Abstract
Highlights
A decision aid was developed to support parents in making ADHD medication decisions.
The decision aid significantly increased parents’ knowledge about ADHD and treatment options and reduced parents’ decisional conflict.
Stakeholders, including parents and health care professionals, reported that the decision aid was acceptable.
The decision aid prepared parents for shared decision making within pediatric ADHD care.
Keywords
Attention-deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental disorder affecting approximately 5% to 10% of children worldwide. 1 It is characterized by persistent patterns of inattention, hyperactivity, and impulsivity that significantly affect daily functioning and overall quality of life. The primary treatment options for ADHD include pharmacologic interventions, behavioral therapy, or a combination of both. 2 However, selecting the most appropriate treatment is often complex, influenced by clinical guidelines, parental values, and societal perceptions. 3 Given the variability in treatment response and concerns regarding medication side effects, it is critical that parents are actively engaged in treatment decisions. 4
The Ottawa Decision Support Framework (ODSF) provides a conceptual model for understanding decision-making needs and guiding the development of decision-support interventions. 5 The main hypothesis underlying the ODSF is that decision support interventions designed to address individuals’ decision-making needs will lead to higher-quality decisions.5–7 Decision aids are a core component of the decision support recommended by this framework. They offer structured, evidence-based information to help patients and parents understand treatment options, clarify their values, reduce decisional conflict, and feel more confident about their choices.8,9
Most clinical guidelines recommend that health care professionals involve parents in ADHD treatment decisions to ensure informed choices.10,11 Shared decision making (SDM) is a structured process in which health care providers collaborate with patients and parents to make evidence-based treatment decisions that align with their preferences. 12 Research has shown that SDM improves parental engagement and reduces decisional conflict.13,14 Despite these benefits, implementing SDM in ADHD care remains challenging due to time constraints, variability in clinician communication styles, and a lack of structured decision-support tools. 15 These tools play a crucial role in bridging the gap between scientific evidence and evidence-informed decision making, by making evidence-based information more accessible, actionable, and relevant for key stakeholders, including health care professionals, patients, policy makers, and the general public. 16
Decision aids are evidence-based tools, including videos, printed materials, and Web-based formats, developed to support patients and health care providers in facilitating shared decision making. 8 Defining elements focus on a specific decision, providing balanced evidence-based information on treatment options, risks, and benefits for a target audience. As well, decision aids are required to help patients clarify their values for outcomes and features of options. The International Patient Decision Aid Standards provide guidelines for developing high-quality decision aids, emphasizing transparency, user engagement, and comprehensibility. 17
Several studies have demonstrated the effectiveness of decision aids in ADHD treatment decision making, reporting that parents who use them not only have higher knowledge scores and feel more informed about treatment options but also experience reduced decisional conflict.18,19 These studies further highlight that decision aids help ensure treatment choices align with parent values and clinical recommendations. The use of a decision aid has been shown to improve the quality of ADHD management, increasing parental confidence in treatment decisions. In addition, decision aids facilitate discussions on medication adherence, treatment alternatives, and drug holidays, making these conversations more structured and effective.11,20 None of these studies considered the child’s values associated with ADHD treatment options or measured the outcomes from the child’s perspective.
Existing decision aids for ADHD are predominantly developed for English-speaking populations within the context of the United States health care system, 19 thereby limiting their cultural and contextual relevance in other countries. This creates a significant gap in decision-support resources that are appropriately tailored to non–English-speaking countries. For example, the Israeli health care system has distinct treatment pathways, health care policies, and diverse population characteristics, including strong influence of religious leaders on certain medical decision-making processes. 21 The Israeli health care system operates under a universal health insurance model in which all residents are insured through 1 of 4 nonprofit health funds that provide access to primary and specialist care. 22 In 2015, a major reform transferred responsibility for mental health services from the Ministry of Health to the health funds, integrating mental health care into community-based services within the national health insurance framework and expanding access to psychiatric and behavioral health services. 23 This reform significantly changed treatment pathways for neurodevelopmental and mental health conditions, including ADHD, with evaluation and treatment typically occurring through referrals from primary care physicians to specialists such as pediatric neurologists, developmental pediatricians, or child psychiatrists. 24
At the same time, sociocultural characteristics of Israeli society, including variation in religiosity across secular, traditional, religious, and ultra-Orthodox communities, may influence how ADHD is perceived and managed. 25 These differences may shape attitudes toward diagnosis and medication treatment, consultation with community or religious leaders when making health-related decisions, and the level of acceptance of pharmacologic treatment. Together, these health care and sociocultural factors emphasize the importance of developing decision-support tools that are responsive to both the structure of the health care system and the diverse social contexts in which treatment decisions are made.
The present study aimed to develop and evaluate a Hebrew-language, culturally adapted, evidence-based decision aid designed specifically for Israeli parents of children aged 6 to 13 y who have been recently diagnosed with ADHD. The goal of the intervention was to support parents in making informed, values-aligned decisions regarding the initiation of pharmacologic treatment, consistent with clinical guidelines and treatment options available within the Israeli health care context.
Methods
Study Design
The development of the decision aid followed the ODSF 6 and IDPAS26,27 to ensure a high-quality, evidence-based tool for supporting parents in ADHD treatment decision making. The development process followed a structured 7 steps approach (see Figure 1):
Phases in the development and testing of the decision aid.
Step 1: Decisional needs assessment
A decisional needs assessment was conducted based on prior empirical research exploring the informational needs, concerns, and decision-making experiences of parents deciding whether to initiate pharmacologic treatment for their child with ADHD. Findings from this body of work helped identify key decisional uncertainties and information gaps that the decision aid was designed to address.
Step 2: Steering committee formation
A multidisciplinary steering committee was established to guide the development process. The committee included a pediatric neurologist, a psychologist specializing in ADHD in children, an educator from a special education setting, a shared decision-making specialist, and 2 parents of children with ADHD. The committee provided clinical expertise, methodological guidance, and lived-experience perspectives to ensure that the decision aid addressed both evidence-based information and real-world parental decision-making needs.
Step 3: Literature review
A targeted review of the literature was conducted to identify available treatment options and their associated benefits, risks, and outcomes. Evidence from clinical guidelines, systematic reviews, and primary studies informed the content of the decision aid, including the presentation of treatment options and probabilities of benefits and harms.
Step 4: Development of the decision aid prototype
Based on the findings from the needs assessment, literature review, and steering committee discussions, an initial prototype of the decision aid was developed. The prototype incorporated evidence-based information on treatment options, graphical presentation of outcome probabilities, values clarification exercises, and structured guidance to support deliberation and discussion with clinicians.
Although behavioral interventions were acknowledged as part of ADHD management, the decision aid was designed to focus primarily on the decision of whether to initiate pharmacologic treatment. Evidence from previous studies and findings from our focus groups indicated that the decision about medication represents the most challenging decision point for many parents, often involving substantial uncertainty and potential for decisional conflict. In contrast, behavioral interventions are typically recommended as complementary strategies and are less commonly perceived as a discrete decision point. In addition, the empirical evidence regarding the benefits and risks of behavioral interventions is less standardized and more difficult to present quantitatively in the format required for a rigorous decision aid. Therefore, the decision aid was designed specifically to support parents in making an informed decision about whether to initiate pharmacologic treatment for their child.
Step 5: Acceptability testing (“alpha testing”)
Acceptability testing of the decision aid prototype was conducted among key stakeholders, including parents, educators, and clinicians. Participants reviewed the prototype and completed a mixed-methods questionnaire assessing clarity, balance of information, usability, and perceived usefulness. Qualitative feedback was also collected to identify areas for improvement.
Step 6: Revision of the decision aid
Following acceptability testing, feedback from participants and stakeholders was reviewed by the steering committee. Revisions were made to improve clarity, simplify language, refine the visual layout, and ensure balanced presentation of treatment options. These modifications resulted in the finalized version of the decision aid used in the field-testing phase.
Step 7: Field testing (“beta testing”)
Field testing was conducted with parents of children who were in the process of making treatment decisions regarding ADHD. A pre/post study design was used to evaluate the acceptability of the final version of the decision aid and its potential effectiveness in improving key outcomes. Specifically, the study assessed changes in parental knowledge about ADHD treatment options and levels of decisional conflict before and after using the decision aid.
This study was approved by the ethics review board of Ariel University (approval No. AU-HEA-YG-20240520).
Stage 1: Alpha Testing (Acceptability Testing)
Participants
Purposeful sampling was used to recruit a diverse group of stakeholders who have previously been involved in making or supporting parents making ADHD treatment decisions and who were not involved in the development of the decision aid. The sample included Hebrew-speaking parents of children diagnosed with ADHD who chose medication treatment, parents who declined medication, health care providers for children with ADHD, individuals involved in child education (including school teachers), and researchers specializing in pediatric health and decision making. The sample size (n = 20) was selected in accordance with the methods used in the decision aid literature for previous acceptability testing.27,28 Participants participated on a voluntary basis and did not receive any financial or material compensation for their participation.
Procedure
The acceptability of the decision aid was assessed through a stakeholder survey. A mixed-methods questionnaire was developed based on a validated acceptability assessment tool, 29 which evaluated key dimensions such as comprehensiveness, length, amount of information, balance of perspectives, and relevance to the targeted decision-making context (Appendix 3a). This methodology is consistent with established standards for decision aid development, enabling iterative refinement based on user input. 27 Participants were asked to review the decision aid prototype and complete the survey. Their feedback informed revisions that led to the development of a final version designed for parental use.
Intervention
The prototype of the decision aid was a small printed A5 (approximately 15 × 21 cm) booklet designed to support parents in making informed decisions about ADHD medication treatment, incorporating several key components to provide comprehensive guidance. The introductory section included an overview of the target population, instructions on how to use the decision aid, a brief explanation of ADHD, and detailed information about available medication options. The decision aid outlined 2 treatment options: starting ADHD medication (option 1) and not starting medication (option 2). A side-by-side comparison table presented the pros and cons of each option, helping parents evaluate the potential benefits and risks. A values clarification exercise encouraged parents to reflect on their preferences and priorities regarding treatment. To illustrate potential treatment outcomes, the decision aid featured evidence-based risk communication graphics comparing medication side effects versus placebo effects. These were presented using pictorial diagrams of 100 faces, with a portion shaded to visually represent the proportion of individuals likely to experience specific outcomes. The decision aid also incorporated personal narratives from parents who had chosen to start ADHD medication and those who had opted against it, providing real-world perspectives to support informed decision making. 30 The narratives were developed with input from 2 parent representatives who served on the steering committee and were based on experiences shared by parents of children with ADHD who had made different decisions regarding treatment, including initiating regular medication use, choosing not to use medication, and using medication selectively in specific situations. The narratives were reviewed to ensure balanced representation of different treatment choices. The values clarification exercise (“What matters most to you?”) provided a structured 0 to 5 rating scale for parents to evaluate the importance of various reasons for initiating or declining medication. The items were developed de novo during the decision aid development process. Potential values were identified based on a review of the literature on parental decision making regarding ADHD treatment and were further refined through discussions within the multidisciplinary steering committee. This process aimed to capture common considerations reported by parents when deciding whether to initiate medication, such as improving attention and school functioning, concerns about side effects, family disagreements, and financial considerations. This step supported reflection on personal priorities, and it is known to facilitate alignment between parents’ values and treatment choice.31,32 The decision aid followed a structured 4-step process: weighing benefits and harms, clarifying values, evaluating knowledge and decision readiness using a quiz, and the 4-item SURE scale to screen for decisional conflict previously tested in parents making decisions for their children. Finally, parents were invited to identify the next steps using a checklist of possible actions (excerpted sections of the ADHD Medication Decision Aid Booklet are provided in Appendix 4).
Data analysis
Data were analyzed descriptively using measures such as means, standard deviations, percentages, and proportions. Qualitative responses were analyzed using a content analysis approach. All comments were reviewed and grouped by themes. Illustrative verbatim quotes were then selected to represent the range of perspectives across stakeholder groups (parents who chose medication, parents who declined medication, clinicians, and teachers).
Stage 2: Beta Testing (Field Testing)
Participants
Participants were parents or legal guardians of children aged 6 to 13 y who had received a diagnosis of ADHD within the past 6 wk and were in the process of considering medication treatment decisions for their child. Inclusion criteria required that participants be able to provide informed consent, be fluent in Hebrew, and have no prior participation in studies involving ADHD decision aids. Exclusion criteria included being a parent of a child with severe psychiatric comorbidities requiring urgent intervention or being unable to complete study procedures due to limited Hebrew proficiency. Participation in the field-testing study was voluntary, and no financial or material compensation was provided to participants.
Procedure
Participants were recruited through an open call disseminated via health care providers, social media platforms, and community organizations. Individuals who expressed interest contacted the research team and underwent an eligibility screening process. Eligible participants were then invited to the “MyHealthAid” Medical Decision-Making Laboratory at Ariel University, where the research team provided a detailed explanation of the study procedures. Written informed consent was obtained prior to participation.
Following consent, participants completed baseline questionnaires and were provided with the printed decision aid. They were encouraged to read the material thoroughly at home. Two weeks later, participants received a follow-up Qualtrics-based survey, delivered via either personal phone or e-mail, according to their stated preference. A 2-wk follow-up period was chosen to give participants enough time to review the decision aid while minimizing disengagement. Similar short-term intervals (1–4 wk) are commonly used for evaluating decision aids. 8
Measures
Demographic and background information was collected to characterize the sample and to account for social factors that may influence health decision making, consistent with the PROGRESS-Plus framework. 33 Variables included parent age, gender, marital status, number of children younger than 18 y in the household, religious affiliation, education level, years of education, and gross household income relative to the national average. Child characteristics included age and gender, and parents also reported the time since the child’s ADHD diagnosis.
Knowledge was assessed using a 10-item multiple-choice questionnaire developed specifically for this study. The items focused on essential information regarding ADHD and its pharmacologic treatments, such as treatment efficacy, side effects, and recommended care practices. The questionnaire was constructed in alignment with the content presented in the decision aid and guided by prior literature on ADHD knowledge measures, particularly the approach used by Valentine et al. 18 for evaluating caregiver understanding of ADHD treatment options (Appendix 3b). Each correct answer was awarded 1 point, and total scores were standardized to a 0 to 100 scale by multiplying the raw score by 10. Higher scores indicated greater factual knowledge.
Decisional conflict was measured using the 16-item Decisional Conflict Scale (DCS), which captures personal perceptions of uncertainty in choosing options, factors contributing to the uncertainty, and the effectiveness of the decision-making process. 34 The scale yields a total score and 5 subscale scores: uninformed, unclear values, unsupported, uncertainty, and ineffective decisions. Each item is rated on a 5-point Likert scale and transformed to a 0 to 100 scale. Scores greater than 37.5 are associated with higher decisional conflict leading to decision delay, while scores less than 25 reflect a readiness to make a decision. The original DCS has demonstrated strong reliability, with Cronbach’s alpha exceeding 0.78, and the Hebrew version used in this study has shown excellent internal consistency in previous research (α = 0.92).21,35
The Decision Self-Efficacy Scale (DSE) was used to assess participants’ confidence in their ability to engage in informed decision-making making. 36 This 11-item instrument evaluates self-efficacy in areas such as obtaining information, discussing options, and implementing chosen options. Responses are provided on a 5-point scale and standardized to a 0 to 100 score, with higher scores indicating greater self-efficacy in decision making. The original English version of the DSE boasts a robust Cronbach’s alpha coefficient of 0.92, 36 while the Hebrew version demonstrates good internal consistency with a coefficient of 0.87. 35
Preparation for decision making was measured using the 10-item Preparation for Decision Making Scale (PrepDM), which evaluates perceived readiness to communicate with health care professionals and make informed choices. 37 Each item is rated on a 5-point scale and converted to a 0 to 100 standardized score. Higher scores reflect greater preparation for engaging in decision making.
Preference for SDM was assessed using a single-item measure that examined how participants intended to make the ADHD medication treatment decision for their child. 38 The item asked: “How do you plan to make the decision about ADHD medication treatment for your child?” Response options reflect varying degrees of parental involvement in the decision-making process, ranging from physician-directed to parent-directed approaches. Specifically, participants could indicate that the doctor would make the decision with little input from them, that the doctor would make the decision but seriously consider their opinion, that the decision would be made jointly between the doctor and themselves, that they would make the decision after seriously considering the doctor’s opinion, or that they would make the decision with little input from the doctor. 38
Treatment inclination was measured with a single-item question: “At this point in time, what do you think you will decide regarding medication treatment for your child?” Responses were coded as indicating a leaning toward initiating medication, not initiating medication, or undecided.
Sample size
Given the paucity of formal guidelines for sample size justification in field testing, we drew upon previous studies using field test methodologies for patient decision aids to inform our approach.39–41 A target sample size of 36 to 40 participants was established to allow for pre/post analysis of the primary outcome—decisional conflict—with sufficient power. Ultimately, 38 participants were enrolled, which meets conventional statistical thresholds for detecting a moderate effect size (0.5) with 80% power at a significance level of α = 0.05. This rationale is further supported by previous pre-/postintervention studies evaluating patient decision aids, which used similar sample sizes for pilot evaluations of feasibility, usability, and preliminary efficacy. 42
Data analysis
All analyses were performed using IBM SPSS Statistics version 29. Descriptive statistics, including means, standard deviations, frequencies, and percentages, were used to summarize participant characteristics and study variables. Paired-samples t tests were conducted to evaluate pre- to postintervention changes in knowledge, decisional conflict, and decision self-efficacy. All tests were 2-tailed, with statistical significance set at P < 0.05. Effect sizes were calculated using Cohen’s d.
Results
Acceptability Testing
The sample comprised 20 participants, including 4 parents of children with ADHD who had chosen to initiate medication treatment, 4 parents who had declined medication, 4 health care providers involved in ADHD care, 4 individuals involved in child education (including elementary and middle school teachers), and 4 researchers specializing in pediatric health and decision making who were not involved in the development of the decision aid.
All participants (100%) agreed that the decision aid was easy to understand (see Table 1). One participant commented on the clarity and readability of the booklet: “The layout was clear, and the colors were pleasant—overall it was easy and comfortable to read” (parent 1, decline medication).
Participants’ Ratings of the Clarity and Presentation of Information in Each Section of the Decision Aid Prototype during Acceptability Testing (N = 20)
ADHD, attention-deficit/hyperactivity disorder; IQR, interquartile range.
Ratings were based on a 5-point Likert scale ranging from 1 (not at all clear/helpful) to 5 (extremely clear/helpful).
Seventeen of 20 participants (85%) reported that the length of the decision aid was appropriate. Regarding the amount of information, 15 participants (75%) felt it was sufficient, while 3 perceived it as too limited and 2 considered it too excessive. Sixteen participants (80%) found the information to be balanced, whereas the remaining 4 perceived the content as biased in favor of medication; all 4 had initially chosen not to begin medical treatment for their children. All participants (100%) agreed that the decision aid would be helpful for others facing a similar decision.
The narrative feedback included positive remarks regarding both the content and the visual design of the decision aid prototype. The participant found that the way probabilities of benefits and side effects were communicated was helpful as indicated in their comment: “The diagrams with the faces really helped me understand the benefits and side effects. It made the information feel more real” (parent 2, chose medication). Another stated: “The decision aid helped me think through the pros and cons and prepare questions to ask our doctor” (parent 3, decline medication).”The decision aid helped parents feel prepared and more confident ahead of their appointment with the physician, as indicated by one participant who said, “I liked that I could write notes or questions—it made me feel more prepared for the doctor’s appointment” (parent 1, chose medication). Participants responded positively to the inclusion of personal narratives: “The parent stories included in the decision aid helped me relate and better understand which category my child might fit into” (parent 2, decline medication). Educators similarly highlighted the tool’s usefulness, with one teacher saying, “This resource could really help parents organize their thoughts” (teacher 3). Clinicians also valued its potential, as one remarked, “I can see this being a very helpful tool in my practice, especially for guiding structured conversations with families” (clinician 5).
Several participants also offered constructive suggestions for improvement by highlighting sections that could be briefer or use more plain language. For example, one participant said, “The visual structure and clear headlines really helped me stay focused, but some sections still felt too long and could benefit from being more concise” (parent 2, chose medication). Another participant reported, “In one section, the language felt too complex; using simpler phrasing could make the information more accessible to a broader range of parents” (teacher 2). A third participant emphasized a practical concern: “There are no page numbers, and some sentences are unclear; I’ve marked those for your review” (teacher 3). Another participant highlighted the importance of the decision aid being an adjunct to consultation with the clinician: “This is a valuable resource, but it can’t replace a conversation with a health care professional” (clinician 1). Another clinician suggested improving alignment with clinical terminology, noting, “Some terms could be more consistent with what we use in practice, such as using ‘stimulant medication’ instead of ‘ADHD pills,’ so parents don’t get confused when they talk to us” (clinician 4).
The decision aid steering committee reviewed the results of the acceptability testing, including both quantitative responses and narrative feedback. The key issues identified and the corresponding modifications to the prototype are summarized in Table 2. The revised decision aid was subsequently used in the field (beta) testing phase.
Participant Feedback from Acceptability Testing and Resulting Modifications to the Decision Aid Prototype
Field Testing
A total of 38 new participants were recruited for this stage of the study, with a mean age of 38.3 y (SD = 5.1 y). Most parent participants were female (94.7%), married (76.3%), and had 3 to 4 children younger than 18 y (52.6%). In terms of Jewish religious affiliation, 65.8% identified as secular, 13.2% as traditional, and 21.0% as religious or orthodox. Most parents (84.2%) had completed academic-level education, with a mean of 16.1 y of education (SD = 2.9). More than half (55.3%) reported earnings at or below the national average (20,000 NIS). The mean time since their child’s ADHD diagnosis was 3.5 wk (SD = 1.2), see Table 3.
Participant Characteristics for Field Testing (N = 38)
ADHD, attention-deficit/hyperactivity disorder; SD, standard deviation; USD, US dollars.
Table 4 demonstrates that following the use of the decision aid, participants demonstrated a statistically significant improvement in knowledge, with mean scores increasing from 67.4 (SD = 13.3) to 84.7 (SD = 12.9). Overall decisional conflict also decreased significantly, from a mean of 29.8 (SD = 11.1) to 20.8 (SD = 6.8), P = 0.01. Significant improvements were also observed in the uninformed (P = 0.04), unsupported (P = 0.03), and uncertainty (P = 0.05) subscales of the DCS, indicating enhanced understanding and emotional support. No statistically significant changes were observed in the unclear values (P = 0.45) or ineffective decision (P = 0.35) subscales. Although decision self-efficacy increased from 83.6 (SD = 8.7) to 90.0 (SD = 3.8), this change did not reach statistical significance (P = 0.09).
Mean (SD) Scores for Knowledge, Decisional Conflict, and Decision Self-Efficacy before and 2 wk after Using the Decision Aid
Knowledge was measured on a 0 to 100 scale, with higher scores indicating greater factual understanding related to attention-deficit/hyperactivity disorder medication decisions. Decisional conflict was assessed using the validated Decisional Conflict Scale (0–100), where higher scores reflect greater uncertainty. Scores less than 25 are associated with decision implementation, while scores greater than 37.5 indicate a likelihood of decision delay or unresolved conflict. Decision self-efficacy was measured using the Decision Self-Efficacy Scale (0–100), with higher scores representing greater confidence in one’s ability to engage in informed and value-congruent decision making.
Following the use of the decision aid, standardized scores on the preparation for decision-making scale were high, with a mean of 89.5 (SD = 0.97) out of 100, indicating a strong sense of readiness among participants. Preferences for decision-making roles showed that 45% of participants preferred to share responsibility with the physician when making decisions about ADHD treatment for their child. Thirteen percent reported a preference for making the decision independently, while another 13% preferred to leave the decision entirely to the physician. Twelve percent indicated that they preferred to make the final decision after seriously considering the physician’s opinion, and 18% preferred that the physician make the final decision while seriously considering their views. Regarding the treatment decision itself, 20 of 38 parents (52.6%) reported a tendency to decide in favor of initiating medication treatment.
Discussion
The current study examined the development and evaluation of a culturally adapted decision aid designed to support Israeli parents of children aged 6 to 13 y in making informed decisions regarding whether or not to initiate ADHD medication for their child. The acceptability testing demonstrated that the decision aid was perceived as acceptable, relevant, and easy to use by a diverse group of stakeholders, including parents, health care providers, educators, and academic experts. Participants reported that the tool was well-structured, comprehensible, and helpful in guiding them through the decision-making process. Participants in the field phase demonstrated improved knowledge about ADHD and available treatment options following the use of the decision aid. They reported that the tool helped them clarify their values, reduced uncertainty about the best course of action, and increased their confidence in making informed treatment decisions for their children.
One of the most prominent findings from the acceptability testing was that participants consistently rated the decision aid as clear, well-structured, and easy to understand. They appreciated the tool’s concise layout and straightforward presentation, which made complex medical information more accessible. While the majority found the information to be balanced, a minority of participants perceived a bias toward medication, interestingly, all of whom had previously decided against starting pharmacologic treatment for their child. This highlights the influence of preexisting treatment preferences on perceptions of neutrality and underscores the importance of maintaining balance and transparency when developing decision-support tools for value-sensitive choices such as ADHD treatment. 43 All participants agreed that the decision aid would be helpful for other parents facing similar decisions. These findings are particularly meaningful in light of previous research showing that parents of children with ADHD often experience confusion and uncertainty when making treatment decisions.44,45 Studies have documented that parents frequently feel overwhelmed by the volume of information, unclear about the benefits and risks of treatment options, and unsupported in clarifying their own values and expectations.46,47 These challenges are compounded by the emotionally charged nature of deciding whether to initiate pharmacologic treatment for a child. 44 Decision aids are designed to address these concerns by offering balanced, evidence-based information and structured guidance in the steps of decision making (including values clarification), thereby supporting parents in navigating complex, value-sensitive choices and improving the quality of the decision-making process. 8
The findings from the field-testing phase, with parents who were actually facing the decision about ADHD treatment for their child, indicate that use of the decision aid significantly improved participants’ knowledge of ADHD and its treatment options, reduced decisional conflict, and further enhanced their decision self-efficacy. Participants reported feeling more informed and supported, and postintervention scores on the overall DCS—as well as its subscales—fell below the established threshold of 25, which is associated with readiness to implement a decision. 34 The increase in decision self-efficacy after using the decision aid was not statistically significant, likely due to a ceiling effect, as participants already had high baseline scores. Nevertheless, the upward trend suggests that the decision aid contributed to strengthening parents’ confidence in making informed, values-based decisions about their child’s ADHD treatment. This suggests that the decision aid not only improved cognitive understanding but also addressed the emotional and psychological components of making a treatment decision. By helping parents navigate the complex tradeoffs involved in ADHD treatment, such as balancing benefits against concerns about side effects, the decision aid functioned similarly to another effective decision support tool used for guiding value-congruent, evidence-informed decisions about ADHD.19,48
Previous studies have shown that parents desire active involvement in SDM when considering treatment options for their children diagnosed with ADHD.19,49 Our findings align with this evidence, as many participants in the current study expressed a preference for sharing decision-making responsibility with their child’s physician rather than delegating or assuming full control. This preference for shared responsibility is important, as SDM has been associated with greater satisfaction with care and reduced decisional regret.50,51
This study contributes to the growing body of evidence supporting the development of decision aids tailored to specific cultural and health care contexts. While existing decision aids for ADHD have shown positive outcomes in US-based and other English-speaking populations,18,19 and another study conducted in Japan accounted for that country’s health care system and cultural characteristics,40,48 the generalizability of such tools remains limited when applied across different settings. The decision aid developed in the present study addressed this gap by incorporating the unique features of the Israeli health care system, available treatment pathways, and the sociocultural values of Israeli families. By contextualizing the information and format to local norms and structures, the tool enhanced its relevance and usability and should lead to better support for effective SDM in real-world clinical encounters.
Limitations
This study has several limitations that should be considered when interpreting the findings. While the sample size was appropriate for field testing and consistent with established methods for preliminary decision aid evaluation, a larger and more diverse sample will be necessary to confirm these findings in future research. In addition, as participants were aware that they were evaluating a new tool, there is a possibility of response bias, particularly social desirability bias, which may have influenced the positive feedback reported. The use of a pre/post design without a control group limits the ability to attribute observed changes solely to the intervention. Nonetheless, this design is consistent with field-testing objectives and will be followed by a more rigorous evaluation in a planned randomized controlled trial. Moreover, it is unknown how many participants discussed the ADHD options with their child or met with their child’s physician between baseline and follow-up, which may have influenced postintervention responses and contributed to changes in decision-related outcomes. Another limitation was the recruitment of parents only and not explicitly including the child. Finally, the study did not assess participants’ health literacy or numeracy levels, raising the possibility that the sample may have included primarily individuals with higher literacy skills, which could affect both comprehension and engagement with the decision aid.
Conclusions
This decision aid was developed to support parents in making informed decisions about ADHD treatment for their child and can be used either before or during consultations with physicians. Its integration into routine clinical practice has the potential to enhance parent–clinician communication 52 and increase satisfaction with treatment choices. Beyond the clinical setting, its applicability in educational contexts and public health initiatives positions it as a flexible tool for broader dissemination and community engagement. As health care systems increasingly emphasize patient-centered care, implementing tools like this decision aid marks an important step toward promoting informed, shared, and personalized decision making in pediatric mental health.
Supplemental Material
sj-docx-1-mpp-10.1177_23814683261446325 – Supplemental material for Supporting Decision Making on ADHD Medication: Development and Evaluation of a Decision Aid for Parents
Supplemental material, sj-docx-1-mpp-10.1177_23814683261446325 for Supporting Decision Making on ADHD Medication: Development and Evaluation of a Decision Aid for Parents by Yulia Gendler, Hedva Stoin, Tehila Volberstein, Lani Ofri and Dawn Stacey in MDM Policy & Practice
Supplemental Material
sj-docx-2-mpp-10.1177_23814683261446325 – Supplemental material for Supporting Decision Making on ADHD Medication: Development and Evaluation of a Decision Aid for Parents
Supplemental material, sj-docx-2-mpp-10.1177_23814683261446325 for Supporting Decision Making on ADHD Medication: Development and Evaluation of a Decision Aid for Parents by Yulia Gendler, Hedva Stoin, Tehila Volberstein, Lani Ofri and Dawn Stacey in MDM Policy & Practice
Supplemental Material
sj-docx-3-mpp-10.1177_23814683261446325 – Supplemental material for Supporting Decision Making on ADHD Medication: Development and Evaluation of a Decision Aid for Parents
Supplemental material, sj-docx-3-mpp-10.1177_23814683261446325 for Supporting Decision Making on ADHD Medication: Development and Evaluation of a Decision Aid for Parents by Yulia Gendler, Hedva Stoin, Tehila Volberstein, Lani Ofri and Dawn Stacey in MDM Policy & Practice
Supplemental Material
sj-docx-4-mpp-10.1177_23814683261446325 – Supplemental material for Supporting Decision Making on ADHD Medication: Development and Evaluation of a Decision Aid for Parents
Supplemental material, sj-docx-4-mpp-10.1177_23814683261446325 for Supporting Decision Making on ADHD Medication: Development and Evaluation of a Decision Aid for Parents by Yulia Gendler, Hedva Stoin, Tehila Volberstein, Lani Ofri and Dawn Stacey in MDM Policy & Practice
Footnotes
Acknowledgements
We extend our sincere gratitude to Dr. Yoram Sandhaus and Mrs. Galit Mansour for their valuable contributions to the conceptualization of the decision aid.
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The study was funded by an internal grant from Ariel University (funding No. RA2100000224).
Author Contributions
Yulia Gendler, conceptualization, methodology, data curation, formal analysis, investigation, supervision, writing – original draft, writing – review and editing; Hedva Stoin, conceptualization, methodology, data collection, writing – original draft, writing – review and editing; Tehila Volberstein, conceptualization, methodology, project administration, data collection, writing – original draft, writing – review and editing; Lani Ofri, conceptualization, methodology, data collection, writing – original draft, writing – review and editing; Dawn Stacey, conceptualization, methodology, supervision, writing – review and editing.
Ethical Approval
This study was approved by the Institutional Review Board of Ariel University (approval code: AU-HEA-YG-20240520).
Informed Consent Statement
All participants provided written informed consent prior to participation in the study. The study procedures were explained in full, and participants were assured of their right to withdraw at any time without consequence. Confidentiality and anonymity were maintained throughout the research process.
Data Availability Statement
All data supporting the findings of this study are available within the article. Additional data may be made available upon reasonable request from the corresponding author, subject to institutional and ethical approvals.
References
Supplementary Material
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