Attention Research Update

September 2011

"Helping parents, professionals and educators stay informed about new research on ADHD"

David Rabiner, Ph.D.  Associate Research Professor, Duke University

Concerns about Stigma Undermine Adolescents' Treatment for ADHD

Because ADHD frequently persists into adolescence, and continues to undermine teens' academic and social functioning, most adolescents continue to need treatment.  However, as issues of self-direction and autonomy become more important for teens, resistance to treatment for ADHD - medication or otherwise - frequently intensifies and many adolescents stop treatment prematurely.  This is a challenge that many parents struggle with.

It is thus important to understand the factors - particularly adolescents' perspectives on treatment - that affect the receipt of ADHD treatment during this critical developmental period.  Examining this issue was the focus of a study published recently in the Journal of Adolescent Health [Bussing et al (2011). Receiving treatment for Attention-Deficit Hyperactivity Disorder: Do the perspectives of adolescents matter.  Journal of Adolescent Health, 49, 7-14.]

Participants were 168 adolescents - about 50% female - and their parents recruited through a public school system in the US.  These adolescents screened positive for ADHD in elementary school and were contacted 6 years later for a follow-up assessment.  At follow-up, over 60% continued to meet full diagnostic criteria for ADHD and many others still had elevated levels of ADHD symptoms. The researchers were interested in how many adolescents had received ADHD treatment in the past year and the parent and child characteristics that predicted the receipt of treatment.

- Parent Perspectives -

Clinical need - Parents rated their teen on symptoms of ADHD, disruptive behavior, emotional distress and overall impairment.  High levels of symptoms reflected high clinical need for treatment.

Treatment receptivity - Parents rated how receptive they were towards obtaining medication treatment or counseling for their child.

Caregiver strain - Parents rated the effect of caring for a child with emotional or behavioral problems, such as demands on time, financial strain, worry, guilt, and embarrassment.  High scores reflect high levels of strain associated with caring for their child.

- Adolescent Perspectives -

Clinical need - Teens their symptoms of ADHD, disruptive behavior, emotional distress and overall impairment.  High levels of symptoms reflected high clinical need for treatment.

Treatment receptivity - Teens rated how receptive they were towards obtaining medication treatment or counseling.

ADHD Stigma - This measure assessed teens' perception that being diagnosed and treated for ADHD would be stigmatizing.

- Receipt of mental health services -

Lifetime and past-year receipt of mental health services for each adolescent was gathered through detailed interviews with parents.  This interview inquired about the receipt of services in a wide range of settings and asked about counseling services and medication treatment.


Lifetime and past year mental health service usage

Although most adolescents, i.e, 79%, had received mental health intervention at some point in their lives, only 42% received any services in the past year.  This was true even though most continued to meet full diagnostic criteria for ADHD and/or continued to struggle with symptoms.

Agreement between parent and teen perspectives

Parent and teen reports of the teen's emotional distress showed moderate agreement.  However, agreement on symptoms of inattention, hyperactivity, and disruptive behavior was poor.  Agreement on receptivity to treatment for ADHD was also poor.

Predictors of prior year use of mental health services

The researchers were especially interested in what predicted adolescents' receipt of mental health services during the past year. Interestingly, neither socioeconomic status or insurance coverage were significant predictors. Neither were parent ratings of their child's hyperactive and disruptive behavior.

Instead, teens who had received services were rated by parents as more inattentive, more depressed, and more impaired in their daily functioning. Treatment was also more likely when parents were more receptive to medication treatment.

- What about adolescents' perspectives? -

Even after taking these parental factors into account, adolescents' perspectives emerged as significant predictors of treatment receipt.  Adolescents who rated themselves as more impaired and who had more positive attitudes towards medication were more likely to have been treated.  The most powerful predictor, however, was concerns that ADHD was stigmatizing.  Adolescents who were worried about being stigmatized for ADHD were far less likely to have received treatment in the past year than other teens.

Summary and implications

Results from this study indicate that many adolescents struggling with ADHD have not received any mental health services in the prior year.  Especially noteworthy was that even after accounting for parents' perceptions of their child's functioning and their receptivity to medication treatment, adolescents' own attitudes were important predictors of receiving treatment. 

Teens who felt they were not functioning well in their daily lives were more likely to have been treated.  And, adolescents with concerns about ADHD stigma were far less likely to have received treatment during the prior year.  In fact, this was the strongest predictor of all.

These findings highlight the importance of eliciting adolescents' perceptions of the need for ADHD treatment, and concerns related to treatment, during evaluation and treatment planning.  In particular, health professionals should discuss concerns teens may have about being stigmatized for ADHD as these concerns can substantially undermine an adolescent's willingness to initiate or continue with indicated treatment. 

These results also suggest that when a teenager refuses treatment, or protests continuing, parents should recognize that there may be more involved than their child's being oppositional, not recognizing the reality of what they require, or exercising their desire for autonomy and self-determination.  While these factors may certainly be involved, an adolescent's worries about being stigmatized can be especially important and need to be understood and addressed.  There is a need to develop effective interventions for addressing such concerns.

Information presented in Attention Research Update is for informational purposes only, and is not a substitute for professional medical advice.  Although newsletter sponsors offer products and services that I believe will be of interest to subscribers, sponsorship of Attention Research Update does not constitute a specific endorsement or guarantee of any company's product or services.

(c) 2011 David Rabiner, Ph.D.