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Missed Treatment Appointments, Mental Health, and Recidivism Among Forensic ADHD Patients

Treatment appointment no-show rates are related to serious psychopathological factors in forensic ADHD patients. This is the bottom line of a recently published article in 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, 61–71

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


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 can 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


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.


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, and lead to additional costs and delays in waiting lists. Besides economic and financial consequences, high rates of no-shows in mental health care are related to poorer treatment outcomes of patients [compared to those who attend appointments, such as] an increase up to three times increase in relapse in previous diseases [and] lower social functioning and more severe mental health problems” (p. 61)

“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. […] Untreated psychopathological problems due to missed appointments can result in higher risk of recidivism. Hence, knowing more about no-show rates and related risk factors in forensic patients is warranted.” (p. 61)

“Risk for no-shows is particularly likely for forensic patients who have a diagnosis of Attention-Deficit/Hyperactivity Disorder (ADHD). ADHD is a psychiatric developmental disorder that is characterized by two major impairments: hyperactivity/impulsivity and attention problems. ADHD is highly prevalent in forensic populations. Estimates of ADHD rates vary from 10–70% in prisoners compared to only 1–6% in the general adult population. Furthermore, ADHD in adolescence and adulthood is associated with elevated levels of criminal behavior. Hence, previous research indicates high levels of ADHD in forensic psychiatric care. One explanation for the high rate of antisocial behavior in patients with ADHD is the limited inhibition and impulse control inherent to ADHD, which may lead to impulsive behaviors, such as reactive aggression and criminal actions.” (p. 62)

“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 symptoms of ADHD, such as impulsivity, attention problems, forgetfulness, reduced planning skills, reduced motivation, and disorganization. […] 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. In particular, behavioral and mood disorders, substance use disorders, cluster B personality disorders are highly prevalent comorbidities in patients with ADHD.” (p. 62)

“In addition to the relation between psychopathology and no-show rates in patients with ADHD, no show rates may be related to psychosocial problems, and treatment and demographic factors. […] As a result of impaired social functioning, individuals with ADHD often experience interpersonal difficulties, such as having fewer friendships, more marital difficulties, employment problems, and family dysfunction than individuals without ADHD.” (p. 62)

“In a previous study on this topic, no-show rates were studied in a sample of forensic patients with ADHD in a Dutch forensic outpatient center. Patients with ADHD missed about 17% of their appointments. These no-show rates were associated with features related to the start of treatment. Specifically, not showing up on the intake appointment and no-shows at the first appointment after the intake procedure was associated with higher no-show rates overall. Disorder-specific symptoms (i.e., symptoms that are indicative of particular mental health disorders), such as internalizing problems and dependency problems, were not associated with no-show rates in that study, but the researchers did not use systematic research instruments to measure these symptoms. In the current study, the relationship between disorder-specific symptoms and no-show rates is examined in a more systematic way.” (p. 62)

“The high rate of ADHD in forensic patients and the comorbidity of ADHD symptoms with other psychopathological and social problems highlight the importance of conducting research in this specific setting. More insight into rates of no-shows in forensic patients with ADHD is needed to effectively reduce no-shows. To this end, we examined the relationship between no-show with disorder-specific symptoms and general psychological well-being in a group of 60 forensic patients with ADHD in The Netherlands. 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.” (p. 63)

“Participants were recruited from a Dutch forensic psychiatric outpatient clinic located in four cities in the southwest of The Netherlands. The patient population varies in the type of psychiatric disorders (e.g., ADHD, Autism, Antisocial Personality Disorder). Patients receive individual or group therapy for their disorder(s) and related delinquent or aggressive behavior. There are a number of disorder-specific treatment programs, but these programs all share the main goal of decreasing patients’ risk for (re-)offending. Patients are either treated compulsory as part of a criminal sentence, or are treated voluntarily after referral by a general practitioner or health care professional. Patients start their treatment with an intake procedure. When they fail to show up at two consecutive intake appointments, they are discharged from the forensic outpatient clinic and therefore are not included in the current study. If ADHD symptoms are observed during the intake procedure (and if patients have not yet been diagnosed with ADHD in another mental health institution), patients receive extensive psychological and psychiatric assessment directly after the intake procedure in order to determine whether they qualify for the diagnosis ADHD (i.e., see measures; ADHD). […] Based on clinical observation and psychiatric assessment, patients are evaluated on (1) whether or not they have an intellectual disability (i.e., IQ = 70), and (2) if they qualify for another, severe, DSM-diagnosis that should be the primary focus of therapy, including psychotic disorders, severe mood disorders, and severe substance dependency (i.e., to a degree that patients are not able to attend treatment appointments sober). If these conditions can be ruled out, patients are recommended for the specialized multimodal treatment program for adults with ADHD and aggressive and antisocial behavior, developed at the clinic. This program adheres to the principles of the risk-need-responsivity model. […] Furthermore, patients are offered psychological treatment for comorbid psychiatric disorders, and substance-related problems if applicable, and are offered “side modules”, such as pharmacotherapy, practical support, and help with social difficulties, financial, work-related, or daily routine problems.” (p. 63)

“To be included in the current study, participants had to be between 18 and 65 years old, have a diagnosis of ADHD in combination with aggressive and/or delinquent behavior, and have received treatment within the forensic outpatient ADHD treatment program between January 2013 and July 2015.” (p. 63)

The final sample included 60 male adult patients with ADHD with aggressive and/or antisocial behavior (M age = 35.9, SD = 8.6) who received treatment at the clinic for more than 1 year on average (the average length of treatment was 471.8 days). Approximately 87% of the patients were in treatment voluntarily, 8.3% received mandatory treatment, 5% were in treatment voluntarily but awaited court appointment for the committed offense.

“Patients who met the inclusion criteria and agreed to participate, were asked to fill out a questionnaire. Data on no-show rates was based on all treatment appointments that patients had received from the start of their treatment until July 2015, and the timeframe in which no-show rates were examined therefore were dependent of treatment duration at that time. Data were obtained from the electronic patient files retrospectively.” (p. 64)

“No-shows were defined as not showing up to treatment without giving notice or cancelling a treatment appointment within 24 hr, which is a rule that patients are informed about at the start of their treatment. Information on no-show rates were obtained from Electronic Patient Files, including the total percentage of no-shows (i.e., higher scores indicate more missed appointments), no-show on the intake-interview (no = 0, yes = 1), and no-show on the first appointment after the intake procedure is completed (no = 0, yes = 1).” (p. 64)

“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). In the clinic, psychological assessment for ADHD comprises the administration of the Diagnostic Interview for Adults with ADHD (DIVA). DIVA is a semi-structured interview that is based on DSM-IV criteria.” (p. 64)

“Disorder-specific symptoms were assessed via four subscales of the Adult Self-Report [ASR]. This 126-item self-report questionnaire is suitable for adults between 18 and 59 years and is designed to measure facets of DSM-oriented problem behavior.” (p. 64)

“General psychosocial well-being was assessed via the adaptive functioning scales of the ASR. The adaptive functioning scales include items concerning friends, spouse or partner, family, job, and education.” (p. 64)

“Electronic Patient Files were used to obtain background information, such as age, ethnicity, living situation at time of inclusion in this study, level of education, level of intellectual functioning (e.g., below-average, average, or above-average, estimated by clinical observations), type of treatment (i.e., voluntarily or mandatory), and treatment waiting times. Information about comorbid Axis I and II disorders as classified on the DSM-IV were obtained. These disorders were either diagnosed through psychiatric consult and/or personality assessment directly after the intake interview.” (p. 65)

“The aim of the present study was to examine psychopathological and psychosocial correlates of no-show rates in forensic patients with ADHD. 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. As such, antisocial individuals may have more problems with showing up for treatment compared to others. Moreover, we found that somatic problems were positively associated with no-show rates, such as having experienced symptoms of palpitations, nausea, and vomiting in the past six months. Evidently, physically not being able to travel from one place to another results in higher no-show rates.” (p. 66–67)

“The finding that anxiety problems were associated with lower rates of no-shows, corresponds to earlier studies on anxiety problems and punishment sensitivity.” (p. 67)

“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 due to the relatively small number of patients with DIVA scores, which limited the statistical power of the analyses. […] 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. This idea is also supported by research suggesting that patients with ADHD are less future-oriented and are more delay-aversive than healthy controls. However, more research is needed to confirm our finding and to examine which ADHD symptoms or underlying symptom deficits are in particular related to higher no-show rates.” (p. 67–68)

“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. We had no prior hypothesis about this relationship, and have not examined it systematically. Therefore, this finding should be interpreted with caution. […] A tentative explanation for these findings is that patients with multiple diagnoses, who are thus more severely impaired, might not be ready to participate in outpatient treatment and consequently do not show up at appointments. Receiving treatment in an outpatient clinic may be difficult because it requires patients to be able to execute a number of complex tasks, such as being able to organize and plan ahead the journey to the outpatient clinic. Such tasks may be more challenging for patients with ADHD and additional psychopathological problems.” (p. 68)

“Our hypothesis that higher rates of no-shows were negatively associated with psychosocial well-being was not supported by the data. This contrasts with earlier research showing that social support of family members can be a protective factor against no-show. However, because we only assessed the quality of the relationship that patients have with different family members and friends, we may have missed important additional features of these social ties, such as the nature of the relationship and characteristics of the network members.” (p. 68)

“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. However, there are some methodological explanations for our findings [substance abuse may not be a discriminating factor for no-show rates].” (p. 68)

Translating Research into Practice

“We showed that antisocial personality problems, anxiety problems, and somatic problems are associated with no-show rates in patients with ADHD. Therefore, patients who display such problems may also be at higher risk of reoffending. Furthermore, in line with earlier findings on rates of no shows in general psychiatry, we found a trend suggesting that symptom severity of ADHD was associated with higher rates of no-shows. 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 organization, 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

“Because there are only a few female patients who are treated at the clinic, only male patients were included.” (p. 63)

“The findings of this study should be interpreted with some limitations in mind. First, there were several methodological limitations. The small sample size has limited the statistical power of the study, and a significant number of missing data on some variables may have resulted in less reliable outcomes in our statistical analyses. […] Additionally, the almost exclusive use of self-reports may have biased the results. […] Finally, no systematic research instruments were used to diagnose comorbid Axis I and II disorders, which warrants caution for interpreting our findings and data. […] Second, because the data on no-show rates were retrospective in nature, it was not possible to link the reported disorder-specific symptoms and psychosocial factors to particular moments of no-shows in time, but only to the number of missed appointments over a specific treatment period. Because of this design, we were also not able to control for the type of treatment that patients received. […] Thus, some of our results maybe confounded by differences in medication use between patient with low and high rates of no-shows.” (p. 68–69)

Join the Discussion

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Authored by Kseniya Katsman

Kseniya Katsman is a Master’s student in Forensic Psychology program at John Jay College of Criminal Justice. Her interests include forensic application of dialectical behavior therapy, cultural competence in forensic assessment, and risk assessment, specifically suicide risk. She plans to continue her education and pursue a doctoral degree in clinical psychology.

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