Low Rates of Treatment Seeking for ADHD

Pauline Anderson

August 13, 2014

Fewer than half of individuals with attention-deficit/hyperactivity disorder (ADHD) seek treatment for the condition, and often only do so decades after symptoms emerge, new research shows.

In addition, researchers found that the reasons for delayed treatment differ between men and women.

Delayed treatment seeking among men is influenced by such factors as being African American and having a low education level, whereas earlier treatment seeking in men is linked to alcohol dependence and certain psychiatric comorbidities.

Interestingly, the study also showed that having antisocial personality disorder delays treatment seeking for ADHD in men.

"In general, treatment seeking is more tenuous for men, so it's more likely to be impacted by factors that might complicate treatment seeking, like socioeconomic status, demographics, and various psychiatric comorbidities.

"What we saw in general in this analysis was that more variables impacted treatment seeking in males than in females," lead author Elias Dakwar, MD, assistant professor of psychiatry, Columbia University, New York City, told Medscape Medical News.

The study was published online August 1 in Psychiatric Services.

Stigma a Contributor?

For the study, researchers used the 2001 to 2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) and the 2004 to 2005 follow-up survey. The NESARC is a nationally representative sample of the adult US population. A total study sample of 34,653 adults had face-to-face interviews.

Researchers used the Alcohol Use Disorder and Associated Disabilities Interview Schedule – DSM-IV version to detect ADHD. Respondents were queried about symptoms and had to meet DSM-IV symptom thresholds for at least 6 months and have significant social, academic, or occupational impairment. Symptom onset must have occurred before age 12 years (as per DSM-5).

Respondents were also asked whether they had ever seen a general medical or mental health professional for ADHD.

About 46% of those with lifetime ADHD reported having sought treatment for the disorder. The probability of lifetime treatment seeking was 55%. This compares to an estimated 87% for seeking treatment for psychiatric disorders in general and "underscores the substantial gap" in treatment seeking, said the authors.

Stigma may contribute to this delay, said Dr. Dakwar.

"It seems that treatment for ADHD become a rallying point for a lot of antipsychiatric movements, including against diagnosing stimulants for children, so although the diagnosis isn't stigmatized, the treatment in certain communities will be."

Novel Result

The estimated median delay to treatment seeking from ADHD onset is longer than 20 years, which is also longer than that for general psychiatric disorders in the United States, said the authors.

In the study, sex did not play a significant role in terms of time to treatment seeking or on the cumulative probability of treatment seeking. In both men and women, being older than 44 years increased delays in treatment seeking.

However, there were several sex differences. For example, in the sample of 409 men and 355 women who had sought treatment for ADHD, age of disorder onset had the opposite effect on men than on women.

Compared with onset between age 12-18 years, the hazard ratio (HR) for men diagnosed up to age 11 years to delay seeking treatment was .32, but in women, it was 3.26 (both P < .05.)

This is an "important and novel finding," the authors note. Whereas disruptive behavior in boys draws attention, in girls, the disorder tends "to go unnoticed," added Dr. Dakwar. "Kids with ADHD aren't bringing themselves into treatment; it's concerned teachers and parents. The more impairing the ADHD is, the more likely it will come to their attention."

Although boys with symptoms are more likely than girls to attract clinical attention, this becomes less true as they reach adolescence, according to the authors. The diminishing role of parents and teachers may help explain this changing pattern, they said.

There were also sex differences related to comorbid psychiatric conditions, including bipolar disorder, many of the symptoms of which ― for example, agitation and impulsivity ― overlap with ADHD in both men and women. For patients with ADHD and bipolar disorder, the adjusted HR (aHR) for seeking ADHD treatment was .91 in men and 2.93 (P < .05) in women.

Sex Differences

Having comorbid paranoid personality disorder appeared to deter men with ADHD from seeking treatment (aHR, .02; P < .05). "Men are generally less likely to seek treatment across the board for different disorders," said Dr. Dakwar. On the other hand, "women are more likely to 'medicalize' what may be happening to them and to seek treatment accordingly."

Although being distrustful of others is often a component of paranoid personality disorder, women "are starting at a kind of higher level of capacity for treatment seeking" than men, added Dr. Dakwar. "So their treatment seeking is less tenuous to begin with, and they are less likely to be disrupted by those other things that might get in the way."

One of the most surprising findings of the study, according to Dr. Dakwar, was that sociopathy delays treatment seeking for ADHD in men. In contrast to past research, having antisocial personality disorder was not a predictor of seeking ADHD treatment (aHR, .36; 95% confidence interval [CI], 0.13 - 1.01).

Counterintuitive Finding

"Our result was actually counter to what we suspected" because in children, conduct disorder, which is "a precursor" to antisocial personality disorder, is associated with faster time to treatment seeking, said Dr. Dakwar.

"ADHD comes to clinical attention because the kids are doing crazy things, aren't following rules, or doing things that are alarming. So we assumed that people with antisocial personality disorder, given that they probably had conduct disorder as kids, were likely to come to treatment earlier. But we found the opposite, that having antisocial personality disorder may in fact delay coming to treatment."

This could be because rule breaking in childhood is viewed as a potential medical problem, whereas in adulthood, it is treated punitively. Indeed, studies show that the prevalence of ADHD in prisons is as high as 45%, or almost 9 times the rate in the general population, said Dr. Dakwar.

Other predictors of delays in treatment seeking for men included being African American (aHR, .37 vs being white; P < .05) and being less educated (aHR, .17 for those with at least 12 years of school vs those with less schooling; P < .05).

Alcohol dependence (aHR, 3.63), dysthymia (aHR, 3.50), and histrionic (aHR, 4.12) and borderline personality disorders (aHR, 4.47) were significantly associated with men seeking treatment earlier.

As the authors pointed out, receiving treatment for one disorder may also promote treatment seeking for other disorders.

Common Disorder

For women, being older than 60 years or being 45 to 60 years old tended to delay treatment (aHR.,14 and .31, respectively). Only bipolar disorder (aHR, 2.93) was significantly associated with earlier treatment seeking.

The investigators note that ADHD is the most common childhood-onset neurobehavioral disorder and that it often persists beyond childhood. Many associated impairments, including interpersonal conflict, impaired driving, substance use, low educational attainment, and criminal involvement, may be diminished by early diagnosis and management.

But up to half of all children with ADHD are not properly diagnosed, and many adults do not receive treatment for their symptoms. To pick up ADHD among older adolescents and young adult men, a "great first step" would be for clinicians to routinely incorporate questionnaires into their evaluation, said Dr. Dakwar. There are a number of such screening tools that do not take much.

Reinforcing the Message

Commenting on the study for Medscape Medical News, R. Scott Benson, MD, a child and adolescent psychiatrist in Pensacola, Florida, and a member of the American Psychiatric Association, did not think the study was very helpful or added anything new to what is already known about treatment seeking for ADHD except to reinforce the message that a lot of adults with concentration and focus problems should have been picked up earlier.

"We would certainly encourage families to understand that ADHD is an important condition that's reasonably treated," said Dr. Benson. "And when appropriately treated, a child's school function, relationships in the family, and relationships with peers dramatically improve, and they have a better life adjustment long term."

He agreed that stigma is still a barrier to treatment seeking.

"I have parents who say, 'No child of mine is going to take any medicine,' " said Dr. Benson.

He has also been asked by parents whether taking stimulants would affect their second-grader's chance of getting into the military. "I tell them that if he doesn't graduate from high school, that will surely affect his chances."

Dr. Benson also was not surprised to learn from the study that antisocial personality disorder is associated with delays in men seeking treatment for ADHD.

"These behaviors delay people from seeking treatment for any medical condition. They don't get treatment for their blood pressure problems or for their drug and alcohol problems or for hyperthyroid problems or for diabetes or anything else."

Limitations of the study were that the information was self-reported and that there was no information on family history of ADHD, he said.

Dr. Dakwar and Dr. Benson report no relevant financial relationships.

Psychiatr Serv. Published online August 1, 2014. Abstract

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