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Child ADHD and anxiety: Parent mental health literacy and information
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Article in Child & Family Social Work · March 2022

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Child ADHD and Anxiety: Parent Mental Health Literacy and Information Preferences

Dylan Davidson, M.A.1, Kristin Reynolds, Ph.D.1, Jennifer Theule, Ph.D.1, Steven Feldgaier, Ph.D.2
1
University of Manitoba, Department of Psychology
2
University of Manitoba, Department of Social Work

This is the pre-peer reviewed version of the following article: Davidson, D., Reynolds, K., Feldgaier, S., &

Theule, J. (2022). Child ADHD and anxiety: Parent mental health literacy and information preferences.

Journal of Child and Family Studies. https://doi.org/10.1111/cfs.12915, which has been published in final form

at https://onlinelibrary.wiley.com/doi/10.1111/cfs.12915. This article may be used for non-commercial

purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions.

Author Note

Data Availability Statement: The data that support the findings of this study are available from the

corresponding author upon reasonable request.

Funding: This project was supported by the Joseph-Armand Bombardier Canada Graduate Scholarship and

the University of Manitoba.

Conflict of Interest: None to declare.

Ethical Approval: This project was approved by the University of Manitoba Research Ethics Board

(#P2018:106 (HS22223)).

Patient Consent: Informed consent was obtained from all patients included in this research.

Correspondence concerning this article should be addressed to Dr. Kristin Reynolds, University of

Manitoba, Department of Psychology, P313 Duff Roblin, 190 Dysart Road, Winnipeg, MB, Canada, R3T 2N2, E-

mail: [email protected]
PARENT MENTAL HEALTH LITERACY 2

Abstract

This research explored parents’ mental health literacy (MHL) skills (i.e., recognizing symptoms, identifying

effective help-seeking strategies) for child attention-deficit/hyperactivity disorder (ADHD) and anxiety, factors

associated with their MHL, and preferences for receiving information about each disorder. N = 128 parents were

recruited from community organizations to participate in an online survey. Parents were randomly assigned to read

one vignette depicting a child with symptoms of ADHD or anxiety. They were asked to identify the depicted

problem and rate the helpfulness of potential help-seeking strategies (i.e., different health professionals,

medications). They also completed measures of parental self-efficacy and parenting stress, and indicated information

preferences for learning about symptoms and treatment. Parents scored just above the mid-range on a measure of

their MHL skills, with no significant difference between parents responding to the ADHD and anxiety vignettes.

Stronger MHL was associated with being a mother, having personal, family, or friend-related mental health

experience, and stronger parental self-efficacy. Parents were interested in receiving more information about child

ADHD and anxiety via health provider or written format. Results are valuable for informing future MHL

intervention efforts to educate parents about symptoms and treatment for common child mental health problems

such as ADHD and anxiety.

Keywords: mental health literacy, child mental health, ADHD, anxiety, information preferences
PARENT MENTAL HEALTH LITERACY 3

Child ADHD and Anxiety: Parent Mental Health Literacy and Information Preferences

Introduction

Mental health literacy (MHL) is defined as “knowledge and beliefs about mental disorders which aid their

recognition, management, or prevention” (Jorm, et al., 1997). Research monitoring public MHL has generally been

concentrated toward two components of MHL that are critical to seeking professional treatment: 1) the ability to

recognize when a mental health problem is developing (or has developed); and 2) knowledge about the helpfulness

of interventions (as well as help-seeking preferences) (Reavley et al., 2014; Reavley & Jorm, 2011). Promotion of

these MHL skills in the public carries multiple benefits, including improved social attitudes and helping behaviours

toward individuals with mental health problems, more positive perceptions regarding seeking professional help,

institutional investment in resources that is commensurate with the negative impact of mental health problems, and

effective management of mental health problems by patients and their caregivers (Bond et al., 2015; Brijnath et al.,

2016; Jorm, 2012; Morgan et al., 2018).

Mental health problems are some of the leading causes of disability among children and adolescents

worldwide, with international prevalence among children and adolescents ranging from 10-20%, and half of these

disorders developing by age 14 (Kessler et al., 2005; Polanczyk et al., 2015; Stockings et al., 2016; World Health

Organization, 2021). Recent literature suggests that the public’s difficulty in recognizing symptoms of specific child

mental health problems, as well as limited knowledge about how to best access help, may decrease likelihood of

intervention in childhood, which is vital to reducing chronic trajectories for these problems (Tully et al., 2019).

Given their influence on and proximity to their children, parents are uniquely positioned to address these challenges

by recognizing early symptoms of mental health problems in their child, and facilitating their child’s access to

treatment (Bonanno et al., 2021; Frauenholtz et al., 2015; Mendenhall & Frauenholtz, 2015; Yap et al., 2016). Thus,

there is a need to increase the relevance of available information about child mental health to parents (Jorm et al.,

2007) by addressing their unique information needs and barriers to strengthening their MHL skills (Tully et al.,

2019).

However, limited research has explored parents’ MHL skills for recognizing and seeking help for child

mental health problems, factors associated with their MHL skills, as well as their unique information needs for

strengthening these skills. This research sought to aid in filling these literature gaps in the context of: 1) child

attention-deficit/hyperactivity disorder (ADHD); and 2) child anxiety. Given that ADHD and anxiety have the
PARENT MENTAL HEALTH LITERACY 4

highest prevalence across child mental health problems (Polanczyk et al., 2015), it is critical for parents to be able to

recognize symptoms and effectively seek help for these common problems.

Problem Recognition & Help-Seeking Skills

Recognition of Symptoms of Mental Health Problems

Early recognition of symptoms and subsequent treatment of mental health problems can minimise their

impact on social and educational functioning (Patel et al., 2007). ADHD is defined by symptoms of

inattention/disorganization (e.g., difficulty concentrating on a task and/or listening), and/or hyperactivity-impulsivity

(e.g., overactivity, fidgeting, difficulty remaining seated or waiting) that are disproportionate to the individual’s age

or developmental level (American Psychiatric Association [APA], 2013). Anxiety disorders involve excessive fear,

worry, and/or maladaptive avoidance behaviours. One common anxiety problem among children is generalized

anxiety disorder (GAD), which is defined by symptoms of persistent, excessive, and uncontrollable worry about

various domains (e.g., school or sports performance, natural disasters) (APA, 2013).

Some research suggests that parents skills for recognizing symptoms of common child mental health

problems are inconsistent for detecting symptoms warranting intervention, and that parents lack confidence in these

skills (Frauenholtz et al., 2015; Moses, 2009). For example, a set of three studies by Lagattuta et al. (2012) evaluated

parent-child agreement in perceptions of the child’s emotions, worry, and anxiety. They found that parent and child

reports consistently did not correlate, suggesting that parents underestimated their child’s worry and anxiety. Similar

findings regarding parent–child agreement have been observed for symptoms of GAD and other anxiety problems,

wherein parents often report fewer severe symptoms than their children (Cosi et al., 2010). Relatedly, a survey of

over 2000 Australian parents found that only 35% were confident in their ability to recognize symptoms of a mental

health problem in their child (Royal Children’s Hospital, 2017).

Knowledge and Beliefs about Treatment

Recognizing symptoms of a mental health problem is often the first step toward parents’ consideration of

seeking professional help for their children (Gulliver et al., 2010). Recommended treatments for child ADHD

include behavioural interventions (i.e., parent psychoeducation/training, classroom management, and peer

interventions), as well as psychostimulant medications (Evans et al., 2018; Felt et al., 2014). For anxiety in children,

psychological treatment – particularly variations of cognitive behaviour therapy (CBT; including strategies such as

cognitive restructuring, exposure, and relaxation) – is recommended as a first-line treatment; when this is
PARENT MENTAL HEALTH LITERACY 5

ineffective, pharmacological intervention via selective serotonin reuptake inhibitors (SSRIs) may be recommended

in combination with psychotherapy, although their use with children presents some risk for safety concerns (e.g.,

insomnia, suicidality) and should be monitored closely (Katzman et al., 2014)

When parents are seeking mental health support for their children, some research suggests that favouring

advice from informal sources of help such as family and friends over professional support is common (Frauenholtz

et al., 2015; Jorm & Wright, 2007; Tapp et al., 2018). For instance, Reardon et al. (2020) investigated parent

willingness and barriers to seeking help for 222 children ages 7-11 with elevated anxiety symptoms. In 38.4% of

cases, parents reported that their child had received professional support for managing anxiety, although less than

3% had accessed evidence-based treatment. Parents’ most common reported barriers to accessing help for their

children included difficulty differentiating between developmentally appropriate and clinically significant anxiety,

lack of awareness regarding how or where to seek help, limited service access, and potential negative consequences

of seeking help (e.g., feeling a sense of blame for their child’s problem, not wanting their child to think they have a

problem). Parents who had not sought help for their children were more likely to report thinking the anxiety may

improve without professional support. These factors collectively present a significant barrier for parents in accessing

mental health services for their children.

Potential Factors Associated with Parent MHL

The outlined research findings serve as the impetus for clinicians and researchers to engage parents in

strengthening their MHL skills through increased exposure to evidence-based information on the symptomatology

and treatment of child mental health problems. Data regarding sociodemographic and experiential factors associated

with MHL among parents is still emerging in the literature (Hurley et al., 2020). One useful example is research by

Mendenhall and Frauenholtz (2015), who found that parents of children with mood disorders obtained scores

slightly above the mid-range (M = 56.5%) on a self-report questionnaire on their knowledge of mood disorders, and

higher on their self-report questionnaire on their knowledge of treatment for mood disorders (M = 74.2%). They also

evaluated potential factors associated with MHL among these parents, finding that stronger MHL was associated

with being female, being White, having higher education, having older children, and having personal experiences

with a mood disorder or mental health services. Previous research has also demonstrated a link between stronger

MHL and female gender (Dey et al., 2015; Pescosolido et al., 2008; Turner & Mohan, 2015), higher level of

education (Fisher & Goldney, 2002; Reavley et al., 2014), and personal mental health experiences (Cutler et al.,
PARENT MENTAL HEALTH LITERACY 6

2018; Teagle, 2002). Expansion of Mendenhall and Frauenholtz's (2015) work by including factors directly

impacting parenting ability, and in the context of other common child mental health problems such as ADHD and

anxiety, is necessary for identifying barriers to strengthening parent MHL skills.

Parenting Stress and Self-Efficacy

The demands of parenting may impact parents’ ability to devote time and resources to learning about child

mental health problems and developing effective MHL skills. Abidin’s (1995) model of parenting stress posits that

parenting stress results from a combination of child characteristics (e.g., temperament, health status) and parental

functioning. Common parenting stressors may include economic anxiety, acculturation, child health problems,

single parenthood, and number of children (Reardon et al., 2017; Umpierre et al., 2015). While these daily parenting

stressors may possess little significance on their own, a substantial body of research has demonstrated that their

cumulative impact over time can precipitate more notable consequences on the parent-child relationship and the

child’s adaptive functioning (Bayer et al., 2006; Rodriguez, 2010). Another common source of parenting stress is a

perceived lack of self-efficacy in one’s parenting ability (Bloomfield & Kendall, 2012). Self-efficacy is defined as

“people's beliefs about their capabilities to produce designated levels of performance that exercise influence over

events that affect their lives” (Bandura, 1994, p.71). Bandura (1997) asserts that individuals high in parental self-

efficacy are able to more effectively guide their children through their development without serious problems, while

those low in parental self-efficacy may struggle to meet these demands. Stronger parental self-efficacy is linked to

raising a child in a healthy and nurturing developmental environment (Gilmore & Cuskelly, 2009), responsiveness to

child needs, and active parent-child interactions (Coleman & Karraker, 1998). Further, reduction of parenting stress

and increased parental self-efficacy have been shown to be associated with more effective outcomes in parent

training programs, such as for management of child behavioural problems (Kazdin & Whitley, 2003). However, to

our knowledge, prior research has not evaluated the effects of parenting stress and self-efficacy on MHL. These

potential relationships warrant further investigation as barriers to parents’ capacity for strengthening and enacting

their MHL skills to protect the wellbeing of their children.

Information Preferences for Child Mental Health

There is promising evidence that MHL can be strengthened within communities over time (Bond et al.,

2015; Furnham & Swami, 2018; Goldney et al., 2009; Jorm et al., 2006; Reavley & Jorm, 2011), but efforts are still

underway to develop MHL interventions that more directly resonate with critical populations such as parents, who
PARENT MENTAL HEALTH LITERACY 7

may have unique needs or preferences for integrating this information into their lives (Hurley et al., 2020; Jorm,

2012; Tully et al., 2019). Numerous resources have been developed in multiple formats to educate parents about

child mental health problems. For example, the Internet is a major source of information for child mental health

problems; however, research has shown that these resources are often of low quality and user-unfriendly despite

their popularity (Jorm, 2012; Reynolds et al., 2015). Additional research is needed to further clarify the best

modalities through which to reach parents and foster their engagement in strengthening their MHL skills.

Objectives

As outlined above, there are several research gaps pertaining to MHL among parents. Limited research has

evaluated rates of MHL among parents to determine the strength of their skills in recognizing child mental health

problems and accessing appropriate treatment. Further, specific factors associated with core MHL skills among

parents require further exploration in the literature. Finally, to improve practices for communicating contemporary

research knowledge to parents, there is a need to highlight their information preferences for learning about child

mental health problems and treatment. In light of these gaps in the literature, this research comprised three primary

objectives. Objective 1 was to evaluate the strength of MHL among parents of school-aged children in terms of: a)

their ability to recognize child ADHD and anxiety; and b) identify effective courses of action for help-seeking and

treatment for these problems. Objective 2 was to determine the extent to which each of the following variables

would be associated with MHL: parental self-efficacy, parenting stress, parent gender, education, parenting

experience, and having personal/friend/family-related experiences with mental health problems. Objective 3 was to

better understand parents’ preferred amount and sources of information to learn about child ADHD and anxiety.

Method

Participants and Procedure

Parents with at least one child ages 4-12 were recruited for participation in this research from October

2018-February 2019. A total of 148 participants responded to the survey; 20 were excluded from analyses due to

missing data beyond demographics, low effort responding (i.e., only selecting responses at one anchor point), and

unusually short or long response times (i.e., less than five or more than 45 minutes), resulting in a total of N = 128

participants. Recruitment was facilitated through community-based family and cultural (e.g., Indigenous, Jewish)

resource centres in [location blinded for peer review]. These organizations advertised the study to their user bases

via email, paper/electronic flyer, newsletters, and/or social media posts. The advertisement notified parents of an
PARENT MENTAL HEALTH LITERACY 8

opportunity to participate in an online survey gathering information about parents’ knowledge and beliefs regarding

child health problems and treatment. Participants followed a link to the informed consent form and online survey

hosted on the Qualtrics platform.

The online survey began by measuring parents’ demographics and whether they or a close friend or family

member had previously experienced a mental health problem. Parents were then randomly assigned to read one

vignette depicting a child with symptoms of either ADHD or anxiety and responded to follow-up items that gauged

their ability to recognize and identify effective treatments and help-seeking behaviours for the depicted problem.

They then indicated their preferences for receiving information about the depicted problem and self-rated their

knowledge of symptoms of child mental health problems and treatment. Finally, they completed measures of

parental self-efficacy and parenting stress. The median survey completion time was 18.05 minutes. Participants

received $5 in compensation and were entered into a raffle for a chance to win one of two $50 Amazon gift cards.

Measures

Mental Health Literacy Scales (Reavley et al., 2014) (Adapted)

MHL was evaluated using a vignette-based approach. Specifically, the MHL scales created by Reavley et

al. (2014) – which include a range of vignettes depicting adults with mental health problems (e.g., depression, post-

traumatic stress disorder, schizophrenia) – were adapted to instead depict an eight-year-old boy experiencing either

ADHD or anxiety (see Appendix A). These adapted vignettes were created by the research team, which includes

child mental health experts with significant clinical, research, and community-based experiences. The adapted

vignettes were written to satisfy the diagnostic criteria for ADHD and GAD, respectively, according to the

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (APA, 2013). The vignettes were also written

for equal accessibility with respect to reading ability (Flesch-Kincaid reading levels of grade 7) and length (ADHD,

85 words; anxiety, 96 words), as well as similar length and structure to Reavley et al.’s (2014) original vignettes

(which ranged from 79 words for depression to 188 words for schizophrenia).

Reavley and colleagues’ (2014) MHL Scales are a revised version of scales that have been used in seminal

MHL research (Jorm et al., 1997; Reavley & Jorm, 2011) since the field’s emergence. They have demonstrated good

construct validity due to links between the composite MHL score and sociodemographic variables (age, gender

education) being in line with those seen in past research, as well as participants with more contact with mental

health problems (mental health professionals, those with a close friend or family member with a mental health
PARENT MENTAL HEALTH LITERACY 9

problem) having higher composite MHL scores (Reavley et al., 2014; Wei et al., 2015). The MHL scales were

deemed to be the best fit for the present research due to the ease and flexibility of adapting the vignettes to depict

child mental health problems using similar follow-up evaluation criteria. A Kuder-Richardson 20 analysis (Kuder &

Richardson, 1937) revealed good internal consistency for the adapted vignettes and response items used in the

calculation of participants’ MHL scores (ADHD, α = .88; anxiety, α = .89). Further, participants’ MHL scores were

strongly correlated with more positive views toward help-seeking (r = .67), and moderately correlated with female

parent gender (r = .37). These variables have consistently shown to be associated with MHL in past research.

providing support for convergent and construct validity for the adapted MHL scales in this research.

As in Reavley et al.’s (2014) original scales, after reading the vignette, participants were asked to enter text

indicating what, if anything, they believed was wrong with the child. This question evaluated their strength at

recognizing either ADHD or anxiety, depending on which vignette they read. Recognition of the problem for the

ADHD vignette was determined based on reference to some form of attentional difficulties or hyperactivity.

Recognition of the problem for the anxiety vignette was determined based on reference to some form of anxiety or

worry. Use of diagnostic labels (i.e., ADHD or GAD) was not required for participants to be considered as correctly

identifying the problem. Regardless of whether participants recognized the problem the child was experiencing, they

were then provided an extensive list of help-seeking and treatment options and asked to indicate for each option if it

could be helpful (measured categorically, as helpful, unhelpful/harmful, neither, or depends) if the depicted child’s

parents employed each of these strategies. These sources of help for the child included: different health professionals

(e.g., family doctor, counsellor, psychiatrist, psychologist, naturopath, social worker); individual medication types

(e.g., antidepressants, benzodiazepines, psychostimulants); self-help strategies (e.g., exercise, meditation, changing

diet); and other forms of support (e.g., religious support, educational aide, electroconvulsive therapy). Minor

modifications were made to some of Reavley et al.’s (2014) items with respect to cultural inclusivity (e.g., inclusion

of Imams and Elders as additional examples of religious support) and better fit with the child and family context

(e.g., removing alcohol use as a potential strategy).

A composite MHL score was calculated based on parents’ ability to recognize the depicted problem (1

point), as well as their beliefs about the helpfulness/harmfulness of different interventions and coping strategies for

the problem (1 point for each correct identification of a helpful or harmful response to the depicted problem).

Correct help-seeking responses were determined by the research team based on responses endorsing evidence-based
PARENT MENTAL HEALTH LITERACY 10

treatment and help-seeking strategies for each disorder (e.g., educational aide for ADHD, psychologist). Labelling

help-seeking options meeting this criterion as helpful led to one additional point each. Labelling other options not

meeting this criterion (e.g., natural remedies, certain medications, religious support) as helpful did not lead to a

reduction of points.

Familiarity with Child Mental Health

Two items were created for this research, which asked to self-rate on a 5-point scale how familiar (1 = not

at all familiar, 5 = very familiar) they consider themselves with: a) the symptoms of child mental health problems;

and b) the types of help and treatment available for mental health problems. This aided in evaluating parity between

scores on the MHL scales and their subjective self-ratings.

Information Preferences

Parents were asked to indicate their information preferences for the problem depicted in the vignette.

Specifically, they indicated on a 5-point scale the amount of information (1 = none, 5 = a great deal (3-6 pages of

detailed information)) they would prefer to receive about different treatment options (i.e., medication,

psychotherapy, self-help strategies) for child ADHD or anxiety. They also indicated on a 5-point scale the extent to

which they would prefer (1 = not preferred, 5 = extremely preferred) to receive this information in several formats

(e.g., a website, discussion with a health care provider). These items have been used in prior research by authors in

our group to evaluate information preferences (see [three studies blinded for review]).

Parenting Sense of Competence Scale (PSOC; Gibaud-Wallston & Wandersman, 1978)

As a measure of parental self-efficacy, this research utilized Gilmore and Cuskelly’s (2009) improved

three-factor solution for the PSOC, including: Satisfaction; Efficacy; and Interest. Satisfaction involves “the quality

of affect associated with parenting or the degree of satisfaction associated with the parenting role” (Johnston &

Mash, 1989, p. 251). Efficacy involves “the degree to which a parent feels competent and confident in handling

child problems” (Johnston & Mash, 1989, p. 251). Interest reflects the parent’s level of engagement in the parenting

role (Gilmore & Cuskelly, 2009). In line with Gilmore and Cuskelly’s (2009) recommendation to remove three

items due to some low factor loadings, these items were removed, for a total of 14 items. Parents rate the extent to

which they agree with each statement regarding their parenting experiences on a six-point scale (1 = strongly

disagree, 6 = strongly agree). Internal consistency for the revised PSOC factor structure has been found to be
PARENT MENTAL HEALTH LITERACY 11

acceptable (mothers, α = .75; fathers, α = .79) (Gilmore & Cuskelly, 2009). Internal consistency was similar in the

present research, (mothers, α = .78; fathers, α = .73).

Parenting Daily Hassles Scale (PDH; Crnic & Greenberg, 1990)

The 20-item PDH is a measure of parenting stress resulting from everyday parenting experiences and

parent-child interactions. Each item presents a common parenting stressor (e.g., difficulty finding privacy, children

not doing what they are asked). Parents rate the frequency of stressor occurrence on a 4-point scale (rarely,

sometimes, a lot, or constantly), as well as the intensity of that stressor on a 5-point scale (from no hassle = 1 to big

hassle = 5). Scores on this measure can indicate whether a parent’s stressors are due to difficulties associated with

meeting the ordinary needs of their children (Parenting Tasks subscale), or due to perceived difficult behaviour in

their children (Challenging Behaviour subscale). Together, these two factors account for 86% of the variance in the

PDH, and are typically the focus of statistical analyses, because they produce the most meaningful findings (Crnic &

Greenberg, 1990). Internal consistency for these subscales was strong in the present research: Parenting Tasks, α =

.88; Challenging Behaviours, α = .86.

Analysis

Objective 1: Evaluate Parent MHL Skills

A one-way between-subjects analysis of covariance (ANCOVA) was conducted to evaluate mean

differences in participant responses between ADHD and anxiety in terms of composite MHL scores, while adjusting

for parenting experience (number of children and age of their oldest child). These variables were included as

covariates in consideration of the natural exposure to mental health information that parents might receive through

parenting experience. A Pearson correlational analysis identified additional covariates to include in the ANCOVA.

Significant moderate correlations were found between MHL and parent gender (r = .37) and mental health

experience (r = .38). Thus, these variables were also included as covariates. An additional Pearson correlation

analysis was performed to determine parity between parents’ self-rated MHL and their total MHL scores.

Objective 2: Determine Factors Associated with Parent MHL

A linear multiple regression analysis was performed to determine the impact of parental self-efficacy,

parenting stress, age, parent gender, level of education, and mental health experience on MHL. As the composite

MHL score was primarily derived from parents’ perceptions surrounding treatments and help-seeking strategies, a
PARENT MENTAL HEALTH LITERACY 12

logistic regression analysis was also performed to determine factors associated with correct recognition of the

problems depicted in the vignettes. The results of all analyses were evaluated using a significance level of α = .05.

Objective 3: Identify Parents’ Information Preferences

Descriptive analyses aided in determining the amount of information parents prefer to receive about ADHD

and anxiety, as well as their preferred sources of information.

Results

Sample Characteristics

Table 1 provides a full list of demographics and sample characteristics. The sample was generally

comprised of younger parents (M = 35.17, SD = 6.11, Range = 23-53) and was largely female (71.9%), with 23.4%

identifying as male, and 3.1% identifying as non-binary. The sample was well-educated, with 83.6% having attained

some form of post-secondary education. Seventy seven percent of the sample identified as White. Two-thirds of the

sample (65.6%) indicated that they personally experienced or had known a close friend or family member who had

experienced a mental health problem. Only 15.6% of parents indicated that one of their children had ever

experienced a mental health problem. Table 2 provides a list of primary outcome scores. Parents’ MHL scores (total

scores out of 20) averaged to just above the mid-range, regardless of whether they responded to the child ADHD (M

= 12.67, SD = 4.28) or anxiety (M = 11.64, SD = 4.2) vignette. The sample collectively demonstrated moderate

parental self-efficacy (M = 56.4/84, SD = 9.7). The sample also demonstrated low-to-moderate parenting stress in

terms of frequency (M = 42.59/80, SD = 11.16) and intensity (M = 44.67/100, SD = 17.65) of stressors, as well as

specifically for parenting tasks (M = 17.6/40, SD = 7.39) and challenging behaviours (M = 16.52/35, SD = 6.44).

Objective 1: Evaluate Parent MHL Skills

For the ADHD vignette, 51.6% of parents correctly identified the child depicted in the vignette as having

ADHD, while for the anxiety vignette, 56.3% of parents correctly identified the child as having anxiety. The sample

held generally positive views toward seeking help from health professionals. More parents indicated it would be

helpful to seek aid from a general practitioner (ADHD, 70.3%; anxiety, 62.5%) or counsellor (ADHD, 69.8%,

anxiety, 82.8%), compared to a psychologist (ADHD, 59.4%; anxiety, 64.1%) or psychiatrist (ADHD, 45.3%,

anxiety, 42.2%). A notable portion of parents labelled medications as unhelpful or harmful and/or were hesitant to

label medications as helpful (i.e., neither helpful nor harmful, that it depends, or that they were uncertain). For

instance, parents responding to the ADHD vignette were divided as to whether psychostimulants (e.g., Ritalin)
PARENT MENTAL HEALTH LITERACY 13

would be helpful (23.4%), unhelpful/harmful (20.3%), that it depends (39.1%), or that they were uncertain (17.2%).

Responses were less favourable for antidepressants and benzodiazepines as potential strategies for the anxiety

vignette: Antidepressants (helpful, 7.8%; unhelpful/harmful, 25%; depends/neither, 48.4%; uncertain, 18.8%);

benzodiazepines (helpful, 7.8%; unhelpful/harmful, 57.8%; depends/neither, 25%; uncertain, 9.4%). Parents more

definitively believed in the helpfulness of receiving education about the problem from an expert (ADHD, 90.6%,

anxiety, 79.7%), as well as self-help strategies such as having the child engage in increased physical activity

(ADHD, 73.4%, anxiety, 79.7%) or a relaxation or mindfulness course (ADHD, 76.6%, anxiety, 84.4%), and doing

personal research/reading about the problem the child is experiencing (ADHD, 82.8%, anxiety, 84.4%).

Self-rated MHL

Parents were also asked to provide a self-rating on a scale of 1 to 5 of their general familiarity with the

symptoms of child mental health problems (M = 2.81/5, SD = 1.22), as well as with treatment (M = 2.67/5, SD =

1.23). A Pearson correlation analysis revealed a significant mild-to-moderate correlation between parents’ total

MHL scores and their self-rated familiarity with symptoms of child mental health problems, r = .19, p < .05. This

trend was not significant when examining parents’ self-rated familiarity with child mental health treatment and their

MHL scores, r = .15, p = .09. This suggests some parity between their more objective and self-perceived levels of

MHL.

Comparison of ADHD and Anxiety Vignettes

The statistical assumptions involved in the interpretation of ANCOVA results were confirmed prior to

beginning analyses. Table 3 displays the results of the ANCOVA. After adjusting for the inclusion of covariates in

the model, mean MHL scores for both vignette conditions were just above the mid-range: ADHD, M = 12.71/20, SE

= .46, 95% CI = 11.8, 13.62; anxiety, M = 11.66/20, SE = .47, 95% CI = 10.74, 12.59. When adjusting for number of

children, age of oldest child, parent gender, and personal/close friend/family-related experiences with mental health

problems, parents’ MHL scores did not significantly differ based on whether they responded to the child ADHD or

anxiety vignette, F(1, 119) = 2.54, p = .11, ηp2 = .02.

Objective 2: Determine Factors Associated with Parent MHL

Total MHL Score

All statistical assumptions necessary for interpreting multiple regression and logistic regression analyses

were met. Table 4 displays the results of the multiple regression analysis evaluating predictors of MHL. The entered
PARENT MENTAL HEALTH LITERACY 14

set of variables significantly predicted MHL, F(11, 102) = 5.42, p < .001, adj. R2 = .3, f 2 = .58. This suggests that

the regression model accounted for approximately one-third of the variance in parents’ MHL scores, with a large

effect. Three predictors provided significant individual contributions to the variance in parents’ MHL: Parent

gender, β = .32, t = 3.52, p < .01; mental health experience (whether personal or related to a close friend/family

member), β = .33, t = 3.79, p < .001; and efficacy (one of three subscales from the PSOC scale), β = .24, t = 3.03, p

< .01. Specifically, stronger MHL was associated with being a mother, having more mental health experience, and

stronger parental self-efficacy.

Recognition of Symptoms

Table 5 presents the results of the logistic regression analysis, which suggests that the included set of

variables collectively predicted approximately one-third of the variance in parents’ ability to recognize the problem

depicted in the vignette, χ2(16) = 36.05, p = .01, Nagelkerke R2 = .36. No significant unique contributions were

observed for most variables, with the exception of parenting interest, which was associated with a greater likelihood

of correctly recognizing the problem, B = -.35, W = 5.45, p < .05, Exp(B) = .7, CI = .52, .95.

Objective 3: Identify Parents’ Information Preferences

Parents indicated interest in receiving more information about both child ADHD and anxiety, with most

preferring to receive a lot (2 pages) or a great deal (3-6 pages) of detailed information regarding medication (ADHD,

72.6; anxiety, 64.1%), psychological treatment (ADHD, 74.2%; anxiety, 61.3%), combined treatment (ADHD, 73.4;

anxiety, 64.1%), and self-help approaches (ADHD, 61.9; anxiety, 57.4%). Parents rated different methods of

information delivery as very or extremely preferred as follows: information received through discussion with a

health provider (ADHD, 79.7%; anxiety, 70.3%); through an information sheet or booklet (ADHD, 65.6%; anxiety,

60.3%); through a recommended Internet website (ADHD, 42.2%; anxiety, 40.6%); through an Internet-based

discussion or support group (ADHD, 33.3%, anxiety, 28.1%); and through a recommended mobile phone

application (ADHD, 17.7%, anxiety, 25%).

Discussion

Implications

This research provides three principal knowledge contributions to the literature, as well implications for

future intervention efforts to strengthen parents’ MHL skills. First, on a measure of core MHL skills (symptom

recognition, identification of effective help-seeking strategies), this sample of parents scored above the mid-range,
PARENT MENTAL HEALTH LITERACY 15

with similar strength for these skills between child ADHD and anxiety. This finding bolsters the small literature base

regarding parents’ MHL skills and suggests room for strengthening these skills. Second, there is a dearth of research

exploring factors associated with parent MHL, and this study identifies being a mother, mental health experience,

and parental self-efficacy to be associated with stronger MHL skills in parents. Third, the results suggest an interest

among parents in receiving more information about child mental health, particularly via health care provider or in

written format compared to Internet or phone-based methods. These findings have value in informing the

development of interventions that are relevant, accessible, and effective for strengthening parents’ MHL skills.

Objective 1: Evaluate Parent MHL Skills

Comparing the strength of parents’ MHL skills between those responding to the ADHD and anxiety

vignettes revealed no difference between these groups when adjusting for parenting experience (i.e., number of

children and age of oldest child), parent gender, and personal/close friend/family-based experience with mental

health problems. While some research has revealed differences in the public’s knowledge and beliefs surrounding

different mental health problems (Pescosolido et al., 2008), this subject appears to be relatively unexplored among

parents. Additional research may facilitate greater understanding about which conditions parents are less

knowledgeable. Parents also provided self-ratings of their knowledge of symptoms of child mental health problems

and treatment that somewhat aligned with the mean MHL scores for the more objective vignette questionnaire (i.e.,

53-63% out of the possible total score, mild-to-moderate significant correlation between MHL score and self-rated

familiarity with symptoms). These results are similar, albeit slightly lower, to findings from Mendenhall and

Frauenholtz’s (2015) sample of parents of children with mood disorders who completed self-report questionnaires

(i.e., knowledge of mood disorders, M = 56.5%; knowledge of treatment for mood disorders, M = 74.2%).

Notably, parents’ symptom recognition rates for child ADHD and anxiety showed that only just over half

correctly identified the depicted child’s problem (ADHD, 51.6%; anxiety 56.3%). This finding reflects past research

showing low confidence in parents’ recognition ability and difficulty recognizing mental health problems in their

children (Frauenholtz et al., 2015; Lagattuta et al., 2012; Moses, 2009; Royal Children’s Hospital, 2017). The

sample expressed generally positive views toward seeking help from professionals, particularly general practitioners

and counsellors, although only just over half rated psychologists as helpful, and just under half rated psychiatrists as

helpful. These findings align with past research suggesting that parent skepticism of mental health services is

common and a significant barrier to treatment for their children (Frauenholtz et al., 2015; Reardon et al., 2020), and
PARENT MENTAL HEALTH LITERACY 16

that general practitioners and counsellors are generally viewed as more helpful than other mental health

professionals (Jorm & Wright, 2007). Views regarding the use of medication to treat the depicted child’s health

problem were less favourable, including for medications that, despite being controversial for use with children, are

at times used to treat child ADHD and anxiety (psychostimulants, antidepressants, and benzodiazepines). Past

research has similarly shown that parents commonly perceive psychotropic medications as less preferable to

psychosocial interventions, and potentially beneficial but at a high risk of danger to the child (Hamrin et al., 2010).

In contrast, general self-help strategies such as having the child engage in physical activity, relaxation or

mindfulness, and receiving education about the health problem were more consistently rated as helpful, likely due to

perceived low risk.

Objective 2: Determine Factors Associated with Parent MHL

Past research has demonstrated that increased education is associated with greater MHL (Fisher &

Goldney, 2002; Mendenhall & Frauenholtz, 2015; Reavley et al., 2014), but parents’ level of education was not

associated with their MHL score in this research. The sample in this research was highly educated, with 83.6%

having attained some form of post-secondary education. Additional research involving a parent sample with more

variation in education levels would likely reveal a relationship between higher education and stronger MHL skills.

Parenting experience, stress, satisfaction, and interest were also not associated with the strength of parents’ MHL

skills. It is possible that these factors may impact awareness and responsiveness to child mental health problems in

one’s immediate environment, but not necessarily base knowledge as measured in this research. Greater parenting

interest was associated with better recognition of the problems depicted in the vignettes, but not total MHL score. It

is possible that those able to be more invested in their parenting were more likely to provide a careful identification

of the depicted problem, whereas other parents were not able to give their responses as much time or consideration.

Factors that were associated with stronger MHL included being a mother, having stronger parental self-

efficacy, and having personal/close friend/family-based experiences with mental health problems. The relationships

found between greater MHL and being a mother, as well as having personal or relational experiences with mental

health problems, have been confirmed in other research (Cutler et al., 2018; Dey et al., 2015; Mendenhall &

Frauenholtz, 2015; Teagle, 2002; Turner & Mohan, 2015). Notably, the present research appears to be the first to

explore and identify a relationship between parent MHL and parental self-efficacy. It is surprising that we found no

association between MHL and parenting stress (i.e., parenting tasks and challenging child behaviours). However,
PARENT MENTAL HEALTH LITERACY 17

this research measured parenting stress broadly in accordance with a common model (Abidin, 1995). Given the

association between higher parenting stress and lower parental self-efficacy demonstrated in prior research

(Bloomfield & Kendall, 2012), further research exploring the relationships between specific parenting stressors

(e.g., having a child with a disability, low family income) and parent MHL is warranted. Overall, these collective

findings highlight subsets of parents (i.e., those with low confidence in their parenting skills, little or no mental

health experience, fathers) that could particularly benefit from targeted MHL intervention efforts.

Objective 3: Identify Parents’ Information Preferences

Most parents indicated interest in receiving a large amount of information about child ADHD and anxiety,

including for medication treatment, psychological treatment, combined treatment, and self-help approaches. They

indicated a strong preference for receiving this information via a health care provider (70-80%) or in written format

(60-66%), compared to the Internet (28-42%) or a mobile phone application (17-25%). The size of this gap was

somewhat surprising, as the mean age of the sample (M = 35.17 years) was fairly young. Past research has

demonstrated that adults in their 20s and 30s – particularly educated women, of which this sample was primarily

comprised – often seek health information via the Internet, even before consulting with a health care provider

(Jacobs et al., 2017). The sample was also well-educated; it is possible that several parents in the sample were more

scrupulous of the relevance and reliability of health information located on the Internet. They may also have been

skeptical of health information that is not directly provided by health professionals (e.g., a written pamphlet). These

findings suggest a need for the development of more trustworthy, evidence-based, and accessible resources for

educating parents about child mental health. For instance, recent research evidence suggests that directive and

streamlined Internet-based parenting support resources are an efficient method for mobilizing evidence-based

information about child mental health to engage parents in informed, supportive, and proactive behaviours towards

child mental health in the long-term (Cardamone-Breen et al., 2018; Yap et al., 2017). Improving the uptake of such

resources is likely to carry multiple benefits, including increased parent access to and persistence with clinical

services for their children, accessing of credible and evidence-based treatments, and reduced stigma surrounding

service access (Jorm & Wright, 2007), as well as reduced cost and burden on the health care system (Berkman et al.,

2011).

Limitations
PARENT MENTAL HEALTH LITERACY 18

One primary limitation to the present research stems from the issue that methods for measuring MHL in the

extant literature have been varied and inconsistent, making it challenging to identify an optimal method for

measuring this construct. Hundreds of original measures have been developed to measure perceptions and

knowledge of mental health problems and help-seeking attitudes, only to be unused in future research (Kutcher et

al., 2016; Wei et al., 2015). Thus, increased efforts are needed to standardize and validate measurement of this

construct. Notably, the vignette approach and measure adapted for this research has been used in seminal MHL

research (Jorm et al., 1997; Reavley & Jorm, 2011) and is one the most commonly used methods of measuring MHL

since the field’s emergence. However, due to its focus on select components of MHL, the utility of this vignette

approach, including the adapted measure employed in this research, is to provide a glimpse of parents’ MHL skills

in two key domains, rather than conduct a full-scale assessment of these skills. The items we included to capture

parents’ self-rated familiarity with symptoms of child mental health problems and their treatment partially help to

circumnavigate this limitation; however, future research is needed to evaluate parents’ MHL skills using a more

comprehensive approach to measuring this construct. Relatedly, findings regarding parents’ information preferences

for learning about child ADHD and anxiety were collected through a brief set of items used in past research

([blinded for review]) from some of the authors in our group. Thus, additional research involving wider assessment

of parents’ preferred information sources (e.g., regarding information sources such as schools) and methods for

information delivery (e.g., online courses, video series) for these and other child mental health problems would be

beneficial.

Other important considerations for interpreting the results of this research involve sample homogeneity.

Only 15.6% of this community sample of parents indicated awareness of one of their children ever experiencing a

mental health problem. Thus, a sample of parents with more children who have experienced mental health problems,

and/or who have more awareness about these problems, may have demonstrated higher scores on the vignette

measure and provided higher self-ratings of their MHL (potentially reflecting more sheer experience, and/or

increased motivation, for managing their child’s mental health problems). Additional research with parents who

endorse greater knowledge of child mental health problems, or are more closely involved with the mental health care

system, would be valuable in determining the strength of their MHL skills. Further, despite this research’s support

from diverse community organizations (e.g., Indigenous and other multicultural centres) in advertising the survey,

there was relative homogeneity with respect to the sample’s cultural and educational backgrounds (i.e., primarily
PARENT MENTAL HEALTH LITERACY 19

White and highly educated), limiting generalizability of the results. Findings from MHL research have often faced

similar challenges with cultural representativeness in particular (Reardon et al., 2017). However, cultural context

can significantly alter how mental health problems manifest, as well as needs for treatment (Kirmayer, 2001). Thus,

there is a critical need for research which elevates the voices of parents from broader cultural backgrounds in terms

of their perspectives on MHL and child mental health. This can potentially facilitate a more holistic and equitable

understanding of how parent MHL skills can be conceptualized within different cultural contexts (Furnham &

Swami, 2018; Spiker & Hammer, 2019).

Conclusion

Mental health problems are highly prevalent among children, and if left untreated, can severely impair their

functioning and lead to poor quality of life outcomes (Patel et al., 2007). Parents are the most readily available to

recognize symptoms of mental health problems in their children and direct them to mental health services (Bonanno

et al., 2021; Frauenholtz et al., 2015; Mendenhall & Frauenholtz, 2015; Tully et al., 2019; Yap et al., 2016). Thus,

strong MHL skills are highly relevant to parents’ role of protecting the wellbeing of their children. This research

found that parents scored just above the mid-range (i.e., ADHD, 63.4%; anxiety, 58.2%) for the MHL skills of

recognizing and identifying effective help-seeking strategies for child ADHD and anxiety. It was also shown that

being a mother, having personal or relational experiences with mental health problems, and greater parental self-

efficacy appear to be associated with stronger MHL skills in parents. Finally, parents expressed interest in learning

more child ADHD and anxiety, particularly from a health provider and/or in written format. Overall, the findings in

this research are informative for future MHL intervention efforts to educate parents about symptoms of and

treatment for common child mental health problems such as ADHD and anxiety. Informing and developing such

initiatives enhances parents’ understanding and responsiveness to mental health problems, and directs more parents

and their children to mental health services – key developments needed to foster improved mental health outcomes

in the generations to come.

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