Clinical practice gaps, uncertainties and need for guidance
As with many other chronic conditions, ADHD rates are higher in custodial settings than in the general population, estimated to be five times higher among youth prisoners and ten times higher among adult prisoners (Konstenius, Larsson, Lundholm, Philips, van de Glind, Jayaram-Lindstrom, et al., 2015; Moore, Sunjic, Kaye, Archer, & Indig, 2016b; Westmoreland et al., 2010; Young, Sedgwick, et al., 2015; Young & Thome, 2011).
Reported ADHD rates depend largely on the age and gender of prisoners (higher in men and younger offenders) participating in studies, the methodology and definitions used. There may also be higher rates among Aboriginal prisoners (Moore et al., 2016b). Many prisoners positively screened for ADHD were never previously diagnosed (Moore et al., 2016b). Although many established ADHD screening tools may not reach the required levels of sensitivity and specificity that warrant screening of all people in prisons (Moore et al., 2016b), some studies have suggested modified tools that do meet sensitivity and specificity levels of over 80% (Young, Gonzalez, et al., 2016).
Among people in prison, ADHD is often complicated by substance misuse and co-occurring mental health disorders, including trauma histories (Konstenius, Larsson, Lundholm, Philips, van de Glind, Jayaram-Lindstrom, et al., 2015; Rosler, Retz, Yaqoobi, Burg, & Retz-Junginger, 2009; Westmoreland et al., 2010; Young, Sedgwick, et al., 2015).
The link with offending potentially arises from the major symptoms of ADHD (hyperactivity, inattention and impulsivity) (American Psychiatric Association, 2013) all of which increase the likelihood of being arrested (Kramer et al 2014), being incarcerated (especially at a young age) (Mohr-Jensen & Steinhausen, 2016), recidivism and violence (Lichtenstein et al., 2012; Moore et al., 2016b; Rosler et al., 2009).
ADHD symptoms also increase the risk of institutional aggressive disturbances/critical incidents in prison (Young, Wells, & Gudjonsson, 2011). ADHD is also associated with conduct disorder in children and later anti-social behaviour, and multiple socio-economic disadvantages and other criminogenic factors (Mohr-Jensen & Steinhausen, 2016).
If left untreated, symptoms create unnecessary challenges in our jails and juvenile facilities. There are, therefore, advantages to managing ADHD in custodial settings (Young et al., 2011) (see below). However, managing ADHD in custodial settings is difficult because many prison health systems are already overstretched and tend to focus their resources on acute mental illness and suicidal ideation. Many prisons are unable to offer mental health services to community standards (for example, regarding continuity of care).
This is particularly problematic within criminal justice systems with many points of transition for offenders between different parts of the service and agencies, particularly between juvenile to adult systems. Further, many people in prison experience socio-economic disadvantage, and co-occurring conditions (particularly substance use disorders), meaning that complexity is the norm. However, in prison, there may an opportunity to provide interventions that may be lacking or not be readily accessed in community settings.
There are potential benefits of addressing ADHD in prison. Treatment may:
- reduce symptoms (Ginsberg & Lindefors, 2012)
- reduce the rate of critical incidents in prison and make them safer places
- reduce the rate of recidivism after release (Chang, Lichtenstein, Langstrom, Larsson, & Fazel, 2016; Lichtenstein et al., 2012; Young et al., 2011)
- assist in the treatment of other disorders (such as personality disorders, substance use disorders, and anxiety disorders).
Specific ADHD symptoms likely to be associated with difficulties in prison include:
- impulsivity (lack of planning)
- mood instability
- difficulties with emotional control
- low frustration tolerance
- lack of organisation (Gudjonsson, Wells, & Young, 2012).
Many of these are effectively reduced with treatment.