Around one-fourth of the prison population meet the clinical diagnostic criteria for ADHD. There is also a high risk of comorbid psychiatric disorders amongst youth and adult prisoners with ADHD, and those with undiagnosed or untreated ADHD have poor clinical and functional outcomes. This report aimed to expand upon the consensus of the UK Adult ADHD Network to identify prison-system barriers preventing the appropriate management of ADHD. This study also provided a practical approach, based on expert consensus, to inform effective identification and treatment of prisoners with ADHD.
This report was developed by a multidisciplinary group of prescribing and non-prescribing clinical and academic experts with experience of working with prisoners with ADHD. The authors initially attended a meeting, hosted in November 2016 by the UK ADHD Partnership (UKAP; funded by Shire, now part of Takeda), which discussed how to identify and treat adult prisoners with ADHD. Researchers, prison staff, clinicians and patient representatives with expertise in offender mental health and ADHD also attended the UKAP meeting. The UKAP meeting included presentations,* discussions and group work, and attendees were tasked with providing practical solutions on a variety of topics, such as “Identification and assessment”, “Treatments and interventions” and “Care management and multi-agency liaison”. The consensus report was developed from the transcript of the UKAP meeting, in conjunction with the authors’ views and experiences, as well as published literature.
A brief summary of the key conclusions from the consensus report is presented below. The authors indicated that although these recommendations are mainly based upon experiences in the UK, they may also be applicable and adaptable to other countries.
Identification and assessment
- Prison staff must have an awareness of ADHD symptoms and psychiatric comorbidities. They must also have training to understand ADHD treatments, the expected outcomes of treatments, and how these treatments may affect the prison regime. Prison staff should also understand that for many prisoners, many psychiatric comorbidities are often secondary to ADHD.
- If rating scales are used, they must be sensitive to both inattention and hyperactivity/impulsivity symptoms, and a clinical diagnostic interview and a suitable primary screen must be used for both youths (Comprehensive Health Assessment Tool [CHAT]†) and adults (Brief Barkley Adult ADHD Rating Scale [B-BAARS]‡).
Interventions and treatment
- Use of appropriate pharmacological and non-pharmacological treatment, as well as psychoeducation about ADHD (e.g. symptoms, psychiatric comorbidities, medication, side effects of medication and expected outcomes) should be provided to all prisoners.
- Educational and occupational programmes, particularly those that advance vocational, creative, technical and/or athletic skills, should be made available to enhance engagement.
Care management and multi-agency liaison
- Within the criminal justice system, educational and mental health services should work closely.
- Each prisoner must have a care-plan coordinator whilst in prison, and a care plan should be established to aid with medication management.
- To aid transition and ensure continuity of care and ADHD medication, a care plan for release should be provided for each prisoner. This care plan should also provide the prisoner with links to supportive services and agencies following their release from prison.
- A critical time intervention approach should be determined to support the prisoner through the release process and aid implementation of the care plan and engagement in healthcare services.
The authors stated that although this consensus report identified a practical approach to treat prisoners with ADHD, future research is required to optimise these approaches and measure their success on health-, behaviour- and offence-related outcomes following implementation in prisoners with ADHD. Additionally, more research is required to assess the needs of female prisoners with ADHD. The authors also emphasised that future research should aim to determine the financial and societal benefits of effectively treating prisoners with ADHD, as this will demonstrate the cost-effectiveness of appropriate intervention and may lead to increased governmental support and subsequent changes in criminal justice and mental health service policies.
In concluding, the authors indicated that use of this consensus report will aid the identification and treatment of prisoners with ADHD, and they expect that if used appropriately, this will have a positive impact on both prisoners and society, leading to decreased utilisation of resources and reduced rates of re-offending.
*The meeting began with four presentations: “The Facts: what we know from empirical data”; “Needs, problems, and obstacles when assessing and treating ADHD in a young offender institution”; “Needs, problems, and obstacles when assessing and treating ADHD in an adult prison”; and “Beyond the gates: needs, multi-agency liaison, and the care pathway”
†The CHAT is mandated by the National Health Service England for use in youth offender institutions in England and Wales. The mental health section of the CHAT is a validated semi-structured interview designed to screen for all health issues amongst youth offenders and covers physical health, mental health, substance abuse and neurodisability. The CHAT takes approximately 1 hour to complete and is available electronically. Although the CHAT has poor specificity for ADHD, it is sensitive in identifying mental health problems including ADHD, so can be used as a primary screen to flag potential mental health issues before a more detailed assessment is conducted
‡The B-BAARS is a short, six-item screen with excellent specificity and sensitivity for predicting ADHD in offending adults, and is available for free. The authors indicated that, in their experience, the B-BAARS is more suitable for prison populations compared with the Adult ADHD Self-Report Scale
Young S, Gudjonsson G, Chitsabesan P, et al. Identification and treatment of offenders with attention-deficit/hyperactivity disorder in the prison population: a practical approach based upon expert consensus. BMC Psychiatry 2018; 18: 281.