It is unknown if academic debates incorporating the aetiology, diagnosis and management of ADHD influence the public’s perception of the condition (Speerforck et al. 2019). Public beliefs and attitudes toward mental illness play a role in an individual’s decision to seek professional help (Angermeyer et al. 1999). In addition, self-stigma and negative attitudes towards those with mental illness decrease the likelihood of personally considering psychiatric help (Angermeyer et al. 2017). The aim of this study was to assess the prevailing beliefs and attitudes of the German population towards ADHD, including possible causes and management, in children and adults.*
A representative population survey of German-speaking adults (aged >18 years) was conducted in Germany between March and May 2017. The sample contained slightly more women, more elderly and more educated persons in comparison with the German general population. A computer-assisted telephone interview was completed by 1008 adults. During the interview, a previously recorded unlabelled case vignette of a child (n = 505) or an adult (n = 503) with all core symptoms of ADHD according to the Diagnostic and Statistical Manual of Mental Disorders – 5th Edition was played. The two vignettes differed with regard to the subject’s age (12 or 35 years) and contextual factors (school or work). The gender of the person in the vignette also varied at random. Initially, survey participants were asked how they would label the depicted problem (open question), to estimate changes in the prevalence of the depicted problem during the last 20 years, and whether they identify the problem as a mental illness. Survey participants were subsequently asked to rate possible causes of the problem described in the vignette and to what extent they would recommend possible interventions/treatments.
Illness recognition and questions about ADHD
- More survey participants identified the condition depicted in the vignette as ADHD or hyperactivity disorder when the subject of the vignette was a child compared with an adult (ADHD: 29% vs 20%, p = 0.011; hyperactivity [disorder]: 28% vs 21%, p = 0.046).
- The depicted symptoms were categorised as mental illness by 44% of survey participants hearing the child vignette and 55% hearing the adult vignette (p = 0.012).
- The majority of survey participants believed the number of people with such problems had risen during the last 20 years (74% child vignette, 83% adult vignette; p = 0.013).
- Only three-quarters of survey participants believed ADHD to be a real disorder (75% child vignette, 77% adult vignette; p = 0.533), despite over 90% having heard of the term before (91% child vignette, 92% adult vignette; p = 0.665), and 20% (both vignettes; p = 0.977) did not consider ADHD a real disorder.
- The most frequently endorsed beliefs about possible causes of the problem depicted in the child vignette were: too much television or Internet (58%), a lack of parental affection (58%), a broken home (55%) and problems with parents or friends (54%). The most commonly endorsed causal beliefs after hearing the adult vignette were: a stressful life event (56%), pressure to perform (49%), problems with partner or family (49%) and chemical imbalance of the brain (49%).
- Biogenetic causes including: chemical imbalance in the brain (39% vs 49%; p = 0.023), brain disease (31% vs 41%; p = 0.017) and drug abuse (21% vs 36%; p < 0.001) were more frequently rejected for the child vignette compared with the adult vignette.
- Causes related to family and social life, including too much television or Internet (58% vs 44%; p = 0.002), lack of parental affection (58% vs 48%; p = 0.015) and poor parenting (33% vs 20%; p < 0.001) were more likely to be endorsed for the child vignette compared with the adult vignette.
Help-seeking and treatment recommendations
- The majority of study participants recommended seeking professional help (71% child vignette, 75% adult vignette; p = 0.340).
- Most participants who initially opted to do nothing and wait, or to try to do something with the help of family and friends (n = 149 [child], n = 115 [adult]) recommended seeking professional help when informed that the condition of the subject in the vignette would not change over several months (78% child vignette, 82% adult vignette; p = 0.368).
- The most frequently endorsed help-seeking recommendations after hearing the child vignette were seeing a psychotherapist (68%), educational psychologist (68%) or psychiatrist (56%); whereas seeing a psychotherapist (71%), psychiatrist (67%) or general practitioner (56%) were most frequently recommended after hearing the adult vignette.
- When participants were forced to recommend a single action, those hearing the child vignette recommended consulting a psychotherapist (30%), educational psychologist (29%) or psychiatrist (24%), whereas those hearing the adult vignette recommended consulting a psychotherapist (30%) or general practitioner (29%).
- For children and adults with ADHD, concentration and memory training (76% child vignette, 79% adult vignette; p = 0.419), psychotherapy (64% child vignette, 63% adult vignette; p = 0.859) and autogenic training (63% child vignette, 66% adult vignette; p = 0.498) were most frequently recommended.
- Stimulants (6% child vignette, 5% adult vignette; p = 0.965) and sedatives (2% child vignette, 4% adult vignette; p = 0.100) were rarely recommended for the treatment of child or adult ADHD; in fact, these were largely recommended against (stimulants: 66% child vignette, 68% adult vignette [p = 0.702]; sedatives: 87% child vignette, 80% adult vignette [p = 0.040]).
- When participants were forced to recommend a single treatment, psychotherapy (37% child vignette, 40% adult vignette) and concentration and memory training (36% child vignette, 32% adult vignette) were the most frequently endorsed.
The study had several limitations. Firstly, the authors acknowledged that reactions to the vignettes may have differed if a selection of symptoms had been presented and if the cases were labelled. Secondly, the study may not be generalisable, since survey participants were of a higher age and education level than the general German population. Additionally, given that the study was carried out in Germany, the findings are unlikely to apply to other sociocultural contexts.
The authors concluded that public opinion does not reflect evidenced-based guidelines for diagnosis and management of ADHD, and recommended that this must be considered by healthcare professionals when counselling patients and caregivers.
*The study aimed to address the following questions: (1) does the German population recognise typical symptoms of ADHD, and is ADHD considered to be a real disorder? (2) what are the suspected causes of ADHD? (3) how many people recommend seeking professional help for a person with the core symptoms of ADHD? And if so, what is expected from professionals? (4) what causal beliefs are associated with a higher approval of professional help or an identification as mental illness or real disease? (5) do disorder-related beliefs differ regarding the age of the person depicted with ADHD?
Angermeyer MC, van der Auwera S, Carta MG, et al. Public attitudes towards psychiatry and psychiatric treatment at the beginning of the 21st century: a systematic review and meta-analysis of population surveys. World Psychiatry 2017; 16: 50-61.
Angermeyer MC, Matschinger H, Riedel-Heller SG. Whom to ask for help in case of a mental disorder? Preferences of the lay public. Soc Psychiatry Psychiatr Epidemiol 1999; 3: 202-210.
Speerforck S, Hertel J, Stolzenburg S, et al. Attention deficit hyperactivity disorder in children and adults: a population survey on public beliefs. J Atten Disord 2019; Epub ahead of print.