6.1 People in the correctional system

6. Considerations – Subgroups

Clinical Questions

What services should prison mental health services provide across life-stages?

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
hyperactivity
restlessness
lack of organisation (Gudjonsson, Wells, & Young, 2012).

Many of these are effectively reduced with treatment.

Summary of narrative review

By virtue of the population at risk and the nature of the major symptoms of the condition, ADHD occurs at a greater rate in custodial settings than in the community and is often complicated by co-occurring conditions. Unidentified and untreated ADHD increases the likelihood of offending, being arrested and incarcerated, being involved with prison incidents and recidivism. However, many prison health systems are overstretched and tend to focus their resources on the acutely unwell or the suicidal.

There are also challenges in the identification and provision of assessment and treatment (for example, screening, provision of psychological approaches, and some types of medication, particularly stimulants). If these challenges can be overcome, there are many benefits to active diagnosis and treatment of ADHD in prisons, including for prisoners, and their families, the prison itself, the criminal justice system and the community.

Recommendations, therefore, include the provision of screening and treatment opportunities, including coordination and integration of care with community services.

Recommendations

Clinical considerations for implementation of the recommendations

The costs of providing care to those in custody with ADHD will be borne largely by medical services (Young et al., 2018), and will depend on the capacity of existing medical teams and services and the configuration of these. If the recommendations are accepted, including ADHD warranting identification and treatment to an equivalent standard as provided in the community, the resources required would be significant and beyond the capacity of most prison health services.

The potential benefits of treating these people would, however, likely offset these costs to a significant extent, in the form of improved quality of life (Young et al., 2018), reduced incidents in custody, and reduced recidivism and violence in the community after release (Lichtenstein et al., 2012).

Many health providers within justice systems aim to provide care and treatment to standards equivalent to those in the community, but there are many barriers to achieving this. People entering the justice system have rates of co-occurring mental health conditions exceeding the prevalence and complexity of those seen in the community. Often services provided are inadequate to meet the need and are provided in counter-therapeutic environments.

As with many other areas in mental health, the care of women and younger prisoners and of juveniles presents specific issues to the justice system. Women with ADHD are less likely to be identified in prison (Young, Sedgwick, et al., 2015) and, therefore, may not receive effective support. There is a high frequency of co-occurring conditions in women (particularly anxiety, depression, PTSD, substance use disorders, self-harm and borderline personality disorder), which may mask the presence of ADHD (Young, Sedgwick, et al., 2015) in those who are imprisoned. Therefore, training in awareness and identification of ADHD would be important for clinicians in the justice system.

In youth offenders, it is particularly important that any primary and secondary screening processes focus on ADHD symptoms, followed by comprehensive assessments where necessary as per this guideline. Carers and parents need to be involved where possible, particularly to organise post-release support and optimise engagement with treatment. If aged below 18, parental consent for treatment may be needed, but this may be problematic, particularly if the family is somehow involved in the offending or if the family has been victimised. Most juvenile justice services have a greater rehabilitative function when compared to adult services (Young et al., 2018).

Potential outcome measures include incident rates in prison, treatment engagement, transfers to lower level of security, and recidivism. An economic analysis to assess the cost-benefit for prison health systems to provide sufficient resources to allow for identification and treatment of all with ADHD would assist in the development of service scopes that include ADHD.

Some aspects of treatment, such as the use of stimulants, may require particular attention to be delivered safely to people in custody. The treatment of ADHD within prison by the use of stimulants has attracted considerable debate. The introduction of stimulants would lead to greater challenges in the safe management and administration of medication and lead to greater attempts at subversion of prescribed medication.

Careful consideration needs to be given to how safe and secure dispensing, and administration practices can be ensured. This includes keeping the person receiving stimulant medication safe from other people in prison seeking their medication.

It is vital for the credibility of prison ADHD services that the right dose gets to the right prisoner at the right time without subversion, abuse, diversion or standover bullying tactics on their return to the wing. The justification of treatment with stimulants in custody needs to be fully understood and accepted by the prison authorities.

It is imperative that stimulants only be prescribed in accordance with state rules and regulations and with the full understanding, knowledge, cooperation and monitoring of custodial services. The risks of such subversion would need to be fully considered and carefully managed.

See Technical Report, section 11.6 for further details

6. Considerations – Subgroups