“Eat, pray, love. Ritalin”: A qualitative investigation into the perceived barriers and enablers to parents of children with ADHD undertaking a mindful parenting intervention

Highlights

• Parents of children with ADHD and healthcare providers reported on barriers and enablers to parents undertaking mindful parenting.

• Themes included parent motivation and capacity, multimodal delivery, and consideration for parent demands.

• To increase feasibility and acceptability, programs should be designed with parent needs and challenges in mind.

Abstract

Background and purpose

There is growing interest in how mindful parenting interventions (MPI) may support families of children with attention deficit hyperactivity disorder (ADHD). The aim of this study was to explore the potential barriers and enablers to parents’ participation in a MPI from the perspectives of parents of children with ADHD and healthcare providers.

Materials and methods

Thirteen parents of children with ADHD attended focus groups, and seven healthcare providers participated in semi-structured phone interviews. Transcripts of the focus groups and interviews were analysed using inductive thematic analysis.

Results

Three overarching themes related to potential barriers and enablers were identified: parent motivation and capacity to engage in a MPI, the need for multimodal and personalised delivery, and considerations for real-world program implementation.

Conclusion

Parents of children with ADHD appear to require flexible, multimodal MPIs that consider parents’ emotional experiences, priorities, and personal struggles.

Introduction

Attention Deficit Hyperactivity Disorder (ADHD) is one of the most common mental disorders affecting 4- to 17- year-olds [1]. Characterized by excessive inattention and/or hyperactivity-impulsivity [2], ADHD is associated with behavioural, emotional, social and educational problems in childhood [3,4], and subsequent increased rates of antisocial behaviour, criminal activity, and substance abuse in adolescence [5].

Caring for a child with ADHD can be highly taxing and has been linked to increased parenting stress, which arises when the demands of parenting outstrip the parent's resources [6]. In a qualitative meta-synthesis of 80 studies on parents' experiences of raising a child with ADHD, parents reported experiencing various negative emotional states, including exhaustion, anxiety, anger, desperation, and helplessness, reflecting the high levels of daily stress experienced by these parents [7]. Parents of children with ADHD have higher rates of depressive disorders, anxiety disorders, and substance-related disorders than parents of children without ADHD [3].

Such parenting stress and psychopathology represent a dual problem. Parents themselves clearly require support; in addition, parenting stress and psychopathology are risk factors for increased problem behaviours in children [8,9]. In a longitudinal study examining the impact of parenting stress on early adult outcomes in females with ADHD, parenting stress mediated the relationship between childhood ADHD symptoms and later self-injurious behaviour, externalising symptoms and internalising symptoms [9]. It was theorised that stressed parents were more likely to engage in maladaptive parenting practices, such as withdrawal of parental support and inconsistent discipline, contributing to poorer outcomes for their child [9]. In another recent, three-year longitudinal study, Breaux and Harvey [8] investigated the relationship between family functioning and ADHD symptoms in 197 preschool children. They found that greater maternal stress and mothers’ overreactive parenting significantly predicted more child ADHD symptoms. Elevated child ADHD symptoms significantly predicted increased parent stress and depressive symptoms, and lower maternal warmth, highlighting the bidirectional relationship between parenting stress and child functioning. Thus, treating parenting stress is not only necessary to improve parental wellbeing, but could also be an effective way to target behaviour problems and improve outcomes in children with ADHD.

One approach to reducing stress and improving wellbeing is mindfulness. Mindfulness can be defined as a process of bringing one's attention to the present moment and fully experiencing one's emotions, thoughts and physical sensations with acceptance [10]. Mindful parenting utilises the principles of mindfulness, applying the practices of attention, acceptance and non-judgment to parenting [11]. Studies on mindful parenting interventions (MPIs) in the context of ADHD have typically combined behaviour management for ADHD with mindfulness training over an eight-week period, and have taught mindfulness to parents and children [12]. Results of preliminary studies have been positive, showing that mindful parenting can lead to significant reductions in parenting stress [[13], [14], [15]], parent-child dysfunctional interactions [13,14], parent emotional reactivity [16,17], and parent anxiety [14]. Benefits for children have included increased positive affect in their relationship with their mother [18], and significant reductions in internalising and externalising symptoms [19]. Researchers have theorised that the enhanced capacity for warm, calm and consistent parenting imbued by mindfulness better enables parents to deal with parenting stress and contributes to more positive parent-child relations, with benefits to both parties [20].

Despite its potential, research on mindful parenting in the context of ADHD is limited by high attrition rates and a lack of data regarding reasons for drop-out [13,14,16]. For example, in a study exploring the benefits of adding a mindfulness bibliotherapy component to a parent training program for ADHD, less than half of participants completed both the pretest and post-test assessments [13]. It was recommended that future studies investigate reasons for participant drop-out. Lack of qualitative data gathered from participants regarding feasibility and acceptability of the intervention has been identified as a key limitation of mindful parenting studies [14].

One approach to improving participant engagement and retention in health interventions is co-design [21]. Rooted in the field of participatory research, co-design methods engage users and other key stakeholders early on in the design process to gain a comprehensive understanding of their intervention needs. Involving key stakeholders in the design process is likely to lead to the development of interventions that are more engaging and feasible to users [21]. This approach has not yet been applied to mindful parenting. Given the unique and complex needs of parents, especially those dealing with challenging child conditions such as ADHD, co-design is likely to offer key insights required for the development of ecologically valid mindful parenting interventions.

Using co-design principles, the present study aimed to identify the potential barriers and enablers of parents of children with ADHD undertaking a MPI, including identification of parent needs and program feasibility. Given their unique insights into the challenges faced by parents of children with ADHD and their role in referring patients to programs, healthcare providers were considered an important stakeholder group to engage in the mindful parenting program design process. Thus, the barriers and enablers of undertaking a MPI were examined from the perspectives of both parents of children with ADHD and healthcare providers. The purpose of the study is to inform the development of MPIs that are feasible and acceptable for parents of children with ADHD.