respectively).

ADHD Stigma Questionnaire

The ADHD Stigma Questionnaire (Kellison et al., 2010) is a 26-item measure of parental perceptions of stigma towards ADHD. We used the 13-item subscale on Concern with Public Attitudes in this study (e.g. People are uncomfortable around someone with ADHD), whereas the other two subscales regarding disclosure concerns (e.g. People with ADHD work hard to keep it a secret) and negative self-image (e.g. People who have ADHD feel guilty about it) were less relevant given our community sample who are not diagnosed with ADHD themselves. Items were rated on a 4-point Likert scale, with higher scores reflecting greater public stigma about ADHD. Internal consistency was high (Cronbach's alpha = .89).

Background measures

Participants completed a demographics measure, reporting on self and family characteristics (e.g. age, gender, education, employment, mental health history). Participants also completed the Vancouver Index of Acculturation (Ryder et al., 2000), a 20-item measure that distinguishes the acquisition of mainstream cultural tendencies from heritage cultural influences. Items are rated on a 9-point Likert scale, with higher scores reflecting greater identification with mainstream (North American) or heritage (familial background) cultures. The European Canadian sample indicated their western European backgrounds for their heritage culture. Participants also completed the ADHD-IV Rating Scale (DuPaul et al., 1998), an 18-item measure of their child's symptoms of ADHD. Finally, participants completed the Impression Management subscale from the Balanced Inventory of Desirable Responding (Paulhus & Reid, 1991), with 20 items on a 7-point Likert scale that assesses whether respondents are misrepresenting themselves to manage their self-presentation.

Translations

All measures and other study materials (e.g. consent form, recruitment brochure) were translated into traditional and simplified Chinese using standard translation guidelines (Van Widenfelt et al., 2005) that included translation from English to Chinese and back-translation by bilingual research assistants, as well as revision of incongruences through consultation with bilingual and bicultural parents, clinicians and research investigators to ensure both cultural and clinical appropriateness of the measures.

Procedure

This study was reviewed and approved by the University of British Columbia/Children’s and Women’s Health Centre of British Columbia Research Ethics Board. Participants first completed the demographic measure, as well as the three primary outcome measures regarding ADHD knowledge, treatment attitudes, and stigma as a baseline of their ADHD literacy. Participants then read a two-page educational pamphlet about ADHD from the Kelty Mental Health Resource Centre (Supplemental data, available online). The Chinese version was previously adapted from the existing English pamphlet about ADHD using a professional linguistic and cultural translation service by the Kelty Centre. Thus, the contents of the English and Chinese pamphlets were the same, without cultural adaptations beyond written translation. After reviewing the pamphlet, participants completed the same three primary outcome measures again to assess any changes in knowledge, attitudes or stigma. They also made rankings of where or who they would seek help from for child attention difficulties, and preferred methods to receive information about ADHD (e.g. pamphlet, webpage, video, workshop). Finally, participants completed background measures of impression management, child ADHD symptom ratings and acculturation. Participants completed the study within one hour and received a $10 gift card honorarium.

Analysis

All analyses were conducted using SPSS version 24. Available case analysis was used, such that participants without observed outcomes (i.e. those with incomplete data) were excluded. The Type I error rate of.05 was used for all analyses. We used t tests and chi-square tests to compare cultural groups on sample characteristics to explore for possible covariates. We conducted a series of mixed analysis of variance (ANOVAs) to determine the effects of cultural group (European Canadian, first-generation Chinese Canadian) and time (pre-, post-education) on each of the three primary outcome variables of ADHD literacy: knowledge, treatment attitudes (medication, parent training) and public stigma. To compare acceptability between treatments (medication vs parent training), t tests were conducted. Finally, correlations were conducted between the primary outcome variables.

Results

Sample characteristics

Descriptive characteristics of the two cultural group samples are presented in Table 1. The majority of participants were middle-aged, employed and married mothers with children around 8 years old, with a middle-class socioeconomic status (e.g. medium business, minor professional, technical). Their children had attention symptoms within the average range, and parental impression management was also within normal limits. There were no significant group differences between these variables after correcting for multiple comparisons. Some 85.7% of European Canadian parents were born in Canada, with an average of 42.16 (SD = 5.55) years lived in Canada; 65.5% of first-generation Chinese Canadian parents were born in China, with an average of 11.62 (SD = 7.67) years lived in Canada. As expected, Chinese Canadian parents identified less strongly with mainstream Canadian culture than European Canadian parents (t(55) = 4.097, corrected p < .013). There was a trend towards Chinese Canadian parents having, on average, lower educational levels than European Canadian parents (χ²(3) = 9.492, corrected p = .091). However, education level was not significantly correlated with any of the changes in outcome variables, and thus was not used as a possible covariate. Even when education level was included as a covariate in the ANOVAs, the interaction effects between outcomes and cultural group remained on par with those outlined below. This suggests that variations in outcomes reflected adherence to different cultural belief systems rather than education level.

Primary outcomes

Mean scores and standard deviations for the dependent variables are presented in Table 2, along with group comparisons. Based on 28 participants per group, we have 80% power at a 5% significance level to detect an effect size (η²) of 0.25.

Table 2.

Group comparisons of primary outcomes.

Variable	Group	Pre-InterventionMean (SD)	Post-InterventionMean (SD)	Main Effects of Group	Main Effects of Time	Interaction Effects
Knowledge	European-Canadian	.47 (.18)	.59 (.12)	F(1,54)=7.720, p=.007, n²=.125	F(1,54)=97.600, p<.001, n²=.644	F(1, 54)=12.992, p=.001, n²=.194
Knowledge	Chinese Canadian	.30 (.15)	.56 (.15)	F(1,54)=7.720, p=.007, n²=.125	F(1,54)=97.600, p<.001, n²=.644	F(1, 54)=12.992, p=.001, n²=.194
Medication acceptability	European-Canadian	3.42 (.91)	3.81 (1.03)	F(1, 54)=.003, p=.995, n²<.001	F(1, 54)=62.384, p<.001, n²=.536	F(1, 54)=9.407, p=.003, n²=.148
Medication acceptability	Chinese Canadian	3.18 (.78)	4.07 (.75)	F(1, 54)=.003, p=.995, n²<.001	F(1, 54)=62.384, p<.001, n²=.536	F(1, 54)=9.407, p=.003, n²=.148
Parent training acceptability	European-Canadian	5.18 (.62)	5.10 (.65)	F(1, 54)=1.874, p=.177, n²=.034	F(1, 54)=2.708, p=.106, n²=.048	F(1, 54)=0.052, p=.821, n²=.001
Parent training acceptability	Chinese Canadian	4.95 (.58)	4.89 (.64)	F(1, 54)=1.874, p=.177, n²=.034	F(1, 54)=2.708, p=.106, n²=.048	F(1, 54)=0.052, p=.821, n²=.001
Stigma	European-Canadian	2.28 (.36)	2.34 (.38)	F(1,54) = 10.844, p = .002, n²= .167	F(1,54)=11.107, p =.002, n²=.171	F(1,54) =1.883, p=.176, n²=.034
Stigma	First generation Chinese Canadian	2.56 (.40)	2.70 (.37)	F(1,54) = 10.844, p = .002, n²= .167	F(1,54)=11.107, p =.002, n²=.171	F(1,54) =1.883, p=.176, n²=.034

Note. Effect size was interpreted as follows: η²: 0.01 is small, 0.06 is medium, and 0.14 is large.

Bolded p-values reflect statistical significance.

Knowledge

In terms of knowledge about ADHD, there were significant main effects of both time and cultural group, which were qualified by a significant interaction between cultural group and time (Figure 1). Post hoc comparisons revealed significant main effects for both cultural groups and at pre-education time, with Chinese Canadian parents reporting significantly less accurate knowledge about ADHD than European Canadian parents at baseline (large effect of η² = .207), and parents in both cultural groups improving their knowledge of ADHD after reading the educational pamphlet, such that there was no significant difference in ADHD knowledge post-education.

Figure 1.

Attention-deficit/hyperactivity disorder knowledge over time across cultural groups. ***p < .001.

Post-education, parents across both groups struggled most with items pertaining to side effects of medication (65% did not know, 5% incorrect), challenging situations for kids with ADHD (35% did not know, 50% incorrect), effectiveness of alternate treatments (45% did not know, 30% incorrect), special education eligibility (45% did not know, 20% incorrect) and symptoms in preschoolers (35% did not know, 30% incorrect).

Descriptively, when comparing between subscales, Chinese Canadian parents started with less accurate knowledge about associated features and treatment about ADHD (26.72% and 25.89% accuracy respectively) compared with knowledge about ADHD symptoms (42.46% accuracy), whereas European Canadian parents began with an equivalent knowledge across domains (47.42% average accuracy), whereas both groups ended with comparable ADHD knowledge across domains after education (57.75% average accuracy). These were comparisons of raw data percentages and were not statistical comparisons.

Treatment attitudes

In terms of willingness to use medication for child's attention problems, there was a significant main effect of time, and a significant interaction between cultural group and time (Figure 2). Post hoc comparisons revealed that the simple main effects of cultural group were significant, with Chinese Canadian parents reporting significantly greater changes in their willingness to use medication from pre- to post-education (very large effect of η² = .527), compared with a smaller change in medication acceptability for European Canadian parents (large effect of η² = .178).

Figure 2.

Treatment acceptability over time across cultural groups. ***p < .001.

With regards to willingness to use parent training for child attention problems, there were no significant main effects or interaction effects between cultural group and time. Parent acceptability for parent training started and remained high for both cultural groups at baseline and post-education (also shown in Figure 2).

When comparing acceptability between medication and parent training interventions, significant differences were found at each time point, showing that parent training is preferred over medication by both cultural groups both at baseline (t(55) = −13.796, p < .001) and post-education (t(55) = −8.394, p < .001).

Stigma

With regard to perceived stigma about ADHD, there were significant main effects of time and cultural group, but no significant interaction (Figure 3). Specifically, Chinese Canadian parents had greater stigma than European Canadians across time (large effect of η² = .170), and both cultural groups increased stigma after psychoeducation (large effect of η² = .190).

Figure 3.

Public stigma over time across cultural groups. *p < .05; **p < .01.

Relationships between outcome variables

After reading the informational pamphlet, changes in ADHD knowledge were significantly related to changes in perceived stigma about ADHD (r(56) = .394, p = .003), as well as changes in both medication acceptability (r(56) = .373, p = .005) and parent training acceptability (r(56) = .286, p = .033). However, change in stigma was not significantly related to changes in treatment acceptability of medication (r(56) = .206, p = .127) or parent training (r(56) = .166, p = .222).

Parent preferences for help-seeking

There were notable descriptive cultural differences in parents’ preferred source of help for child's attentional difficulties, such that a greater proportion of European Canadian parents (53.6%) ranked their family physician as the primary source to go to for help, whereas Chinese Canadian parents were almost as likely to turn to the school (28.6%) as their doctor (35.7%).

With regards to their first-choice method of receiving information about ADHD for their child, European Canadian parents best preferred either a webpage (35.7%) or workshop (32.1%), whereas Chinese Canadian parents also preferred pamphlets (25.0%) in addition to workshops (32.1%) and webpages (25.0%). Only 21.4% of European Canadian parents, and none of the Chinese Canadian parents had previously heard of the Kelty Mental Health Resource Centre, which is the source of the informational pamphlet used in this study. As with earlier results, these were comparisons of raw data percentages and were not statistical comparisons.

Discussion

This study assessed cultural differences between European Canadian and first-generation Chinese Canadian parents’ mental health literacy regarding ADHD, including their knowledge about ADHD, treatment acceptability, and the stigma they associate with ADHD. Results partially support our first hypothesis in that at baseline, first-generation Chinese Canadian parents have less knowledge (about associated features and treatment of ADHD) and greater public stigma about ADHD than European Canadian parents; but unexpectedly, there were no cultural differences in their treatment attitudes about medication or parent training. After reading the ADHD informational pamphlet, both cultural groups improved in ADHD knowledge and medication acceptance, and first-generation Chinese Canadian parents had greater increases in both factors than European Canadian parents. On the other hand, both cultural groups maintained their high acceptability of parent training intervention (which was rated consistently above medication acceptability), but unexpectedly their public stigma about ADHD increased post-education. Across both groups, improvements in ADHD knowledge corresponded to increased treatment acceptability and public stigma. Finally, cultural differences in help-seeking preferences were explored, with a greater proportion of European Canadian parents seeking their family physician as the first source of help, whereas first-generation Chinese Canadian parents are almost equally likely to turn to their family physician or the school.

ADHD knowledge

This study shows the significant impact of an informational resource on improving ADHD knowledge and medication acceptability among a community sample of parents, with greater benefits for the first-generation Chinese Canadian population who started with lower levels pre-education. This adds to the literature suggesting that education is an effective method of improving mental health literacy, which is a common intervention with positive effects on formal help-seeking behaviours for mental health (see Nussey et al., 2013 and Xu et al., 2018 for systematic reviews). First-generation Chinese Canadian parents particularly benefited from learning about associated features and treatment of ADHD, whereas recognition of symptoms was comparable with European Canadian parents. This could be because, as Gong and Furnham (2014) suggest, the symptoms of ADHD are behavioural and externally observable, matching the Chinese term for ADHD (literally translated to be ‘much movement disorder’). On the other hand, it is clear that efforts to improve ADHD literacy among first-generation Chinese Canadian populations should focus on associated features (e.g. general information about the nature, causes and prognosis of ADHD) and treatment (e.g. evidence-based interventions).

Despite improvements in ADHD knowledge post-education for both groups, average accuracy was still only at 60%. This is comparable with previous findings where ADHD knowledge accuracy improved from 48% to 63% following a 1-hour educational lecture on ADHD (Sciutto & Terjesen, 2004). Post-education, parents across both groups struggled most with items pertaining to side effects of medication, challenging situations for kids with ADHD, effectiveness of alternate treatments, special education eligibility and symptoms in preschoolers. Future psychoeducational resources can be improved by addressing these areas for both cultural groups.

Treatment acceptability

Contrary to expectations, there were no cultural differences in treatment acceptability of either medication or parent training. Although studies have explored treatment attitudes among other cultural groups (Arcia et al., 2004; Bussing et al., 2003), to our knowledge this is the first study that has directly compared ADHD treatment acceptability between first-generation Chinese Canadian and European Canadian parents. Research has documented similar concerns regarding medication treatment for ADHD in each of the cultural groups separately, particularly with regard to fears of adverse effects (e.g. personality changes, future substance addiction; Bai et al., 2015; Corkum et al., 2015). Moreover, research has shown similar preferences in each of the cultural groups for psychosocial (e.g. parent training) over pharmacological treatments for child ADHD (Corkum et al., 2015; Johnston et al., 2008). This was supported in our study, which showed a ceiling effect of consistently high acceptability of parent training, which is consistent with previous research (Krain et al., 2005).

Our findings that medication acceptability improved post-education for both cultural groups and that this change is related to increased ADHD knowledge are consistent with previous research showing that knowledge about ADHD is positively correlated with treatment acceptability (Bennett et al., 1996; Corkum et al., 1999; Sciutto, 2015). Furthermore, the pre-existing information pamphlet used in this study had more information pertaining to the safe and effective use of medications for ADHD, addressing this approach first and referring to it as ‘the best treatment’. By contrast, parent training was specifically addressed in only in one sentence that was less definitive (‘[it] may also be helpful…’). However, on average, parents’ medication acceptability improved only from ‘somewhat disagree’ to ‘somewhat agree’, so it is unclear if this attitude would be enough to shift treatment engagement. As Sciutto (2015) points out, simple didactic readings may have limited effectiveness, whereas refutational texts that specifically dispute misconceptions followed by a discussion with expert guidance (Guzzetti, 2000) could lead to more change.

Stigma

At both time points, first-generation Chinese Canadian parents indicated significantly greater stigma (i.e. concern with public attitudes about ADHD) than European Canadian parents. Unexpectedly, both groups showed a similar increase in stigma post-education, which was associated with increased knowledge about ADHD. Although it may seem counterintuitive that having more accurate knowledge about ADHD would lead to increased stigma, studies examining public education or anti-stigma efforts have found that providing information on neurobiological explanations for symptoms and pharmacological interventions (which is often done with regards to ADHD, including the pamphlet used in our study) had little or no impact on, or even intensified, public stigma in the United States (Pescosolido et al., 2010). Furthermore, we acknowledge that improving mental health literacy and attitudes on a cognitive level (e.g. knowledge through education) may not be sufficient for changing the emotional or behavioural outcomes of stigma (Stuart, 2016), and the effects on stigma may not be as consistent over time (Ren & Lei, 2020). Thus, increasing knowledge that ADHD is a brain-based disorder could increase perceptions of the unchangeable and internal nature of ADHD, and thereby increase feelings of shame and withdrawal rather than decreasing blame.

Clinical implications

Many existing informational resources (like the pamphlet used in this study) are first developed by and for mainstream populations, and then translated linguistically but not adapted culturally for other cultural groups. Although findings from this study show that this approach is effective in increasing knowledge and treatment attitudes, psychoeducation resources that target culturally specific areas of need could be incrementally beneficial. Specifically, based on the findings from this study, first-generation Chinese Canadian parents benefited most from information about associated features (i.e. the nature, causes, and prognosis of ADHD) and treatment (i.e. evidence-based interventions) of ADHD, rather than from correctly identifying symptoms of ADHD. In addition, we suggest that when discussing ADHD with parents from both cultural groups, it is important to cover topics that families are less knowledgeable about, including the symptoms in preschoolers, challenging situations for kids with ADHD, side effects of medication, effectiveness of alternate treatments and special education eligibility. Furthermore, enhancing resources with content beyond factual information to include explanations that address common and culturally specific beliefs would be worthwhile. For instance, in their culturally responsive model of mental health literacy, Na et al. (2016) recommend using culturally specific terms and somatic expressions of distress to enhance knowledge and recognition of mental illness, expanding culturally salient explanatory models or beliefs about the causes of illness, respecting holistic intervention approaches that are congruent with culturally specific values to engage knowledge and attitudes towards help-seeking, and offering culturally specific self-help strategies and social support. Specific to ADHD, this could include acknowledgement of the ‘much movement’ disorder and an increase in awareness of the underlying features such as inattention and executive dysfunctions, explanation of the neurobiological basis of ADHD balanced with the empowerment that change and success through evidence-based interventions are achievable, and encouragement to connect with peer and family supports. Furthermore, pairing psychoeducation with stigma-reduction interventions may be required, such as Acceptance and Commitment Therapy that was particularly effective for reducing internalized stigma among Chinese Canadian men or Contact-based Empowerment Education for reducing mental illness stigmatizing attitudes (Fung et al., 2020). In addition to developing appropriate content, the dissemination of psychoeducational resources to reach underserviced cultural populations would be important. Thus, having online resources available for families is insufficient; there is a need to promote credible mental health literacy sources to the public so that parents know where to turn to for trusted information. Moreover, there is a need to circulate these resources to key front-line help-offering sources such as family doctors and school personnel. Those seeking to develop culturally sensitive psychoeducational materials should consider partnering with families from diverse ethnic backgrounds at all stages of the development process.

Limitations and future directions

This exploratory study was limited by a small sample size of 28 parents in each of the two cultural groups. Thus, findings should be interpreted with caution, and should be replicated with a larger and more diverse sample. In addition, the outcomes were all based on parental self-report on rating scales in a single sitting. Future studies would benefit from mixed methods including both quantitative and qualitative (e.g. focus groups, in-depth interviews) data, based on parental report as well as objective measures (e.g. behavioural outcomes related to help-seeking and stigma), across multiple time points in the help-seeking process.

Although our study focused on the treatment acceptability of medication and parent training, multimodal treatment for ADHD involves a broader scope including school-based interventions and other occupational needs (e.g. sleep, sensorimotor processing) (Drechsler et al., 2020). Furthermore, we acknowledge the intersectionality of multiple factors (e.g. gender, ethnicity, immigration) that converge for this population. Rather than reducing interventions and resources to address any single aspect, multiple dynamic dimensions should be considered to customize for unique individuals. Future studies can benefit from co-design to partner with people with intersecting lived experiences so their input can enhance the relevance and meaningfulness of study objectives, outcomes and impact.

Conclusion

Knowledge about ADHD plays a key role in treatment acceptability. Passive psychoeducation can improve ADHD knowledge and medication acceptability, particularly among first-generation Chinese Canadian parents. There is a need to tailor mental health literacy resources to better address diverse explanatory beliefs and perceived public stigma about ADHD.

Supplemental Material

sj-pdf-1-tps-10.1177_13634615251327886 - Supplemental material for Gaps and gains in parents’ mental health literacy: A cross-cultural comparison on attention-deficit/hyperactivity disorder

Supplemental material, sj-pdf-1-tps-10.1177_13634615251327886 for Gaps and gains in parents’ mental health literacy: A cross-cultural comparison on attention-deficit/hyperactivity disorder by Janet W.T. Mah and Wendy Li in Transcultural Psychiatry

Footnotes

Acknowledgements

The second author was supported by the BC Children's Hospital Research Institute Brain, Behaviour & Development Summer Studentship. Kelty Mental Health Resource Centre contributed to the participant honoraria. We thank Mandy Chen, Meredith de Freitas, & Bessie Wang for their help with project development, Ariel Ko for assistance with data collection, and Jeffrey Bone for statistical consultation.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Janet W.T. Mah

Supplemental material

Supplemental material for this article is available online.

Janet W.T. Mah, PhD, is a psychologist and investigator at BC Children's Hospital and Research Institute. She is also a clinical assistant professor in the Department of Psychiatry at University of British Columbia. Her clinical and translational research focuses on parenting contributors to treatment engagement and adherence, and mental health literacy and stigma among cultural groups.

Wendy Li, MA, is a graduate of the clinical and counselling psychology programme at the University of Toronto, where her research focused on career decision-making and the application of creative approaches to career counselling. She is interested in critical and applied research in mental health and counselling.

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