ORIGINAL ARTICLE
Knowledge and Attitudes About Attention-Deficit/Hyperactivity
Disorder and Specific Learning Disorder in an Urban
Indian Population
Sayantani Mukherjee, MBBS, MD,* Henal R. Shah, MBBS, MD,*
Seethalakshmi Ramanathan, MD,†‡ and Mantosh Dewan, MD†
Abstract: Attention-deficit/hyperactivity disorder (ADHD) and specific learn-
ing disorders (SLDs) are an important cause of scholastic backwardness among
children and often go unrecognized. Few studies have examined knowledge
and attitudes toward ADHD and SLD among school-aged children. To address
this deficit, 120 school-aged children, attending a child guidance clinic in Mumbai,
were interviewed using a questionnaire that examined children’s knowledge and
attitudes about ADHD and SLD. The results were compared both qualitatively
and quantitatively with a frequently occurring medical illness, common cold. Ap-
proximately 80% to 100% of children were aware of their illness; however, a
large variation was noted in the proportion of children (15%–80%) who could
describe their symptoms, provide accurate attributions for their illness, and
identify treatment modalities. Children with ADHD reported greater control
over their illness. The study identified a significant lack of knowledge about
ADHD and SLD among school-aged children in India and discusses implica-
tions of this finding.
Key Words: ADHD, children, knowledge, SLD, stigma
(J Nerv Ment Dis 2016;204: 458–463)
A ttention-deficit/hyperactivity disorder (ADHD) (Greenhill, 2009)
and specific learning disorders (SLDs) (Tannock, 2009) are being
increasingly reported in urban India (due to rising community aware-
ness) and diagnosed, with prevalence rates of approximately 11.33%
(Venkata and Panicker, 2013) and 15.17% (Mogasale et al., 2012), re-
spectively. The 2 disorders present most often as scholastic backward-
ness in children (Haneesh et al., 2013; Karande and Kulkarni, 2005;
Loe and Feldman, 2007) and frequently occur as comorbid conditions.
Children with these disorders often recognize that they have a problem;
however, they have varying understanding of its causes, effects, and
treatment (Fox et al., 2008). Studies have identified that the knowl-
edge of ADHD is more limited as compared with SLD among chil-
dren (Brook and Boaz, 2005). Contributing to the lack of knowledge
is parental stigma arising from their child’s, which in turn can get in-
ternalized by the child (Mukolo et al., 2010). Together, self-stigma
and parental pressure on academics, driven by cultural elements,
can lead to low self-esteem and eventually other comorbid condi-
tions (Shmulsky and Gobbo, 2007), such as mood, anxiety, conduct,
learning, and substance use disorders.
Understanding the child’s knowledge and attitudes about the dis-
order can act as important avenues for secondary intervention to prevent
further disability and improve recovery. Unfortunately, there is only a
modest amount of literature in this area. This deficit inspired us to con-
duct an exploratory study to evaluate knowledge and attitudes toward
*Department of Psychiatry, Topiwala National Medical College, Mumbai, India;
†Department of Psychiatry and Behavioral Sciences, SUNY Upstate Medical Uni-
versity; and ‡Hutchings Psychiatric Center, Syracuse, NY.
Send reprint requests to Seethalakshmi Ramanathan, MD, Department of Psychiatry
and Behavioral Sciences, SUNY Upstate Medical University, 650 Madison St,
Syracuse, NY 13210. E-mail: seetha.ramanathan@omh.ny.gov.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0022-3018/16/20406–0458
DOI: 10.1097/NMD.0000000000000524
458 www.jonmd.com The Journal of Nervous and Mental Disease • Volume 204, Number 6, June 2016
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
ADHD and SLD among children who received a diagnosis of these dis-
orders. Furthermore, as previous studies have identified the role of ac-
ademic performance in the differences in knowledge, we felt that the
Indian society would be a unique society to study, primarily because
of the immense importance the society places on academic perfor-
mance. Because ADHD and SLD are often considered as part of a spec-
trum (Mayes et al., 2000), we included a third frequently occurring
independent disorder, common cold, as a comparator. We chose com-
mon cold as the comparator primarily because it is a frequently occur-
ring physical ailment that would occur in the same frequency in the
2 groups. Common cold has also been used as a comparator to ADHD
in an earlier study (McMenamy and Perrin, 2008). Finally, we aimed to
assess self-esteem and its relation to their understanding of the disorder.
We hypothesized that knowledge and understanding of ADHD and
SLD would be limited, and that children with more limited knowledge
about their illness would have lower self-esteem.
METHODS
A cross-sectional study with qualitative and quantitative compo-
nents was carried out. The qualitative part was based on Grounded The-
ory (Martin and Turner, 1986), exploration of the target population’s
awareness and understanding of its own disorder without a prior hy-
pothesis. The quantitative portion of the study explored the relationship
between knowledge about the illness and self-esteem. Approval was ob-
tained from our institutional review board.
Subjects
One hundred twenty consecutive children with a diagnosis of
ADHD (n = 60) or SLD (n = 60) between the ages of 8 and 14 years,
attending a Child Guidance Clinic in a tertiary health center in urban
India, were recruited for the study. Only children with the combined
type of ADHD were recruited. Care was taken to include participants
who had only ADHD or only SLD. These children had received treat-
ment for at least 3 months. Children with IQ of less than 84 on Wechsler
Intelligence Scale for Children were not included in the study. Appro-
priate assent to participate was obtained from the children along with
parental consent. In the Child Guidance Clinic, diagnoses of the spe-
cific disorders were made by a multispecialty team using Diagnostic
and Statistical Manual of Mental Disorders, Fourth Edition, Text Revi-
sion criteria and testing, including educational achievement tests such
as Woodcock-Johnson Psychoeducational Battery. All interviews were
carried out by 1 interviewer (S.M.) in a single sitting.
A semistructured interview was used to obtain demographic data
and details about family history, including a history of ADHD and SLD.
An open-ended questionnaire was developed, which inquired about the
children’s awareness and understanding of their disorder (SLD or
ADHD) and a comparison illness, common cold. The questionnaire
was designed to elicit responses regarding awareness about the illness
and included questions pertaining to nosology, etiology, and prognosis
(included as supplemental material). Specifically, the themes included
awareness about the disorder, recognition about the disorder’s medical
nature, attributions regarding the etiology of the disorder, perception
The Journal of Nervous and Mental Disease • Volume 204, Number 6, June 2016 Mental Health Literacy in Children

regarding volitional control over the symptoms, knowledge about treat-

ment modalities, perception about prognosis, and, finally, subjective TABLE 1. Percent of Subjects Responding to the Various Themes
Presented as Proportions
distress and coping styles. The themes were identified in focus groups
conducted with 3 expert psychiatrists and facilitated by one of the coau-
Children Children
thors (S.M.); questions developed based on these themes were further
With ADHD With SLD
reviewed by the 3 experts. Finally, to ensure integrity of the question-
naire, it was translated and back-translated from English into 2 local Common Common
languages and back (by 2 nonmedical professionals who were profi- Themes ADHD Cold SLD Cold
cient in all 3 languages) then compared and modified until uniformity
Awareness of symptoms 80 100 100 100
was confirmed. The responses to the questions were documented verba-
Recognition as a disorder 15 100 25 100
tim to ensure accuracy of data.
A pilot study was carried out with 10 children to determine ap- Accurate attributions 35 1.67 80 23.33
about etiology
propriateness of the questionnaire. The questions were then modified
based on the pilot study. The final questionnaire was used in the study. Perception of volitional 40 63.33 15 61.67
control over symptoms
A visual analog scale (VAS) ranging from 1 to 5 (1 being the best and 5
being the worst) was used to assess distress from the disorder. Hoge and Coping with disorder
McCarthy’s (1983) adaptation of the Rosenberg’s Self-esteem Scale Positive 51.67 100 40 100
was used to assess self-esteem. The scale has a concurrent validity of Negative 1.67 46.67
0.5 to 0.8 and test-retest reliability of 0.7 to 0.9 and has been used for Knowledge about treatment
children, adolescents, and adults (Hoge and McCarthy, 1983). Scores Aware about treatment 53.33 100 40 100
less than 15 are suggestive of low self-esteem. Finally, a VAS was cre- Understand mechanisms 35 73.33 13.33 81.67
ated, which rated symptoms on a scale of 1 to 5, with 1 being the best
and 5 being the worst (illustrated in Appendix 1).
A. Awareness about their disorder (ADHD or SLD)
Data Analysis Awareness of symptoms. Eighty percent of children with ADHD
were aware of their full symptoms (attention deficit and hyperac-
For the purpose of qualitative analysis, responses were classified tivity), 5% were aware only of the attention-deficit symptoms,
into specific themes: awareness of symptoms (identification of their and 15% were not aware of their symptoms; 100% of the SLD
disorder in a dichotomous manner and describing their symptoms), children were aware of their symptoms, significantly more than
recognition as disorder (a narrative of the child’s understanding of the ADHD group ( p < 0.05). Similar to SLD, all the children
their diagnosis), attribution of disorder (discussed in detail in Results), (100%) were aware of the symptoms of common cold.
perception of volitional control over symptoms (a dichotomous re- Description of symptoms. Forty-five percent of children with
sponse), coping with the disorder (distress due to their illness and ADHD described their symptoms to be of behavioral nature de-
various coping strategies), and treatment description (based on the scribing hyperactivity-impulsivity (e.g., “I make too much mis-
available methods of treatment in India). Specifically, the children were chief and irritate everyone”), whereas only 8.33% of the
encouraged to elaborate in their views about their illness in these vari- children described the inattention component appropriately—in
ous categories, including in the questions that would primarily elicit a relation to academic difficulties (“My mind cannot stay on one
dichotomous response to ensure accuracy of the response. These re- thing for long; it wanders, so I can’t finish my homework.”).
sponses were then categorized into appropriate categories as deemed All the children with SLD described their symptoms in terms
by the questions (as an example, correct and incorrect attributions) by of difficulties in academics (e.g., “When I read, the words don’t
2 of the authors, S.M. and H.R.S. Responses were then converted into make sense”). This difference between the 2 groups was statisti-
frequency tables for nonparametric analysis between the 3 groups: cally significant ( p < 0.05). In contrast, all children described
ADHD, SLD, and common cold. For assessing the relationship of the symptoms of common cold correctly, responses being
self-esteem, scores on the Self-esteem Scale were dichotomized as nor- combinations of “runny nose,” “throat pain,” “headache,” “fever,”
mal (≥15) a nd low (<15) and then used in Fisher exact test. This test “coughing,” and “sneezing.”
was chosen because it gives accurate results even with widely varying Existence of a formal disorder name. Of the children with
cell values (0–99 in case of this test), which suited our study well as ADHD and SLD, 63.33% and 78.33%, respectively, said that their
the individual values varied greatly, but none were less than 0 or greater problem had a specific formal name. The SLD group was signif-
than 99. For parametric data, independent-samples t test was done. All icantly more knowledgeable about whether there was specific
analyses were done using SPSS (version 16) (SPSS Inc, 2007). name for their disorder than the ADHD group ( p < 0.05). The
“correct” ADHD group (11.67% of the total ADHD group) gave
fully or partially accurate terminology, that is, “ADHD,” “hyperac-
tivity,” and “attention deficit.” The “incorrect” ADHD group
RESULTS (51.67% of the total ADHD group) gave lay responses, for exam-
One hundred twenty children were studied. The ADHD group ple, “masti,” “vedepana” (mischief and madness, respectively, in
consisted of 54 boys and 6 girls (45% and 5% of the total population, local language); 76.67% of all the SLD children gave “correct” re-
respectively). The SLD group consisted of 45 boys and 15 girls sponses: “LD,” “learning disability,” and “dyslexia/dysgraphia/
(37.5% and 12.5% of the total population, respectively).The average dyscalculia/combination of all of them.” The SLD group gave sig-
age of children in the SLD group (11.81 ± 2.05 years) was significantly nificantly more correct responses compared with the ADHD
higher (p < 0.05) as compared with children in the ADHD group group ( p < 0.05).
(10.63 ± 1.89 years); 11.67% of ADHD children and 31.67% of the Source of awareness/knowledge. Most common sources of
SLD children had family members with similar complaints. awareness were both parents and teachers (86.67% and 90% of
The responses to the various themes in the questionnaire are ADHD and SLD groups, respectively). Other sources included
summarized in Table 1 and detailed in the following list: friends and media. Notably, doctors were not a source of knowl-
1. Understanding of ADHD/SLD (as compared with common cold): edge for any of the children. According to all the children,

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Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

Mukherjee et al. The Journal of Nervous and Mental Disease • Volume 204, Number 6, June 2016
knowledge about common cold is a part of general knowledge
and did not identify a source.
B. Recognition as a medical disorder
Only 15% of ADHD and 25% of the SLD children recognized
their difficulties as a medical disorder ( p > 0.01). The rest of
them gave varied responses, of which the 2 most common
were thinking the symptoms were normal or a temporary
sociobehavioral/academic difficulty. In contrast, 100% of the
sample recognized the common cold to be an illness.
C. Attributions regarding etiology of the disorder
The responses were analyzed and condensed into themes and
further condensed into “correct” (C) and “incorrect” (I) attribu-
tions. Thirty-five percent of children with ADHD provided accu-
rate attributions. Children with SLD (80%), on the other hand,
provided significantly more correct attributions ( p < 0.05). Chil-
dren with SLD (23.3%) were also more likely to provide cor-
rect attributions for common cold as compared with children
with ADHD (1.67%) ( p < 0.05).
Among children with ADHD, the themes included the following:
1. Hereditary/genetic: for example, “Both my brother and I have it, so it
runs in the family.” (C)
2. Functional neurological (i.e., attribution of symptoms to neurologi-
cal malfunction): “My brain runs too fast.” (C)
3. Organic neurological (i.e., attribution of symptoms to structural neu-
rological deficits): “My brain has not developed properly.” (C)
4. Congenital: “I was born with it.” (C)
5. Effect of certain stimulus: “Watching TV makes me hyperactive.” (I)
6. Postillness sequelae: “I have become more mischievous after I got ty-
phoid.” (I)
7. Voluntary behavior: “I like doing a lot of masti (mischief ); that’s
why I do it.” (I)
8. Normal: “It’s normal for kids to be naughty, so there’s no problem
with me.” (I)
Among children with SLD, the themes were as follows:
1. Hereditary/genetic: for example, “It is a genetic disorder.” (C)
2. Functional neurological: “My brain is slow and doesn’t understand
properly.” (C)
3. Organic neurological: “The calculation area in my brain has not de-
veloped properly.” (C)
4. Congenital: “I was always this way.” (C)
5. Effect of certain stimulus: “I once played too much of video games
and exhausted my mind; that is why it is slow.” (I)
6. Postillness sequelae: “I developed reading problem because I got
asthma attack.” (I)
7. Voluntary behavior: “I hate homework—it takes such a long time to
finish; that’s why I don’t do it.” (I)
8. Somatic: “My hand writes slowly.” (I)
For common cold, themes were as follows:
1. Environmental: for example, “I can get a cold by drinking cold
Pepsi.” (I)
2. Infectious: “Bacteria and viruses can both cause common cold.” (C)
3. Both environmental and infectious: “My throat grows bad bacteria in
cold weather.” (C)
4. Congenital: “I always had a cold.” (I)
D. Perception of volitional control over disorder
Forty percent of the ADHD group and 15% of the SLD group
reported they could control their symptoms whenever they
wanted ( p < 0.05). Furthermore, the ADHD group felt signifi-
cantly more in control of their own behavior when they did not
label it as a disorder (90%) as compared with when they did
460 www.jonmd.com
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(27.27%) ( p < 0.05). Perception of volitional control over symp-
toms of common cold was higher and similar between the 2
groups (ADHD, 63.33%; SLD, 61.67%; p > 0.05).
E. Knowledge about treatment
Treatment modalities. Correct responses for ADHD included
pharmacotherapy and occupational/behavior therapy and for
SLD remedial education with or without certification for educa-
tional concessions. The ADHD group (53.33%) gave signifi-
cantly more correct responses about treatment as compared
with the SLD group (40%) ( p < 0.05). All the children from both
groups gave correct responses when asked about treatment of
common cold.
Mechanism of action of treatment. The ADHD group (35%)
had significantly more ( p < 0.05) accurate knowledge of the
mechanism of the prescribed treatment (example of correct re-
sponse: “The medicines calm my brain down and help me fo-
cus”) as compared with the SLD group (13.33%) (example of
correct response: “it’s specific teaching for my brain because I
can’t learn like everybody else”); 73.33% of the ADHD group
and 81.67% of the SLD group identified the mechanisms of
treating common cold accurately ( p < 0.05).
F. Perceptions regarding prognosis
Significantly more children with SLD (36.67%) felt despondent
about their prognosis as compared with children with ADHD
(3.33%) (p > 0.05). Fifteen percent of ADHD and 70% of SLD
children said it would be a big problem if their symptoms do
not resolve soon (p < 0.05). On the contrary, 70% ADHD and
98.33% SLD children felt it would a big problem if common cold
did not resolve fast showing that the SLD group’s perception of
common cold as a big problem was also significantly more than
the ADHD group (Fisher p = 0.016).
G. Subjective distress and coping
Perception of distress due to symptoms. On the VAS, children
with ADHD reported less distress as compared with children
with SLD. Furthermore, children with ADHD reported signifi-
cantly more distress with common cold (4.18 ± 1.15) as com-
pared with their own disorder (2.08 ± 1.14). Children with
SLD (4.36 ± 0.87), on the other hand, reported significantly
more distress with their own disorder as compared with common
cold (3.74 ± 0.70) (Table 2).
Perceived impairment in aspects of daily life due to disorder. Of
the 6 areas (academics, extracurricular activity, play, and rela-
tionship with family, friend, and teachers), both ADHD children
(60%) and SLD children (100%) identified academics as the
most affected area (p < 0.05) followed by relationship with
teachers, family members, and friends and play and extracurric-
ular activities, which were not statistically significant. A signifi-
cantly greater proportion (p < 0.05) of children with SLD
(83.33%) as compared with children with ADHD (48.33%) re-
ported that their disorder affected their lives every day.
Coping strategies to deal with the symptoms. The following
themes emerged and were classified into “positive” (P) and
“negative” (N) coping strategies:
• (P) Constructive self-improvement: for example, ADHD: “I focus
all my energy into 1 hour of sports everyday so that my mind is
calm enough to do homework”; SLD: “I put in more effort in
TABLE 2. Comparison of VAS Rating of Perceived Distress Due to
Their Own Disorder and Common Cold by Children With ADHD/SLD
Group ADHD/SLD Common Cold
ADHD distress ratings 2.08 ± 1.14 4.18 ± 1.15 −9.710 (<0.05)
SLD distress ratings 4.36 ± 0.87 3.74 ± 0.70 4.231 (<0.05)
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The Journal of Nervous and Mental Disease • Volume 204, Number 6, June 2016
school”; common cold: “I put on warm clothes and stay away from
cold drinks.”
• (P) Seeking external help: “I visited the school counselor to ask how
to be better at studies.”
• No felt need for active coping: (children emotionally at peace with
their disorders and feel no need to expend emotional energy over
them), for example, “Nothing extra needs to be done; I’m happy with
the way my life is right now.”
• (N) Externalizing behavior: “I get angry, scream, and hit people’
• (N) Avoidance of problem: “I try not to think about it as it makes
me upset.”
The first 2 were included in “positive” and last 2 in “negative”
coping strategies, whereas the third was taken as a standalone category.
Children with SLD used significantly more negative coping
strategies than did the ADHD children when it came to their disorder
( p < 0.05); 28.33% of ADHD children and 18.33% of SLD children felt
there was no need for active coping. In contrast, for common cold, most
children of both groups reported positive coping strategies ( p > 0.05).
Furthermore, children who labeled their problems as due to SLD used
significantly more (60%) negative coping mechanisms compared with
those who did not (37.77%) ( p < 0.05).
2. Relation of understanding of ADHD/SLD with
A. Family members having same disorder
Significantly more awareness of disorder, less sense of perceived
control, and less felt need for active coping were seen in children
with ADHD who had a family member having similar com-
plaints than those who did not ( p < 0.05). In comparison, ADHD
children who did not have a family member suffering from
the same disorder used significantly more positive coping. There
were no significant findings regarding these issues when it
came to the SLD group ( p > 0.05).
B. Self-esteem
The mean scores on Rosenberg’s Self-esteem Scale for the
ADHD and SLD groups were 22.33 ± 3.86 and 15.02 ± 2.76,
respectively. Children with ADHD had significantly higher self-
esteem than did SLD children (independent-samples t = 11.935;
p < 0.01). In addition, we found that significantly more ( p <
0.01) ADHD children (90.90%) with normal self-esteem felt
in control of their disorder than the SLD group (37.78%), and
in both groups, children with low self-esteem felt signifi-
cantly more (Fisher p < 0.01) lack of control over their dis-
order (ADHD, 100%; SLD, 91.67%) as compared with those
with normal self-esteem (ADHD, 9.01%; SLD, 62.22%).
C. Age
Because of the difference in ages that was noted between the 2
groups, we further examined the influence of age on the various
themes. For this purpose, the children were divided into 2 groups
based on Piaget’s stages of cognitive development (8–11 and
11–14 years). A significant difference ( p < 0.05) was noted only
among children with ADHD, with older children reporting
more correct attributions about their disorder as compared with
younger children. Younger children also tended to “normalize”
their disorder as compared with older children; however, this
was not statistically significant. No statistically significant differ-
ence was noted in responses to any of the other themes between
the 2 age groups.
DISCUSSION
Our study explored knowledge and understanding about 2 com-
mon childhood disorders, ADHD and SLD, among children identified
as having the disorders. As hypothesized, we found significant differ-
ences in knowledge and attitudes about ADHD and SLD among
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Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Mental Health Literacy in Children
children who received a diagnosis of these disorders. Awareness about
the disorder was higher in children with SLD as compared with ADHD.
This increased awareness may have been driven by the difference in age
group; SLD children were older than children with ADHD. However,
among children with SLD, age did not seem to affect the responses to
various themes, including awareness. A second explanation could be
the importance of academic performance in the Indian community.
We can speculate that children with SLD were likely being labeled
as “disabled,” whereas children with ADHD were normalized as
“mischievous.” This pressure of academic success may also explain
the observation that both groups reported more distress with unre-
solved cold as compared with ADHD and SLD. We can speculate
that this could be because cold keeps the child out of school as
against having ADHD or SLD, which keeps the child in school.
Our findings do not appear to be unique to the Indian population
and are similar to studies from Western societies (Feurer and Andrews,
2009; Palladino et al., 2000) that have reported that children with SLD
are more mindful about their symptoms. Recognition of symptoms as
a disorder was similarly low in both groups. According to the partici-
pants, ADHD and SLD do not feel like conventional medical illnesses
such as common cold; this belief likely led to the rejection of the theme
that ADHD and SLD are medical illnesses. Furthermore, the concept of
an “illness” does not crystallize in a child’s mind until the age of 12 to
13 years, so immaturity of cognitive processes may have led to this ob-
servation (Perrin et al., 2008). Surprisingly, children in our study re-
ported a high number of biological explanations. This could be the
result of an increased focus on biological causes of psychiatric disor-
ders spilling over into the community (Hinshaw, 2005). It may also
be a mechanism for self-preservation. An organic cause leads to reduc-
tion of stigma as the negative social perception attached to being behav-
iorally and academically poor is transferred from the self to an organic
cause (Hinshaw and Stier, 2008).
Compared with children with SLD, children with ADHD report
more perceived control over their illness and have more knowledge
about treatment modalities. Children with SLD showed distress about
their illness and also demonstrated more despondence about the prog-
nosis as compared with children with ADHD. Interestingly, among chil-
dren with SLD, the perceived distress was higher for common cold, as
well as compared with children with ADHD. One possible explanation
for these observations could be learned helplessness and lack of ability
in children with SLD (Shmulsky and Gobbo, 2007; Tominey, 1996). It
could also be the result of a general negativistic attitude among children
with SLD (Shmulsky and Gobbo, 2007) secondary to the development
of depressive symptoms. This was also reflected in the lower self-
esteem, the perception of poor prognosis, and the use of more negative
coping strategies among children with SLD. In contrast, children with
ADHD appeared to use more positive coping strategies and had a
higher self-esteem. The importance of mental health literacy in the chil-
dren’s responses can be noted in the differential responses among chil-
dren with family members with similar diagnoses; children with ADHD
who also have family members with ADHD demonstrated a better ad-
justment to their illness and reported as compared with children without
family members with the diagnosis.
Mental health literacy (Jorm et al., 1997) and stigma have been
identified as important barriers to help-seeking behaviors (Gulliver
et al., 2010). Our study illustrates some of the qualitative elements in-
volved in the association between mental health literacy and stigma
and dysfunctional perceptions about mental illnesses among children.
The dysfunctional perceptions noted in the study may be driven by var-
ious cultural elements such as the relative comfort of accepting medical
explanations as compared with psychiatric labels (Kermode et al.,
2009). Thus, in India, a more medical explanation of psychiatric ill-
nesses may help improve help-seeking behaviors. An interesting aspect
of the study is that school performance was a significant contributor
to the perceptions and attitudes among the children. This in turn may
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Mukherjee et al. The Journal of Nervous and Mental Disease • Volume 204, Number 6, June 2016
be driven by the emphasis on academic performance in traditional
Indian society.
Considering the importance of academics, school-based inter-
vention programs may be an ideal form of intervention in terms of im-
proving mental health literacy and addressing stigma. School-based
mental health programs have been implemented in a number of coun-
tries including the United States (Wahl et al., 2011). A recent meta-
analysis (Calear and Christensen, 2010) noted that approximately half
the studies (14 of 27) reported significant changes in stigmatizing atti-
tudes and greater help seeking. A study of a school-based mental health
program done in a culturally similar society, Pakistan, noted a signifi-
cant change in stigmatizing attitudes among the students and the com-
munity (Rahman et al., 1998).
An important limitation of the study is its exploratory nature.
While exploratory studies provide detailed insights into the mecha-
nisms that may be involved, they do not draw definite conclusions. This
limitation is mitigated by our employment of quantitative methods and
the use of a wide range of questions that address similar issues, thus
giving a more complete and nonrandom view. Another potential limita-
tion of the study is that it uses a novel questionnaire that has not been
previously tested for reliability and validity. However, the questionnaire
was constructed based on discussions with a panel of experts in child
psychiatry, who are also familiar with Indian society, thus ensuring
content validity.
A second limitation is that the study was conducted in a special-
ized clinic that caters to children who received a diagnosis of ADHD
and SLD. The responses provided by the children in our sample could
have been inadvertently influenced by their treatment teams, and they
may not be generalizable to community samples.
Another important factor that could have driven a number of our
findings is the difference in age, which may have resulted in increased
awareness, and lower self-esteem among children with SLD as com-
pared with children with ADHD. Finally, we were unable to obtain de-
tails about the severity of ADHD and SLD (including functioning in
school), which would have provided us a more accurate representation
of real versus perceived distress. Nevertheless, the findings of our study
clearly demonstrate an important public health need to educate children
about the various disorders in different settings, including schools.
CONCLUSIONS
This study provides important insights into the level and signif-
icance of mental health literacy and stigma among children who re-
ceived a diagnosis of mental illnesses and their family members. It
also illustrates the need for individual and group psychoeducation for
children with ADHD and SLD. More importantly, the study identified
a larger need for studies exploring the efficacy educational programs
enhancing mental health literacy and stigma reduction campaigns at a
school/community level in India. The study also identifies some impor-
tant public health issues including promoting a medical model about the
illness, which promotes treatment and hope and is less stigmatizing. It
also highlights the clinical need for psychoeducation among children
with ADHD and SLD as improved understanding about the illness
can prevent or alleviate comorbidity arising from low self-esteem.
ACKNOWLEDGMENT
The authors thank the Head of the Department of Psychiatry,
Topiwala National Medical College, Dr Ravindra Kamath, for his sup-
port of their work and Dr Stephen Faraone, SUNY Upstate Medical
University, for his review of the manuscript. They thank the children
and parents who participated in the study.
DISCLOSURE
The authors declare no conflict of interest.
462 www.jonmd.com
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B. If Yes:
i. How can you help yourself get better?
ii. How can others help you?
Medicines/talking to the doctors about your problems/school
teachers/special teachers/others ____________________ (specify)
iii. How will this treatment (ii.) help you?
13. How long do you think it will take for you to get better?
14. Do you think you will get completely better?
15. If it takes a long time, is it going to be a really big problem for you
or is it going to be okay?
16. Rate on the following scale how bad is it according to you to have
this problem?

APPENDIX 1: QUESTIONNAIRE

Part I
1. Why do you have to come to this hospital?
2. Do you think you have a problem? Yes/No 17. How would you deal with it on a daily basis?
3. What do you think is the problem? Academic/behavioral/others Part II
(specify) __________ 1. Do you know what common cold is? Yes/No
4. A. Does it have a name? Yes/No 2. Have you ever had it? Yes/No
If Yes: 3. What happens when you get a common cold?
What is it called? _________________________ 4. A. Is it any different from the disorder that you have? Yes/No
B. Have you heard of it before? Yes/No B. If Yes: then how?
If Yes: C. If No: why not?
How did you come to know? 5. How do you catch a cold?
Parents/other family members or relatives/neighbors/teachers/ 6. Can you catch a cold if you want to or does it happen by itself?
friends/media (Radio/TV/public awareness posters)/doctor/others How?
(specify) __________________ 7. How does it affect your:
If No: A. Studies?
C. Have you heard your parents/friends/teachers talk about it? B. Extracurricular activities?
If Yes: C. Play?
What do they call it? D. Relationship with parents and siblings?
5. Why do you think you have it? E. Relationship with friends?
6. How did it begin? F. Relationship with teachers?
7. Do you think it is a disease? Yes/No G. Others? ________________________________ (specify)
If No: what is it?
8. How does this problem affect you? 8. Which of the above aspects of your life gets affected the worst
A. Studies? because of it?
B. Extracurricular activities? 9. Can you make a common cold go away? Yes/No
C. Play? If Yes, how will you do that?
D. Relationship with parents and siblings? If No, what can be done to make a common cold go away?
E. Relationship with friends? Medicines/taking rest/others _________________________ (specify)
F. Relationships with teachers? 10. How will the treatment you are talking about work?
G. Others? _________________________ (specify) 11. How long does it take for a common cold to get better?
12. If it doesn’t get better in that time, does it become a really big
9. Which of the above aspects of your life is affected the worst? problem for you or is it okay?
10. How often does this problem affect you? 13. Rate on the following scale how bad is it according to you to have
11. Do you think that this problem can occur on its own? this problem
12. Do you have any control over this problem? Yes/No
If Yes:
A. Can it occur and can it go away when you wish it to?
B. How do you do that?
If No:
A. Do you think something can be done to help you get better?
Yes/No 14. How do you deal with it?

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