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17 Mar 2021

Young S, Cocallis K. J Neural Transm (Vienna) 2021; Epub ahead of print

There are reportedly higher rates of ADHD in offender populations and it is estimated that the prevalence rate within the prison setting of youths and adults with ADHD is 25.5% (95% confidence interval 20–32.4; Young et al, 2015). However, the prevalence of ADHD within the criminal justice system does not differ significantly between the genders (Baggio et al, 2018; Young et al, 2015). The aim of this literature review was to investigate the vulnerabilities of offenders with ADHD and how this may affect assessment and treatment of this population.

Vulnerabilities

The authors determined that compared with individuals without ADHD, those with ADHD are more likely to have greater contact with the police; be younger at first arrest and conviction; have multiple convictions and be at increased risk of later and faster arrest, convictions and imprisonment. Low educational attainment is considered one of the most prominent environmental risk factors for subsequent criminality, and adolescents and young adults with ADHD are at increased risk of experiencing educational difficulties.

Additionally, individuals with ADHD may be vulnerable during police and court proceedings, as research suggests that they may show greater compliance, but not interrogative suggestibility, than individuals without ADHD, and are more susceptible to providing false confessions or information. The personal risk of providing a false confession could be exacerbated by the context (association with criminal peers and peer pressure) and situational factors (length of detention and use of leading questions). Also, ADHD could be associated with difficulties in acclimatising to a restricted environment (such as a custodial setting), which could promote behavioural disturbance on police staff. Within a prison setting, individuals with ADHD have an eight-fold increase in aggressive incidents compared with individuals without ADHD and a six-fold increase when controlling for antisocial personality disorder. Furthermore, ADHD has been found to strongly correlate with increased risk of self-harm, especially in females, and suicidal behaviour in detained settings.

Assessment

Diagnosing ADHD within a prison setting may be difficult due to limited availability of resources and limited expertise among staff to identify and assess ADHD. The authors suggested that diagnosing ADHD may also be complicated by an inability to obtain evidence of functional impairment if individuals are not participating in activities that would allow their functioning to be assessed. Additionally, the transient nature of the prison population and possible lack of keeping and updating medical records throughout prison transfers is another diagnostic obstacle. Structured diagnostic interviews are recommended for the diagnosis of ADHD within the general population; however, none have been specifically developed for offenders with ADHD. Continuous performance tests (CPTs) aim to provide an objective marker of ADHD symptoms (Hall et al, 2016). CPTs could overcome the shortcomings of subjective reporting that may occur when diagnosing offenders with ADHD due to poor childhood behaviour recollection. The individuals could also minimise the extent of their ADHD symptoms and associated impairments. However, according to the authors, CPTs are not recommended to be used as a stand-alone diagnostic measure of ADHD within the criminal justice system population. Nevertheless, CPTs may be useful for determining specific individual difficulties and consequently identifying rehabilitation targets.

Treatment

The authors believe that there is evidence that undiagnosed and untreated ADHD may lead to substantial use of resources and financial burden. However, treating offenders who have an ADHD diagnosis could result in a return on investment in terms of social value and costs to wider society. The authors recommended that a multimodal treatment approach that combines pharmacological and psychological interventions could be utilised to treat offenders with ADHD. Pharmacological interventions may reduce core ADHD symptoms and increase functional outcomes within the offender population. The aim of non-pharmacological interventions is to aid the individual with ADHD to develop skills to accomplish life goals, facilitate behavioural change, improve their quality of life and manage ADHD-related functional impairments.

The authors highlighted that ADHD is disproportionately represented in the criminal justice population. Individuals with ADHD encounter the criminal justice system at a younger age; have higher rates of recidivism, behavioural disturbances in custody and health risk behaviours; and have lower health-related quality of life compared with individuals without ADHD. Also, assessment and treatment within this population may be more complex due to their presentation and likelihood of comorbid psychiatric disorders. The authors emphasised that cultivating understanding of ADHD within this setting is vital, as early identification and treatment could lead to gains across the criminal justice, healthcare and social care sectors.

Read more about the vulnerabilities, assessment and treatment of offenders with ADHD here

Baggio S, Fructuoso A, Guimaraes M, et al. Prevalence of attention deficit hyperactivity disorder in detention settings: a systematic review and meta-analysis. Front Psychiatry 2018; 9: 331.

Hall CL, Valentine AZ, Groom MJ, et al. The clinical utility of the continuous performance test and objective measures of activity for diagnosing and monitoring ADHD in children: a systematic review. Eur Child Adolesc Psychiatry 2016; 25: 677-699.

Young S, Moss D, Sedgwick O, et al. A meta-analysis of the prevalence of attention deficit hyperactivity disorder in incarcerated populations. Psychol Med 2015; 45: 247-258.

Young S, Cocallis K. ADHD and offending. J Neural Transm (Vienna) 2021; Epub ahead of print.

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