ADHD in forensic settings Susan Young Imperial College London and Broadmoor Hospital
Police Custody Study Learning Disability (N=195) 6.7% screened positive Conduct Disorder (N=194) 75.3% screened positive for CD ADHD (N=196) 32% screened positive for childhood ** 23.5% screened positive for current 18.5% full diagnostic interview (adjusted) ~ 0.3-2% ~ 1.7% boys 5-10yrs ~ 0.6% girls 5-10yrs ~ 3-4% UK child ~ 2.5% world adult Co-morbidity Of those who screened positive for ADHD, 96% also screened positive for co-morbid CD and/or LD. **London riots (August 2011) increased to 38% for those processed in the 2 weeks following the start of the riots. Increase was not significant - possibly due to small sample size. Young et al., 2013, BMC Medicine
Behaviour in custody The number of requests for food/drink and telephone calls was recorded during time spent in custody. Significant positive correlations between number of demands made and......childhood CD (r=.20, p<.01)...childhood ADHD (r=.16, p<.05)...and current ADHD symptoms (r=.28, p<.001) (Controlled for length of time spent in detention) For each diagnosis, those screening positive made significantly more demands than those screening negative. Multiple regressions showed (1) ADHD and (2) alcohol drive demanding behaviours over and above comorbid CD. Young et al., 2013, BMC Medicine
Vulnerable in police interview Significantly impaired immediate and delayed verbal memory No difference in suggestibility scores Strategy of don t know even for recognition items 1 Current symptoms of ADHD associated with compliance and false confessions 2 1 Gudjonsson et al, 2007, Personality and Individual Differences. 2 Gudjonsson et al, 2008, Psych. Med.
Vulnerable in Court Regular breaks Avoid lengthy questions and complex language Questions broken down in small stages. Important info put across directly and simply Explain problems/deficits to jury, as may become frustrated, impatient, labile in the witness box.
Prevalence of ADHD in mental health settings N Screen positive Estimated prevalence ADHD Forensic MI 81 9% 0% Forensic PD 52 36% 13% Anxiety 54 13% 6% Addiction 274 20% 12%
Personality Disordered Offenders with ADHD and Critical Incidents in Forensic Mental Health Settings 6 5 Mean score 4 3 2 1 Non-ADHD n = 46 ADHD n = 23 0 Mean overall incident score* Mean overall incident score Verbal aggression* Verbal aggression Physical aggression Physical aggression Damage to property* Damage to property Incident Arson Arson Self-injury Severity of aggressive behaviour Self-injury Severity of aggressive behaviour 33% of male PD patients in a high secure forensic mental health service had ADHD symptoms. The ADHD group had a significantly greater number of incidents overall, especially Verbal aggression and Damage to property. Young et al., 2003. J Forensic Psychiatry & Psychology
Young et al. (2015). Psychological Medicine
Data Extraction Prevalence of ADHD Age (Youth/Adult) Gender Design (Screening/Interview) (Current/Retrospective) Study Location Young et al. (2015). Psychological Medicine
Prevalence of ADHD in youth and adult offenders from clinical interview 26.2% (95% CI 18.4-37.5) 30.1% (95% CI 19.3-35.2) No significant difference between adults (>18 years) and youths (<18 years) Young et al. (2015). Psychological Medicine
Prevalence of ADHD in male and female offenders from clinical interview 26.1% (95% CI 19.3-35.2) 30.3% (95% CI 23.9-38.4) No significant difference between males and females (all ages) Young et al. (2015). Psychological Medicine
No Gender x Age Interaction p=.242 Young et al. (2015). Psychological Medicine
Geographical Location 65.2% 6.6% Significant difference between countries examined individually (15 countries, p<0.0001) Young et al. (2015). Psychological Medicine
Geographical Location 26.9% 32.1% 17.6% However, when grouped into regions there was no significant difference: North America vs. Europe vs. Other (Brazil, Nigeria, Iraq and South Korea) Young et al. (2015). Psychological Medicine
Comorbidity with ADHD in incarcerated samples 80% 70% 2.07* 5.06* 3.58* ADHD Youths ADHD Adults 2.89* 60% 50% 5.26* Prevalence 40% 30% 2.10* 1.89* 20% 10% 0% Conduct Disorder Substance Use Disorder Mood Disorder Depression Anxiety Disorder Personality Disorder Comorbid to ADHD Appears to be an incremental effect in comorbidity in adulthood - all OR s significant for adults compared to non-adhd inmates For youths, OR s were only significant for mood disorder (possibly due to greater heterogeneity in effect sizes for youth samples) Young et al. (in submission)
ADHD was associated with higher rate of recidivism (controlling for ASPD) 50 * 40 Mean frequency 30 20 10 0 Total Convictions * * Property Violent Traffic violation Drugs Other Non-ADHD (N=171) ADHD (N=27) Offence Mann- Whitney U test * p <.05, two-tailed test Heroin was the best predictor of total convictions; ADHD was the best predictor of violent convictions (official records) Young et al., J Psychopharm, 2011
Young et al., 2009, PAID These slides are intellectual property of Susan Young and must not be reproduced Critical incident ratings made by prison staff ** ** No significant association with ASPD. Significant association with ADHD (controlling for ASPD)
Young et al. J Psychopharm, 2011 These slides are intellectual property of Susan Young and must not be reproduced Significant predictors of offending Total offences 1. Regular heroin use (β =.23) 2. Child ADHD (β =.16) Violent offences 1. Child ADHD (β =.26) 2. Alcohol dependence (β =.22) Drug offences 1. Regular crack cocaine use (β =.20) Other offences (e.g. breach of bail, criminal damage, arson and sexual offences) 1. Regular heroin use (β =.23) Property offences No significant individual predictors Similar pattern for 'current' ADHD symptoms Predictors investigated were age at first conviction, current ADHD symptoms, ASPD, alcohol and substance dependence (Millon scales), and regular use (weekly +) of heroin and crack cocaine (self-reported on the Substance Use Questionnaire).
Beyond the Gates - Probation Survey Poor response rate (11%) - few had received training in ADHD. Estimated 8% of caseload had ADHD vs 20% actual, including ADHD clients had specific difficulties (neuropsychological dysfunction, lifestyle and compliance problems) that hindered meaningful engagement with the service and/or rehabilitation. Difficult to manage due to internal processes (motivation and engagement) and external processes (inadequate or inappropriate interventions). Screening provisions are needed in probation settings, together with training for staff. Young et al., 2014, AIMS Public Health
Costs of ADHD? UK average prison population is 85,120. Estimated prevalence of prisoners with ADHD is 25.5% = 21,280 prisoners 1 25.5% is conservative youth rates were 30.1%. Lichtenstein et al. found crime rate decreased by 36.5% when patients were taking medication for ADHD 2 This means there will be 7,767 fewer prisoners with ADHD in custody. 1 Young et al, 2014, Psychological Medicine 2 Lichtenstein et al, 2013, New England J. of Medicine
7,767 x 26,138 = 203,013,846 Decrease of people in custody Average cost per prisoner per year (excludes prison overheads) Potential saving of over 203 million per year 2 billion over 10 years
Conclusions High rates of offenders are presenting across justice services. In prisons x5 increase of ADHD in youth offenders, and x10 in adult offenders. They have substantial comorbid psychopathology in comparison to non-adhd offenders and there seems to be an incremental effect towards adulthood. ADHD is being missed and/or misdiagnosed
Conclusions It is associated with higher rates of recidivism. A history of ADHD in childhood predicted violent offending. It is associated with demanding behaviours and incidents of aggression in custody settings. Identification and treatment of ADHD in young offenders is likely to be associated with a reduction in crime and lead to substantial savings across the justice system
www.psychology-services.uk.com Follow me: @DrSusanYoung1 Thanks to the collaboration of colleagues at Broadmoor Hospital, Institute of Psychiatry, HMP Craiginches and University of Iceland and special thanks to Gisli Gudjonsson, June Wells, Jon Fridrik Sigurdsson, Philip Asherson, Emily Goodwin, Rafael Gonzalez and Ottilie Sedgwick. Thanks to Janssen- Cilag and Shire for research funding.