“The Way the System is Working Out, It's Not Working at All”: Parent Perspectives on Social Determinants of Health and ADHD Symptoms in Preschoolers
Auteurs:
Andrea E. Spencer, Tierney P. McMahon, Ren Mondesir, Nadia Garriga-Cerni, Meera Savage, Madeline C. Smith, J. Krystel Loubeau, Jennifer Sikov, Imme Kobayashi, Jasleen Singh, Rohan Dayal, Valeria Ladino, Christina Borba, Arvin Garg, Michael Silverstein
Adverse social determinants of health (SDH) are associated with higher risk for ADHD and worse prognosis. Understanding the reason for this association is critical for planning interventions to reduce inequities in ADHD outcomes. To answer this question, we conducted a qualitative study with parents of preschoolers aged 3–5 years old with ADHD symptoms, recruited from a safety net hospital, to understand their perspectives on the relationship between SDH and ADHD symptoms. Nineteen parents (53% Black, 26% Latine, 16% White; median income $32,500) completed in-depth interviews, and the data was analyzed using thematic analysis. Parents described bidirectional relationships between three main themes: (1) unmet social needs, (2) child ADHD symptoms, and (3) parent stress. Our findings suggest that early intervention to address unmet social needs in the child’s environment and support parent mental health could be tested to improve symptom trajectories in preschoolers with emerging ADHD.
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Introduction
Attention Deficit Hyperactivity Disorder (ADHD) is one of the most common pediatric conditions. Symptoms typically begin in the preschool years and often have a chronic course [18]. Children with ADHD experience greater difficulties in school and social relationships, and these impairments extend into occupational, health, and relationship difficulties in adulthood [6, 16]. ADHD is highly heritable, but research from the past decade also indicates that social determinants of health (SDH), or the social and economic factors that affect health and healthcare outcomes such as low household income, low parental educational attainment, food insecurity, housing instability, and parental mental health, are associated with ADHD onset, severity, and prognosis [12, 13, 19, 21]. Several studies have shown that low household income is associated with an increased risk of ADHD in childhood, and that the strength of the association is related to the timing and duration of economic strain [4, 8, 13, 24, 29]. However, despite the replicability of these findings across samples and settings, the directionality of and mechanism behind the association between ADHD and SDH remains unclear.
There is some evidence to support the possibility that economic adversity increases ADHD risk in childhood. For example, studies have found that change in economic status predicts childhood ADHD symptoms over time, but not vice versa [4, 25]. One reason for this could be that lower income and adverse SDH means fewer resources and enrichments to support child development, increasing risk for ADHD and other learning and behavioral challenges [5, 7]. Lower income and fewer resources may also adversely affect parent wellbeing and mental health [1, 27], which may increase the risk for ADHD via an impact on parenting and family relationships [22, 25, 28].
However, it may not only be that adverse SDH increases the risk for ADHD, but also that having a child with ADHD subsequently worsens adverse SDH. Having a child with ADHD incurs familial economic burden, primarily due to excess educational and treatment costs [15, 26, 34]. Furthermore, childhood ADHD symptoms themselves contribute to parental stress and worsen parental mental health, which might explain some of the association between parental mental health and ADHD [9, 14, 25, 31]. In addition, ADHD is highly hereditary, so the association between child ADHD and SDH may be confounded by parental ADHD, which is associated with employment difficulties, reduced wages, and other parental mental health challenges [6, 16, 30]. That said, multiple studies that controlled for parental ADHD have found that parental ADHD does not fully explain the association between ADHD and socioeconomic status [13, 21].
Better understanding the directionality and mechanisms behind the connection between SDH and child ADHD could inform the development of new early intervention strategies for young children with emerging ADHD who are exposed to adverse SDH. This includes a better understanding of how SDH affect and are affected by ADHD, and which SDH might be of greatest concern for families of young children with ADHD symptoms. Parents raising a child with ADHD symptoms and exposure to adverse SDH could provide key insights into these relationships and potential early intervention targets, but the literature currently lacks parental perspectives on this topic. Thus, we conducted a qualitative study to seek parent perspectives on the connections between adverse SDH and ADHD symptoms in preschoolers to fill this gap and inform family-centered early intervention strategies.
Methods
We conducted a qualitative study guided by thematic analysis and followed COREQ guidelines in the reporting of this research. This study was approved by the Boston University Medical Campus Institutional Review Board in an expedited review.
Setting and Recruitment
Parents of preschool-aged children (3–5 years old) were recruited via convenience sampling from clinical practices at a large, urban, academic pediatric ambulatory clinical practice at a safety net hospital in the Northeast US from August 2019 to October 2021. Potential participants were identified via (1) direct provider referral to the study team; (2) child psychiatry and developmental pediatrics waitlists; and (3) the electronic medical record (EMR) (based on meeting age criteria plus having the diagnosis of ADHD or symptoms of inattention/hyperactivity/impulsivity on their diagnosis list). We advertised the study to pediatric clinicians and sent letters to potentially eligible parents about the study, followed by a phone call that included eligibility screening, according to IRB approved procedures. Parents were eligible for the study if they (1) were the legal guardian and primary caregiver of the preschool-aged child; (2) if they could consent and understand study procedures in English, Spanish, or Haitian Creole, and (3) if their preschool-aged child had a previous clinical diagnosis of ADHD or scored above the 80th percentile based on age and gender norms on the inattentive, hyperactive, or total symptoms subscales of the ADHD Rating Scale IV (ADHD-RS-IV) Preschool Version [10, 11], which was administered to the parent by phone during screening. We included both children with and without known clinical diagnoses of ADHD because symptoms begin to emerge at this age but are often not yet diagnosed, and we were interested in children who might benefit from early intervention [2, 28]. Parents were ineligible for the study if their preschooler had a diagnostic history of intellectual disability or autism, or if the parent could not complete study procedures in English, Spanish, or Haitian Creole. Parents who met study eligibility criteria provided written informed consent to participate.
Data Collection
Parents completed a demographic questionnaire and a semi-structured 45–60 min interview either in person or over videoconferencing software conducted by a trained research staff member who was fluent in the participant’s preferred language (English, Spanish, or Haitian Creole). Data collection occurred in person between July 2019 and March 2020, and transitioned to either phone or Zoom formats between August 2020 and January 2022 to adjust to the COVID-19 pandemic. Children were not present during the interview. Participants were compensated with a $30 gift card.
The interview guide consisted of open-ended questions intended to elicit families’ experience of managing their child’s ADHD symptoms, their experience with unmet social needs and accessing social and economic resources, and parents’ own mental health and experience of stressors. “Unmet social needs” refers to not having adequate resources needed for healthy living, including access to childcare, food, health care, and housing. Based on previous research on SDH and emerging ADHD symptoms in preschool, we explicitly asked about the following social needs: housing, money, food, childcare, healthcare, transportation, child activities, and intervention. The interview guide is included as Supplemental File 1.
Data Analysis
Interviews were audio-recorded, transcribed verbatim, de-identified, and translated to English when necessary. After reviewing for accuracy, transcriptions were analyzed using thematic analysis [3]. In thematic analysis, the interview transcripts are broken into codes that are used to identify themes across the interviews. Transcripts were open coded by at least 2 members of the research team and then discussed as a group. The codebook was developed through iterative discussions as team members coded additional interviews until thematic saturation was reached (i.e., new codes were no longer emerging in interviews). Once thematic saturation was reached, we stopped recruiting new parents and the finalized codebook was used by two independent coders to code all interviews. Intercoder reliability (Cohen’s κ) remained above 70% for each interview. Once all interviews were fully coded by both coders, the research team met weekly for axial coding to examine the relationship between codes and create a thematic model to describe the data. We used NVivo Software to code the interview transcriptions and review themes.
Researcher Identities and Reflexivity
Our study team included researchers with multiple expertise and genders, including a child psychiatrist (principal investigator), two pediatricians, a public health professional, a clinical psychologist, graduate students in child development, medicine, and psychology, undergraduate students with an interest in and lived experience with ADHD, and research staff ultimately interested in pursuing doctoral degrees in psychology and psychiatric epidemiology. The interview guide was developed by the child psychiatrist (AS), pediatricians (AG and MS), and public health professional (CB), who are experts in qualitative research (CB, MS, and AS), child mental health equity (AS) and social determinants of health in pediatric populations (AS, AG and MS). Interviews were conducted by research staff and students who were trained in qualitative interviewing techniques and use of a qualitative interview guide, and who were not mental health professionals nor experts in the field. Two of the participants had been clinically evaluated by the child psychiatrist prior to the study and diagnosed with ADHD. There were no other relationships between researchers and study participants. Coding was completed by students and research staff. Thematic analysis was conducted by the child psychiatrist, clinical psychologist, students, and research staff. During the analysis, the research team engaged in the process of both written reflexivity (documenting memos and reflections during the code development process) and collaborative reflexivity (intentional process of mutual responsibility and reflection about how each researcher’s perspectives, expertise, and biases may influence their interpretation of the data) [17].
Results
Sample Characteristics
Our recruitment procedures identified 99 potential participants, and 19 parents consented to participate in the study. Interviews were conducted in English (n = 14), Spanish (n = 4), and Haitian-Creole (n = 1). Seven parents were interviewed prior to the COVID-19 pandemic in-person, and the remaining interviews were conducted remotely during the pandemic.
Demographic information on parents who participated in the present study is reported in Table 1. Demographic information was missing for one parent out of the 19 parents who participated. Parents had a mean age of 33.8 years old (SD = 14.8) and primarily identified as female (n = 16). A majority of the parents were the biological mother (n = 14), 3 were the adoptive mother or father, and 1 was the biological father. Most parents identified their race as non-Hispanic Black/African-American/Caribbean (n = 10), while 5 identified their race as Hispanic/Latine, and 3 identified their race as non-Hispanic White. Most of the parents were born in the United States, while 5 were born outside of the United States. Parent educational attainment ranged from attaining a high school degree or GED (n = 2) to a doctorate or professional degree (n = 1), with almost half of parents attending some college without a degree (n = 9). The median income of the sample was $32,500 (IQR = 36,375).
Table 1
Demographic characteristics of parent participants
Sex, n (%)
Male
2 (11%)
Female
16 (84%)
Missing
1 (5%)
Age, mean (SD)
34 (15)
Marital Status, n (%)
Married or living with a partner
5 (26%)
Divorced or separated
4 (21%)
Never married
7 (37%)
Missing/Refused
3 (16%)
Race/Ethnicity, n (%)
Non-Hispanic Black/African-American/Caribbean
10 (53%)
Non-Hispanic White
3 (16%)
Hispanic/Latine
5 (26%)
Missing
1 (5%)
Relation to Child, n (%)
Biologic Mother
14 (74%)
Biologic Father
1 (5%)
Adoptive Mother/Father
3 (16%)
Missing
1 (5%)
Study visit language, n (%)
English
14 (74%)
Spanish
4 (21%)
Haitian Creole
1 (5%)
Primary language spoken at home, n (%)
English
12 (63%)
Spanish
5 (26%)
Haitian Creole
1 (5%)
Missing
1 (5%)
Birthplace, n (%)
In the United States
13 (68%)
Outside the United States
5 (26%)
Cape Verde
1 (5%)
Dominican Republic
1 (5%)
Haiti
1 (5%)
Honduras
1 (5%)
Jamaica
1 (5.3%)
Missing
1 (5.3%)
Education level, n (%)
High school degree or GED
2 (11%)
Vocational, trade, or business program
2 (11%)
Some college
9 (47%)
Master’s Degree
3 (16%)
Doctorate or Professional Degree
1 (5%)
Missing
2 (11%)
Employed at least 50 of 52 weeks, n (%)
9 (47%)
Household income, median (IQR)
$32,500 (36,375)
Demographic information on the preschool children of participants is reported in Table 2. Because two parents of the same child participated in this study, we report on the demographic information of 18 unique preschool-aged children with emerging ADHD symptoms, although demographic information for one child is missing. The mean age of these children was 4.3 (SD = 0.7) and the majority of children were identified as male (n = 11). Parents identified their children’s race as non-Hispanic Black/African-American/Caribbean (n = 9), Hispanic/Latine (n = 6), non-Hispanic White (n = 1), and as multiple races (n = 1). Most children had public insurance (n = 14) and were enrolled in school (n = 13). The most common psychiatric diagnosis reported in the sample of children was ADHD (n = 8), followed by behavior or conduct problems (n = 7). The most common medical diagnosis in the sample was asthma (n = 5). Only a few (n = 3) were taking medication for ADHD, while half had received therapy or another behavioral intervention for ADHD (n = 9).
Table 2
Demographic characteristics of preschool children of parent participants
Sex, n (%)
Male
11 (61%)
Female
5 (28%)
Missing
2 (11%)
Age in years, n (%)
Three
2 (11%)
Four
7 (39%)
Five
8 (42%)
Missing
1 (6%)
Age in years, mean (SD)
4.3 (0.7)
Race/Ethnicity, n (%)
Non-Hispanic Black/African-American/Caribbean
9 (50%)
Non-Hispanic White
1 (6%)
Multiple Races
1 (6%)
Hispanic/Latine
6 (33%)
Missing
1 (6%)
Health Insurance, n (%)
Public
14 (78%)
Commercial
1 (6%)
Public and Private
2 (11%)
Missing
1 (5.6%)
Other Psychiatric Conditions, n (%)
Attention-deficit/Hyperactivity
8 (45%)
Depression
1 (6%)
Anxiety
4 (22%)
Behavior or Conduct
7 (39%)
Other Developmental Conditions, n (%)
Speech or Language Problems
2 (11%)
Developmental or Cognitive Delay
1 (6%)
Medical Conditions, n (%)
Asthma
5 (28%)
Vision problems not corrected with standard glasses
1 (6%)
Food allergies
2 (11%)
Seasonal allergies
1 (6%)
Treatment History, n (%)
Ever taken medication for ADHD
3 (17%)
Currently taking medication for ADHD
3 (17%)
Ever received therapy or other behavioral intervention
9 (50%)
Early intervention for language, literature, and motor skills, n (%)
Previously received
9 (50%)
Currently in school (Yes), n (%)
Yes
13 (72%)
No
4 (22%)
Missing
1 (6%)
Currently has special education services, n (%)
Yes
3 (17%)
No
13 (72%)
Missing/Refused
2 (11%)
Thematic Analysis
Parents described bidirectional relationships between three main themes: 1) unmet social needs, 2) child ADHD symptoms, and 3) parent stress and wellbeing (Fig. 1). These themes were not described as causing one another but rather as exacerbating eachother. Parents often discussed unmet social needs in the context of financial hardship that made meeting all needs for their family difficult. In discussing their child’s ADHD symptoms, parents described both core ADHD symptoms as well as related behavioral and emotional symptoms, including impulsivity, hyperactivity, and negative emotionality (e.g., temper tantrums). In addition, parents discussed their own stress, wellbeing, mental health, and personal growth as it relates to raising a preschooler with emerging ADHD symptoms in the context of financial hardship. As depicted in Fig. 1, when parents discussed one of these themes (e.g., access to adequate childcare), they often also discussed how it relates to at least one of the other themes (e.g., their wellbeing). For example, parents described ways their own mental health was affected by both their child’s ADHD symptoms and their ability to maintain employment, as well as how managing their child’s ADHD symptoms affected their ability to maintain employment. We describe the bidirectional nature of these three themes in further detail below.
Fig. 1
Thematic Associations Among Unmet Social Needs, Parent Stress, Child ADHD Symptoms, and Financial Hardship
Relationship Between Unmet Social Needs and Child Symptoms
Parents described a bidirectional relationship between unmet or inadequately met social needs and their child’s ADHD symptoms (Table 3). They described a number of situations in which difficulty meeting social needs made it more challenging to support their child’s behavioral and emotional development, and ways in which their child’s ADHD symptoms created complexities in how they would be able to meet these needs.
Table 3
Selection of Representative quotes for the relationships between unmet social needs, child symptoms, and caregiver stress in the context of financial hardship
(a) Quotes describing the relationship between unmet social needs and child symptoms
Subcategory
Unmet social needs and child symptoms quotes
Child symptoms affecting unmet needs
“I had to change her daycare.…In that daycare there was no structure with a fixed teacher since the teachers rotated… So, the problems started and she didn't want to stay there anymore, she didn't want me to leave her. She was willing to stay for like an hour if something entertained her, like games, but once the hour was finished, they would call me at work and tell me that she was crying, kicking, throwing things.”
“I would prefer to continue to work from home or have a job where I make my own schedule. With kids, especially a kid like him, I mean, you kind of need a job that allows you to have some kind of flexibility. I can't have a job that I have to wait for someone to relieve me before I can leave. I can't ever work anything like that. Because whether they relieve me or not, I got to go depending on what the situation is which can make me look irresponsible, which I'm not.”
“The person who was taking care of him told me she couldn’t. That the child was too hyperactive. She couldn’t deal with him. The person became hysterical one day and called me and told me she couldn’t take care of him. She brought him here. I was so upset. It made me very angry. Furious. Obviously, like any mom, I felt bad. I felt like he had been discriminated against just for being hyperactive. Sometimes, I have to carry that. Something that’s normal. I think not everyone is going to understand that he has a condition… That’s what happened. That’s why I didn’t keep working. My mom supports me and says, ‘No. Don’t work for now. Take care of him yourself.’ Because I think that he will not be better taken care of in my hands than in other hands and they will neglect him, and something can happen to him.”
“I don’t know if putting her, even in gymnastics and [dance]….I would love to put her in it, but I don’t want to set her up to fail…start getting yelled at…because she’s not doing what she’s supposed to do."
“It was very complicated when the speech specialist called me to give him his speech therapies and the food specialist. He wasn’t still. He didn’t pay attention. He doesn’t know—I mean, it’s very complicated. Like, I want to have him here and he’s moving around. It was like that. That’s why the pandemic was super difficult for me. I think it’s been the worst thing that’s ever happened.”
“It’s the same everywhere. He would grab and throw everything at the children. He doesn’t know how to share. He knocks everything down. He would knock the stools down, the closets, and everything. There they did an early intervention. He was small. They said he wasn’t okay. Over in [state omitted], too. The teacher was sending me the same thing. And here it started now in September. Since they wouldn’t move him, he was sent to a specialist. Because they can’t stand him… Because not even three teachers can work with him. They can’t. I am alone.”
Unmet needs affecting child symptoms
"I am living in an apartment, and it does affect us. Because, for example, I live on a second floor. My neighbor on the first floor has already come here twice. We’ve had arguments because the girl is running in the house… I’m even looking to move to a first floor or a house because of her condition. It has brought me problems. It has been very tough for me… It’s hard to control her because I tell her not to run and she runs. It’s hard. [If I had more money] I would buy my own house.”
“So, the process of getting an [individualized education plan] was very long and even for someone with experience was pretty complicated. Just not knowing your rights and not knowing—like they wanted to offer [occupational therapy] once a week and I was like well that doesn't seem like enough. I wanted two times a week. But if I didn't know that I could push back or negotiate, I would have just taken what the school offered and been like okay I guess that’s as good as it’s gonna get.”
“I go to pantries. I have a list of pantries. I am in [name of city omitted]. I go to a pantry whenever I need to. So, I have all those things in place. Definitely. But, he eats too much, still. Even though I have resources, it's like, I can't buy groceries and make it to the house, he is stealing out the bag. Like,"Mom, can I please open?""No, son. We have to get to the house."”
That was our plans, to move. We were already looking for an apartment, but because of issues when the pandemic started, I could not think that—my son got worse during the pandemic. That’s where I went crazy, and it was where they told me he had ADHD [attention deficit hyperactivity disorder]. I feel like that’s where he got worse. I was limiting him because the owners of the—the owners of the property live on the first floor. Truthfully, my child is a handful. He’ll jump hysterically running around. I couldn’t control him
“I was having a rough time getting to the right person in behavioral health because I felt like [child’s name] and I were in regression, and we went backwards.”
“They can't go outside. They can't go to the park. It's just too cold. They have no yard to go outside and play. They're just in the house, that's depressing in itself. And so, what else is good for him to do but act out? You know what I mean? He's confined. So, yeah. I mean, if I had more money I would have a house. I would have… Or at least somewhere where I had some kind of a backyard, which will be like maybe a townhouse or something like that, so my kids could play.”
Financial hardship and child symptoms
“Yeah, honestly, the way that, basically, this day and age, you need money to do a lot of stuff. With him having the ADHD symptoms, and because we are on a fixed income, there are some things I can't do with him because you have to pay. For instance, like, trampoline and um the iPhone, that's something that is perfect for him, but because I have so much bills and there's only one income right now, I can't do a lot of those things. So, I don't know if that's a part of financial, whatever you call it. So, food, too. Yeah, he needs more. I am constantly spending more money than I used to.”
“I would like to have a normal job with hours and benefits, but I can’t. Because of her hyperactivity, not many people have wanted to take care of her. They are afraid something is going to happen to her. I’ve had to cope with my finances with a part-time [job].”
I think finances is huge, right? Because money can't buy happiness, but it can buy a bigger house and it can provide some stress relief of not feeling like we're always pinching pennies. So, you know, I think and my husband to like just making more money is always helpful. We chose the wrong field, but what are you gonna do about that and to help me achieve my goal? I mean, I think I'm on the right path of what I need to be doing, I've been Like I said, you ladies all appear to be much younger from, you know, it's been 20 years that I've been working at this, but you know, I've slowly worked my way up from being a clinician to being a manager to being a program director. This is my last week, but I'm currently a regional director and now I'm going to be an assistant director for a major hospital. So, I feel really good about where I'm at in my life professionally
“Because she’s so energetic, and I wanna get her into things, it’s just everything costs us money.”
(b) Quotes describing the relationship between unmet social needs and caregiver stress
Subcategory
Unmet social needs and caregiver stress quotes
Unmet needs and financial hardship
“But as a mother, a single mother right now, I'm paying a mortgage on my own, everything that comes with that mortgage or my home. Food then becomes something that goes against something else. I always choose food. So, me and my kids eat very well. However, my utilities are struggling because of that. But it's something that I'll catch up on. But I can't send my kids to bed hungry, so yes, we eat well.”
“I opened up a daycare but I had it for six years but then when I got him I had to close it because he was at the hospital maybe three of four times a week and I was spending more money with people watching the kids in my daycare than I was making myself. So, I had to close down.”
“She’s there from nine to five, but the jobs I’ve looked for start at seven or at eight. I have no one to take her to day care. Then I would get out late, at six or seven, so I have no one to pick her up from day care. That’s the problem….I enrolled her [in school] today. I hope there will be an after-school program when she can go to so that I can be more financially stable.”
She's fine. [child] She got clothes. She made, I made sure she eat. It's everything else that falls behind when it comes to money, because it's the bills that get, you know, you gotta pick and choose what you wanna pay, when, what you can pay rather, and if it's not this check, then you gotta wait till the next check, so it's just like, I hope to one day just not be living check to check. That's my goal, for one day
Unmet needs and personal growth
“The way the system is working out, it's not working at all. Sometimes, the more you work, the more help you need. You're not getting those. The more effort you put to get out of needing help, it's not working. For example, I cannot need help paying for my rent but then I do need help to pay for food. If I spend the money on food, I cannot pay the rent and stuff like that. Ever since you make a single dollar more, they count that. Everything goes towards bills or expenses. If you don't go to school or you don't work, then you get food stamps. You get welfare. Your rent goes to zero. I think the system wants you just to stay home and be a couch potato instead of that way. I would love to stay home, and be just part of my kids'life, and educate them, and all that, but then what about myself? How will I grow?”
Unmet needs affecting caregiver stress
“Yes… the pandemic… I think my son would be much more different. I even walked in—I was starting to have depression and anxiety again because of [my son]. Because the child could not be physically taken to therapies. They say they work more in person than on a video call.”
[About childcare] “The whole thing. It’s been tough. It’s one thing that I struggle with. Who I trust him with because I know how he can be. Also, it’s the idea I don’t have that much support because all my family, everybody works. The ones that don’t work, they’re not close by. The whole thing has been difficult. I mean right now I have my goddaughter who watches him three days a week. She’s also in high school doing her remote learning. Also, trying to do remote learning with him. The whole idea is tough.”
“My immigration status. That's what’s blocking me. But, even though I have that blocking me, I know I need to take care of it, but making sure my son's development, and my son, is more important to me. It doesn't mean I'm not going to take care of whatever, but things will happen when they need to happen. Right now, because I don't have the financial means anyways, I can't at all, what I can do right now is focus on my son right now.”
“Yeah, I was. I had no choice, though, because I'm thinking I have a team and in reality it was just me. So, even though all these adults are there, I was the only adult doing everything, like making sure…the house has this, running here and there. By the time it's time to do something for me I'm like, forget about it. I'm done. I'm exhausted. You know?”
Financial hardship and caregiver stress
“I haven't paid my rent yet. I haven't paid my car payment yet. So, I know my car is, like, in jeopardy of being repossessed if I don't pay it anytime soon…I'm just tired, because I do so much, like, I literally do so much driving back and forth, it's really tiring, and it's stressful.”
Every time I start babysitter work, my child is handed back to me. They gave me my money back. if I don't have someone to keep the child for me. When it doesn’t work. Work as Nursing room, I am a CNA, nursing room work is seven to three, three to eleven, eleven to seven. I used to go to work at eleven o'clock at night because it was not good for me. At that time he used to go to daycare. I have until 9:00 to get him to daycare. However, it was not good for me. I used to go to work at the agency when I dropped him off at daycare and then I went to an old man's house to go to work. Everything I tried was not good for me. So… and I saw that I was working for the babysitters. There is no money left for me. I figured I'd say"sh*t."If you have a guy, someone you are with, you make your plans with him instead of fighting to live. I choose not to go to work anymore. Here I was working in [city omitted], on [month] 18 it's been 1 year in [city omitted]
Financial stability as stress relief
I think lately what I've been doing relatively is just acknowledging that even though things are not super great, I'm still making forward movements. So, in these couple months, I haven't really been able to pamper myself or do anything that I really want to do for me. But paying my bills on time is equivalent to that for me. And I know that there's a cut-off point and you have to understand that, that's still not self-care, but understand that it is the less second thing, last is one less thing that I have to worry about and that to me is self-care
Caregiver stress affecting unmet needs
“I think my own issues might affect me with work'cause there's times I just don't feel like I wanna work. But, you know, I get disability, so I have my own things going on… Yeah, so… I have fricking, uh, utility problems. I feel like every time I pay them my bill gets double.”
“This is why I call out of work, because I need the time… I've been into the point where it's just like, I get in a mood… I've called out of work, like, pretty much probably every other day, because it's just like, I get to a point. I just don't feel like dealing with anybody. I don't wanna be around anybody, and it's just like, I can't afford to call out of work…I guess you can say it's depression. I don't know. I mean, stress… It's just like, look, I can't. I can't take another hit, because I'm-a break after a while, and I don't want that to happen. So, I just take time, when I feel like I need time. Call it a day.”
(c) Quotes describing the relationship between child symptoms and caregiver stress
Subcategory
Child symptoms and caregiver stress quotes
Child symptoms affecting caregiver stress
“There are things I can’t do as I see my other family members going out with their children do. They go out and enjoy their time. They walk calmly. They give them something and they are easily entertained. With mine it’s harder to do that. Mostly because of the worry that…something may happen to him… Because I always have to watch him. Any little thing or a minimum carelessness, and something can happen to him. He falls because he jumps too much. I think that’s what has caused me all of this stress.”
“Yeah, definitely has increased some anxiety at times and just, you know, it can be exhausting dealing with a child… Trying to manage all of her feelings can be exhausting, because she can have a 180 where she's doing great and then the next minute she's having a major meltdown in public and you're trying to just finish your grocery shopping, and just having to like regulate myself and teach my husband about, kind of attachment parenting and different trauma approaches, because he's culturally, and approaches things differently than me. I have the social work background where I'm trying to manage all of those things in a different way, which is not always possible and I'm still a human and still a parent that sometimes just wants my kid to listen to me the first time, not the 100 th time. So yes, I would say, you know, I've definitely sought my own therapy to kind of figure out how to be the best parent I can be to a child who is obviously looks different than me has the adoption, trauma has some behavior challenges and whose birth family has a pretty significant history of mental illness. So, all of those things.”
“Sometimes he makes me angry, you know. Because like you said, [child name] it's all about him. It’s all about him. Even on the bus, if I'm sitting with him on the bus, someone talks to me and says"mommy, you don't know him, what he's saying."There was a time when a man greeted me, the man said"you look very nice"he took my hand and lifted me up and sat in another place with me. Everyone does [applause sound]. I'm ashamed! [laughs]”
“And she would still just go all out just like none of this has just happened. And that's so discouraging. It's exhausting as hell. I just feel sometimes it's better just to stay home. I do Instacart a lot of times, because I don't want her to take to the grocery, Walmart pickup, so we just got to go car right down and it's challenging.”
“Everybody's being mean when he doesn't get his way. There's no talking to him. Everything that I do, I am bending over backwards. We're walking on eggshells. We can't do anything here without him being happy. Everything has to go his way. Every day, I have to promise him something, from school, something that he wants — roller skates, a bicycle, a skateboard, a scooter, bubble gum, cotton candy…… so he does good in school because he will go off on them in school and then I would have to pick them up and I can't because I have things I have to do.”
“Ignoring him, and blocking him out, and paying no mind for the sake of my own sanity. I'm not going to allow him to drive me crazy because I cannot be drove crazy because I am a single mother. You and your sister need me to be as sane as possible. Me along with your little three-year-old self to take me out of character, it ain't going to happen. I'm going to ignore you. He'll slam his door. I can do the same thing too, [Child Name]. I could slam my door harder. I can scream louder. I can roar louder. That's just my way of reprimanding my children.”
“And when we do, like I said, the ice cream parlor somewhere that we'd like to do, that's something that we all like to do. But you go, you have a good time, and then it's time to go. Now, you're kicking out in the street, you're making a big scene. Then, you're in the car, you're kicking my car, so the back of my chair, I can't drive. We're not going. You know what I mean? We're not going, we're just going to be home. So, those things are so frustrating. They're so frustrating.”
“It’s every time. Then they start with the comparisons. ‘Look at so and so. He’s the same age. Look at how well behaved he is. Why can’t your son stay in the table to eat? Why he has to sit on the floor?’ It’s simple little things that maybe don’t mean anything and I’m just taking it that way. It does affect me every time.”
“It makes me panic to think that no one is going to be watching for him like I do. A child who has that problem, you really have to keep an eye on them. They’re careless. They climb up anywhere and don’t ponder danger. I do not know. It’s too much. For that reason, I prefer to take care of him myself
“I know it’s stressful because at one time I kept getting this chest pain and my doctor said it too she said it’s stress. I said yeah that’s him yelling at him all day and trying to make him do this and do that and stuff….it’s like I don’t get no break with him.”
Caregiver stress affecting child symptoms
“Whereas, when she comes home, it's just me and her, and I feel like…, sometimes like, I can see the look on her face, like, when I tell her, like,"Get out of my room,"like, her face just drops. And I don't like that feeling, but it's just…sometimes, it's, it becomes too much…,…you're just doing too much. And right about now, I cannot do that. Like, I just wanna rest. Like, I can't do the bouncing,…or, I…I can't, like, so, if you can't sit still, then you…you can get out. And the look she gives me is just, like, I just crushed her soul. But, I mean, it…it gets that way sometimes. I think when it's at the point where she and I are both escalated, because like she's having difficulty regulating and I can't regulate her so now I'm feeling dysregulated, I think in those moments like she's very much a child who needs connection, so being able to like hug her, she does well with pressure…. So being able to like give her a hug, squeeze her and then take space is good, you know, we'll say like when you're ready to talk to mommy, you can come back and usually within like four minutes she's like I'm ready. And that's given me just enough time to like get it back together and then kind of manage both of our feelings.” I think I put a lot of emphasis on the fact that everybody needs space sometimes, even if it's just me going to the bathroom and wash my hands taking a minute, I think is really effective because trying to regulate myself and regulate her is not effective.”
“And if I’m up like this, my son is up like this. You know? So, now I have my therapy and psych, so I’m leveled out. So, since I’m leveled out, now I have to get my son leveled out.”
“Taking space and being able to talk to [child’s name] about what it is that's going on is again in a very age-appropriate way, like I'm feeling frustrated because you're not keeping our hands to ourselves or like my body feels hurt because you're hitting me, I don't like that. So, I think all of those things can be helpful. They don't always work, but I try them all.”
“He'll be like,"Mommy, are you mad at me?"And I'll be like,"I'm just disappointed because I feel like you could behave better."And he doesn't like the word disappointed. Nobody does. So, sometimes he'll straighten up, sometimes he won't. His twin will be like,"Mommy’s getting upset. You're making mommy mad,"or whatever. And she'll be like,"Let's go clean up our room."And sometimes he'll go with that. Or if it was warm outside, then I'd be like,"Oh, let’s go to the park, get em out. Run, run it off,"type of thing.”
Parents described a pressing need for more resources and support as a result of their child’s symptoms (e.g., for extracurriculars, entertainment, and food) as well as increased financial hardship in the effort to meet these needs.
“Yeah, honestly, the way that, basically, this day and age, you need money to do a lot of stuff. With him having the ADHD symptoms, and because we are on a fixed income, there are some things I can't do with him because you have to pay. For instance, like, trampoline and…the iPhone…because I have so much bills and there's only one income right now, I can't do a lot of those things…food, too. Yeah, he needs more. I am constantly spending more money than I used to.”
Many parents discussed difficulty in finding adequate daycare or schools that included staff who were prepared for managing their child’s ADHD symptoms.
“I had to change her daycare.…In that daycare there was no structure with a fixed teacher since the teachers rotated… So, the problems started and she didn't want to stay there anymore, she didn't want me to leave her. She was willing to stay for like an hour if something entertained her, like games, but once the hour was finished, they would call me at work and tell me that she was crying, kicking, throwing things.”
Parents described other needs that were made more pressing due to their child having ADHD symptoms. One common concern was the unmet need for sufficient safe and private space for the child to play and expend energy.
"I am living in an apartment, and it does affect us. Because, for example, I live on a second floor. My neighbor on the first floor has already come here twice. We’ve had arguments because the girl is running in the house… I’m even looking to move to a first floor or a house because of her condition. It has brought me problems. It has been very tough for me… It’s hard to control her because I tell her not to run and she runs. [If I had more money] I would buy my own house.”
Parents also described a need for more extracurricular activities for structured enrichment and entertainment because of their child’s symptoms.
“I would definitely have him in soccer…or something like swim lessons. I [would] keep him busy. Because with someone hyper, the only way to... Otherwise, he's annoying…he's always doing something that he shouldn't be doing.”
Child symptoms also made it harder for parents to access an adequate public education for their child because they needed to advocate for educational support services related to learning challenges in the classroom and often were doing this on their own.
“The process of getting [special education services] was very long and even for someone with experience was pretty complicated. Just not knowing your rights and not knowing - like they wanted to offer [occupational therapy] once a week and I was like well that doesn't seem like enough. I wanted two times a week. But if I didn't know that I could push back or negotiate, I would have just taken what the school offered and been like okay I guess that’s as good as it’s gonna get.”
Multiple parents described how their child’s ADHD symptoms influenced their ability to find safe and stable childcare, leading to difficulty maintaining employment.
“The person who was taking care of him told me she couldn’t. That the child was too hyperactive. She couldn’t deal with him. The person became hysterical one day and called me and told me she couldn’t take care of him. She brought him here. I was so upset…I think not everyone is going to understand that he has a condition… That’s why I didn’t keep working…My mom supports me and says, ‘No. Don’t work for now. Take care of him yourself.’ Because I think that he will not be better taken care of in my hands than in other hands and they will neglect him, and something can happen to him.”
Relationship between Unmet Needs and Parent Stress
Parents described many examples of the effects of unmet social needs in the context of financial hardship on their own stress, wellbeing, and mental health, as well as some examples of their own mental health impacting their ability to work or meet their family’s basic needs (Table 3).
Importantly, unmet needs were described as highly interdependent in the context of financial hardship. The difficulty was often not meeting one specific need but rather choosing which need would go unmet as a result of financial hardship.
“As a…single mother right now, I'm paying a mortgage on my own, everything that comes with that mortgage or my home. Food then becomes something that goes against something else. I always choose food. So, me and my kids eat very well. However, my utilities are struggling because of that…But I can't send my kids to bed hungry…but, everything else is, like, you gotta pick and choose between bills, and my rent, and my car, because I need my car to get back and forth to work and get her back and forth. So, it's either the...the car or her school, so, I need the car.”
Similarly, parents described how decisions regarding their financial resources affect their own wellbeing and personal development. In many ways, parents described a cycle of feeling stuck in their financial strain.
“The way the system is working out, it's not working at all. Sometimes, the more you work, the more help you need. You're not getting those. The more effort you put to get out of needing help, it's not working. For example, I cannot need help paying for my rent but then I do need help to pay for food. If I spend the money on food, I cannot pay the rent and stuff like that. Ever since you make a single dollar more, they count that. Everything goes towards bills or expenses. If you don't go to school or you don't work, then you get food stamps. You get welfare. Your rent goes to zero. I think the system wants you just to stay home and be a couch potato instead of that way. I would love to stay home, and be just part of my kids'life, and educate them, and all that, but then what about myself? How will I grow?
Parents also described how difficulty accessing behavioral treatment and support for their child, which worsened during the pandemic, negatively impacted their own mental health.
“Yes…the pandemic…I think my son would be much more different. I even walked in - I was starting to have depression and anxiety again because of [my son]. Because the child could not be physically taken to therapies. They say they work more in person than on a video call.”
Parents also commonly explained that a lack of familial and friend support systems greatly added to their stress levels and inability to focus on their own self-care.
“Yeah, I was. I had no choice, though, because I'm thinking I have a team and in reality it was just me. So, even though all these adults are there, I was the only adult doing everything, like making sure…the house has this, running here and there. By the time it's time to do something for me I'm like, forget about it. I'm done. I'm exhausted. You know?”
While parents mostly described their restricted resources and unmet social needs as stressors, parents also described instances where their high levels of stress contributed to difficulty working and therefore impacting their financial situation and ability to cover expenses.
“This is why I call out of work, because I need the time…I've been into the point where it's just like, I get in a mood… I've called out of work, like, pretty much probably every other day, because it's just like, I get to a point. I just don't feel like dealing with anybody. I don't wanna be around anybody, and it's just like, I can't afford to call out of work, but if I don't...I guess you can say it's depression. I don't know. I mean, stress…it's just like, look, I can't. I can't take another hit, because I'm-a break after a while, and I don't want that to happen. So, I just take time, when I feel like I need time. Call it a day.”
Parents discussed being able to make ends meet as a relief of stress and even as its own form of self-care.
“I think finances is huge, right? Because money can't buy happiness, but it can buy a bigger house and it can provide some stress relief of not feeling like we're always pinching pennies… even though things are not super great, I'm still making forward movements. So, in these couple months, I haven't really been able to pamper myself or do anything that I really want to do for me. But paying my bills on time is equivalent to that for me. And I know that there's a cut-off point and you have to understand that, that's still not self-care, but understand that it is the less second thing...one less thing that I have to worry about and that to me is self-care.”
Relationship Between Child Symptoms and Parent Stress
Many parents outlined a reciprocal relationship between their child’s behavioral and emotional symptoms and their own stress and mental health (Table 3). Parents described stress and frustration related to managing their child’s symptoms as well as others’ reactions. Some parents also described how their child responds to their stress.
Parents reported stress from their child’s hyperactivity symptoms, as they frequently observe their child engage in activities that may result in physical harm.
“There are things I can’t do as I see my other family members going out with their children do. They go out and enjoy their time. They walk calmly. They give them something and they are easily entertained. With mine it’s harder to do that. Mostly because of the worry that…something may happen to him... Because I always have to watch him. Any little thing or a minimum carelessness, and something can happen to him. He falls because he jumps too much. I think that’s what has caused me all of this stress.”
Parents also reported stress related to constant management of their child’s symptoms and worry about both what will happen at home and how they will do in school.
“Everybody's being mean when he doesn't get his way. There's no talking to him. Everything that I do, I am bending over backwards. We're walking on eggshells. We can't do anything here without him being happy. Everything has to go his way. Every day, I have to promise him something, from school, something that he wants — roller skates, a bicycle, a skateboard, a scooter, bubble gum, cotton candy… so he does good in school because he will go off on them in school and then I would have to pick them up and I can't because I have things I have to do.”
Many parents reported stress related to managing their child’s ADHD symptoms in public spaces or during everyday tasks (e.g., shopping, taking public transportation). Some parents even described disengaging from activities in public because of the high levels of stress surrounding these situations.
“And when we do, like I said, the ice cream parlor somewhere that we'd like to do, that's something that we all like to do. But you go, you have a good time, and then it's time to go. Now, you're kicking out in the street, you're making a big scene. Then, you're in the car, you're kicking my car, so the back of my chair, I can't drive. We're not going. You know what I mean? We're not going, we're just going to be home. So, those things are so frustrating. They're so frustrating.”
Similarly, parents described the negative emotional impact from criticism of other adults about their child’s behavior compared to the behavior of neurotypical children.
“It’s every time. Then they start with the comparisons. ‘Look at so and so. He’s the same age. Look at how well behaved he is. Why can’t your son stay in the table to eat? Why he has to sit on the floor?’ It’s simple little things that maybe don’t mean anything and I’m just taking it that way. It does affect me every time.”
A few parents also described the physical effects of chronic stress related to managing their child’s behavioral and emotional challenges.
“I know it's stressful because at one time I kept getting this chest pain and my doctor said…it's stress. I said yeah that's him yelling at him all day and trying to make him do this and do that and stuff… it’s like I don’t get no break with him.”
Some parents describe the use of planned ignoring as both a symptom management strategy for their child and as important for their own mental health.
“Ignoring him, and blocking him out, and paying no mind for the sake of my own sanity. I'm not going to allow him to drive me crazy because I cannot be drove crazy because I am a single mother. You and your sister need me to be as sane as possible. Me along with your little three-year-old self to take me out of character, it ain't going to happen. I'm going to ignore you. He'll slam his door. I can do the same thing too, [Child Name]. I could slam my door harder. I can scream louder. I can roar louder. That's just my way of reprimanding my children.”
Many parents outlined a reciprocal relationship between their own stress and their child’s behavioral and emotional symptoms.
“Sometimes like, I can see the look on her face, like, when I tell her, like, ‘Get out of my room,’ like, her face just drops. And I don't like that feeling, but it's just…sometimes, it's, it becomes too much…And right about now, I cannot do that. Like, I just wanna rest. Like, I can't do the bouncing...if you can't sit still, then...you can get out. And the look she gives me is just, like, I just crushed her soul. But, I mean...it gets that way sometimes. I think when it's at the point where she and I are both escalated, because like she's having difficulty regulating and I can't regulate her so now I'm feeling dysregulated, I think in those moments like she's very much a child who needs connection…so being able to like give her a hug, squeeze her and then take space is good, you know, we'll say like when you're ready to talk to mommy, you can come back and usually within like four minutes she's like I'm ready. And that's given me just enough time to like get it back together and then kind of manage both of our feelings.”
A few parents described that their own mental health treatment helped them to take better care of their child’s mental health.
“And if I’m up like this, my son is up like this. You know? So, now I have my therapy and psych, so I’m leveled out. So, since I’m leveled out, now I have to get my son leveled out.”
Discussion
This study aimed to deepen our understanding of the known association between adverse SDH and symptoms of ADHD through interviews with parents of preschoolers with emerging ADHD symptoms. Thematic analysis of parent interviews supported three key domains (unmet social needs, ADHD symptomatology, and parent stress and wellbeing) with bidirectional impacts on one another that help to explain the associations seen in the literature. Parents in our study describe how child ADHD symptoms further impact parent stress and mental health, and how having a child with ADHD creates additional needs and additional financial strain. Importantly, our findings do not suggest that unmet social needs or parent stress cause ADHD, but rather that these conditions both exacerbate and are exacerbated by emerging ADHD symptoms in young children. While existing literature has explored the bidirectional associations between ADHD and SDH, this is the first study to our knowledge that delves into the parent-reported mechanisms by which these three core domains interconnect to mediate this association in preschoolers. This data contributes critical information to the question of what early interventions could do to improve the trajectory of preschoolers with emerging ADHD who are more difficult to treat with existing evidence-based treatments.
Although we were interested in whether certain specific needs would be more important than others in the critical preschool age group, parents often described these needs as intersecting and interrelated in the context of financial hardship. Often, parents would not describe one unmet need in isolation, but a web of interconnected needs that could not all be met at once. Importantly, they described how the difficulty meeting these needs specifically impacted their child more because of ADHD symptoms, or correspondingly how these needs were made greater due to the child’s symptoms. For example, parents discussed their child needing more space, a higher quality and structured school, a more skilled childcare provider, more food, more attention, more family support, more health care, and more activities to support their symptom management and development. Correspondingly, they discussed how their child’s symptoms were magnified by lack of structure and activities, space to be physically active, therapeutic support, educational support, personal attention, and food choices. Our findings suggest that parents of preschoolers with ADHD symptoms could benefit from additional resources and benefits to alleviate some of these needs as part of an early intervention plan.
There is additional quantitative literature supporting the economic burden of raising a child with ADHD [26, 34]. Zhao et al. [34] estimated that raising a child with ADHD incurs a financial burden that is five times greater than raising a child without ADHD, resulting from costs of services including medical care and special education as well as income loss due to missed parent workdays related to the child’s symptoms. The estimated annual societal excess costs of $19.4 billion for children with ADHD, with $2.7 billion due to extra caregiving costs [26]. Moreover, evidence suggests that families of children who are younger at diagnosis experience greater financial burden related to ADHD [15, 34], emphasizing the importance of social programs for families of very young children with ADHD to reduce both the short- and long-term financial impact of ADHD and prevent the accumulation of unmet social needs.
Parents reported many examples of both unmet social needs and child ADHD symptoms worsening their own stress and wellbeing. While the reverse relationships were also noted (stress exacerbating unmet social needs and child ADHD symptoms), descriptions of the former relationships predominated in parent interviews where they discussed their own mental health. Parents discussed the stress of financial hardship and having to choose which needs they could prioritize for their family and which they could not. They also discussed stress related to specific unmet needs, including transportation and commuting, obtaining enough food for their family, inadequate housing and space, under-resourced school or daycare, covering utilities, accessing healthcare, and neighborhood climate. In addition, parents discussed not only how their child’s symptoms caused stress and frustration, but also how this stress was exacerbated by difficulty meeting their child’s needs because of the complications of their ADHD symptoms. As one example, a small apartment was more difficult for a child with hyperactivity and behavioral challenges, and the resulting complaints of neighbors and difficulty managing the child in this setting without feeling safe out in the neighborhood or being able to pay for outside activities and entertainment created stress for parents. While literature has suggested an important link between parent mental health and wellbeing and ADHD symptoms [28], the impact of child ADHD symptoms combined with financial hardship and unmet social needs has been underrecognized. These findings suggest that funding social programs for low-income parents of preschoolers with ADHD symptoms, including extracurriculars, high quality schools, child-friendly housing with adequate play space, and cash interventions, could improve both parent stress and child symptoms, and could be a candidate early intervention strategy for this population. Furthermore, our data does suggest that detecting parent mental health concerns and providing referrals and connections to treatment could be an important part of treatment for preschoolers with ADHD symptoms.
Our study refutes the idea that the association between ADHD and SES is related to a phenocopy of ADHD arising from early exposure to violence and abuse [33]. The parents we interviewed, who readily discussed any connections among unmet social needs, parent mental health, and ADHD symptoms, did not describe any particular adverse experiences as causal of their child’s symptoms and rather described unmet social needs and their own stress as exacerbating the child’s symptoms as well as the other way around. Parents also did not directly make connections between traumatic experiences and ADHD symptoms. While our interpretation is limited by what parents were willing to discuss with us and the questions in the interview guide, the many connections they drew between these constructs without discussion of a connection between trauma and ADHD suggests that the phenocopy theory is not the only reason for the association between ADHD and socioeconomic disadvantage.
Limitations of our study include the use of convenience sampling, single site design at one urban safety net hospital in the Northeast US, and participant population that was predominantly Black and Hispanic/Latine. Therefore, our study may not generalize to other populations, and additional multisite qualitative research could help to understand the generalizability of these findings. In addition, we did not conduct diagnostic evaluations for ADHD but rather used preexisting clinical diagnosis or the ADHD-RS-IV-Preschool Version 80th percentile cut-off for inclusion criteria. This limits understanding of the clinical characteristics of our sample, and some symptoms described in the interviews by parents may be due to conditions other than ADHD. Our study included some quantitative data collection but did not include collection of adverse childhood experiences on children or parents. In addition, our study began prior to the COVID-19 pandemic and was completed in the early phase of the pandemic. It has been noted in the literature that the pandemic resulted in worsened parent and child mental health due to several factors, such as change in environment, disrupted routines, and limited access to care [32], which may have impacted some of the results. Finally, our findings are limited by what we asked parents in our interview guide and by what parents felt comfortable discussing during the interview.
Our study had several strengths. We used rigorous qualitative methodology to address a gap in knowledge about the connection between ADHD symptoms and socioeconomic disadvantage that could help direct early intervention development to reduce disparities. Most participants were low-income and from minoritized racial and ethnic groups in the US, including participants who did not speak English or spoke a different primary language, many of whom were immigrants to the United States. Thus, our study lifted up the voices and diverse perspectives from families often not included in research, who were experiencing high levels of unmet social needs and financial hardship. This sample selection was critical for our goal to use the findings to develop an early intervention to reduce inequities in ADHD care.
Conclusion
This qualitative study describes the complex interrelationships between SDH, child ADHD symptomatology, and parental stress for families experiencing financial hardship. Our findings not only underscore the importance of early access to care for children with emerging ADHD living in low-income households, but suggest that early intervention to address unmet social needs in the child’s environment and support parent mental health could be tested to improve symptom trajectories in preschoolers with emerging ADHD.
Declarations
Conflict of Interest
The authors declare no competing interests.
Ethical Statement
This research was approved by the Boston University Medical Campus Institutional Review Board on October 31, 2018.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
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“The Way the System is Working Out, It's Not Working at All”: Parent Perspectives on Social Determinants of Health and ADHD Symptoms in Preschoolers
Auteurs
Andrea E. Spencer Tierney P. McMahon Ren Mondesir Nadia Garriga-Cerni Meera Savage Madeline C. Smith J. Krystel Loubeau Jennifer Sikov Imme Kobayashi Jasleen Singh Rohan Dayal Valeria Ladino Christina Borba Arvin Garg Michael Silverstein