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ADHD Symptoms and Antisocial Traits Associated with Higher No-Show Rates

Sixty male patients with ADHD who received treatment in a Dutch forensic outpatient center completed the Adult Self-Report on disorder-specific symptoms and general psychosocial well-being. Results of the analyses reflect that patients with high no-show rates (15-45% missed appointments) had more ADHD symptoms compared to patients with low no-show rates (0-14.9% missed appointments). Furthermore, rule-breaking, externalizing problems and somatic problems were associated with higher no-show rates while anxiety problems were associated with lower no-show rates. This is the bottom line of a recently published article in the International Journal of Forensic Mental Health. Below is a summary of the research and findings as well as a translation of this research into practice.

Featured Article | International Journal of Forensic Mental Health | 2018, Vol. 17, No. 1, 62-71

Disorder-Specific Symptoms and Psychosocial Well-Being in Relation to No-Show Rates in Forensic ADHD Patients

Authors

Tessa Stoel, Forensic outpatient clinic het Dok (Fivoor), Department ADHD and related disorders, Rotterdam, The Netherlands
Jenny A.B. M. Houtepen, Department of Developmental Psychology, Tilburg University, The Netherlands
Rosalind van der Lem, Forensic outpatient clinic het Dok (Fivoor), Department ADHD and related disorders, Rotterdam, The Netherlands
Stefan Bogaerts, Department of Developmental Psychology, Tilburg University, The Netherlands
Jelle J. Sijtsema, Department of Developmental Psychology, Tilburg University, The Netherlands

Abstract

No-show rates in forensic psychiatry are related to higher recidivism risk and financial costs in mental health care, yet little is known about risk factors for high no-show rates. In this study, the extent to which disorder specific symptoms and psychosocial well-being are related to no-show rates in forensic patients with ADHD was examined. Sixty male patients with ADHD (M age = 35.9, SD = 8.6) who received treatment in a Dutch forensic outpatient center completed the Adult Self-Report on disorder-specific symptoms and general psychosocial well-being. Data on no-show rates and background characteristics were obtained via electronic patient files. Independent sample t-tests showed a trend in which patients with high no-show rates (15–45% missed appointments) had more ADHD symptoms compared to patients with low no-show rates (0–14.9% missed appointments). Furthermore, multivariate regression analyses showed that rule breaking, externalizing problems and somatic problems were associated with higher no-show rates, whereas anxiety problems were associated with lower no-show rates. Results suggest that no-show rates in forensic patients with ADHD are related to specific psychopathological symptoms. This knowledge can be used to prevent no-show in forensic psychiatric treatment.

Keywords

No-show, adult ADHD, forensic psychiatry, disorder-specific symptoms, psychosocial well-being

Summary of the Research

“Outpatient services can provide an efficient form of health care, but the high rates of missed outpatient appointments (i.e., no shows) result in inefficient use of these services…Besides economic and financial consequences, high rates of no-shows in mental health care are related to poorer treatment outcomes of patients…In the current study, no-show rates among forensic outpatients will be addressed. Mental health treatment in forensic psychiatric outpatient clinics is often a compulsory part of a criminal sentence. Therefore, low intrinsic treatment motivation and a negative attitude toward professional help may increase risk for higher no-show rates in these patients…This is problematic because untreated psychopathological problems due to missed appointments can result in higher risk of recidivism…” (p.61).

“Risk for no-shows is particularly likely for forensic patients who have a diagnosis of Attention-Deficit/Hyperactivity Disorder (ADHD)…Research on treatment compliance in patients with ADHD is scarce, but researchers stress that adequate treatment of ADHD in forensic psychiatric institutions is needed to decrease the risk of reoffending. ADHD in (forensic) psychiatric patients may affect treatment adherence for two reasons. First, patients with ADHD may experience difficulties with compliance to treatment in general, due to the core problems of ADHD, such as impulsivity, attention problems, forgetfulness…Second, non-forensic patients with ADHD are at risk for no-show due to the high prevalence of comorbid psychiatric problems, which in turn are associated with treatment attrition…” (p.61-62).

“We hypothesized that higher rates of no-shows are associated with more disorder-specific symptoms, including severity of ADHD symptoms, substance use, and (antisocial) personality problems. Furthermore, we hypothesized that higher rates of no-shows are associated with lower psychosocial well-being…Participants were recruited from a Dutch forensic psychiatric outpatient clinic located in four cities in…The Netherlands…About half of the participants were diagnosed with ADHD at the clinic (N=34), whereas the other participants received their ADHD diagnosis before intake at another mental health institution (N=26)” (p.63-64).

“In the current study, participants missed on average 16.2% of their appointments and this no-show rate was related to several psychopathological factors. Specifically, rule-breaking, antisocial personality, and somatic problems were associated with higher no-show rates, whereas anxiety problems were associated with lower no-show rates. These findings suggest that rates of no-shows during forensic psychiatric treatment are related to antisocial behavior in daily life, which consist of having difficulties with complying with rules in general…In addition, by comparing patients with high and low levels of no-shows we showed that those with high no-show levels had more ADHD symptoms. However, these findings should be treated with caution…When controlling for multiple testing, this finding was only marginally significant” (p.67).

“This trend in which severity of ADHD symptoms were associated with higher rates of no-shows, corresponds to research showing that ADHD is positively associated to medication non-compliance. It is tempting to speculate that the core symptoms of ADHD (e.g., attentional problems, impulsivity, forgetfulness, and disorganization) affect the ability to achieve long term goals, such as compliance in therapy…Of note, we found that patients with ADHD and high no-show rates more often have comorbid axis I disorders compared to patients with low no-show rates…Our hypothesis that higher rates of no-shows were negatively associated with psychosocial well-being was not supported by the data…Also in contrast to our hypothesis, no relation was found on substance use and rates of no-shows. This is surprising, given that substance abuse is one of the most stable factors associated with treatment non-adherence” (p.68).

Translating Research into Practice

“The current study highlights the importance of accounting for psychopathological factors to explain and potentially reduce no-show rates in forensic patients with ADHD. Efforts to reduce triggers for no-show in patients with externalizing, anxiety, and ADHD problems may, for example, include staying in touch with patients and reminding them about appointments, have a neat clinic organizations, clearly scheduled appointments, consistent staff adherence, and reduced waiting times. Insight into patients’ psychopathological problems may thus generate more awareness in therapists about who is at risk for no-shows” (p.69).

Other Interesting Tidbits for Researchers and Clinicians

“In future studies, it may be particularly important to use prospective study designs, which allow for following patients from the start of their treatment and provide insight into the timing of no-shows. This design would also allow to collect data on medication use in a more controllable manner, which could be an important discriminating factor in explaining rates of no-shows. Moreover, the current findings should be replicated and extended in a larger sample of forensic ADHD psychiatric patients, thereby taking into account whether treatment was received mandatory or voluntarily” (p.69).

Join the Discussion

As always, please join the discussion below if you have thoughts or comments to add!

Authored by Amber Lin

Amber Lin is a volunteer in Dr. Zapf’s research lab at John Jay College of Criminal Justice. She graduated from New York University in 2013 with a B.A. (honors) and is a second year Masters student at Fairleigh Dickinson University. Her research interests include forensic assessment, competency to stand trial, and the refinement of instruments used to assess the psychological states of criminal defendants.

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