Concerns about Stigma Undermine Adolescents' Treatment
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
in Attention Research Update is for informational purposes only, and is
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(c) 2011 David Rabiner, Ph.D.