ADHD in Forensic Settings

Research suggests there is a disproportionately high concentration of ADHD individuals involved with the CJS, and for these individuals criminal justice procedures often interface with a complex web of behaviour, substance use and mental health issues. International studies from the USA [6], Canada [7], Sweden [8, 9], Germany [10–12], Finland [13] and Norway [14] report that up to two-thirds of young offenders and half of the adult prison population screen positively for childhood ADHD, and many continue to be symptomatic with rates reported at 14% in adult male offenders [15] and 10% in adult female offenders [10]. In young offenders rates are around 45% [12, 16]. A UK study of personality disorder wards in Forensic Mental Health Services found similar screening rates (33%), with a sizeable number of individuals in partial remission of symptoms [17].

UK prison studies have indicated a rate of 43% in 14-year-old youths [16] and 24% in male adults screening positive for a childhood history, 14% of whom had persisting symptoms [15]. Those with persisting symptoms accounted for eight times more aggressive incidents than other prisoners and six times more than prisoners with Antisocial Personality Disorder. They had a significantly younger onset of offending by around 2.5 years (16 vs. 19.5 years); and they had a significantly higher rate of recidivism [18]. ADHD was the most important predictor of violent offending, even above substance misuse.

Thus the rate of ADHD in the CJS far exceeds that in the general population, and offender behaviour, both within and outside of prison settings, is something that society cannot afford to ignore. The higher rate of ADHD individuals involved in the CJS however is not paralleled by the knowledge, skills and training of practitioners in the disorder and who are involved in their care. NICE Guidelines for ADHD [1] were comprehensive in their recommendations for service delivery, emphasising the need for integrated services reflecting developmental needs across the lifespan, including forensic services. Establishing who, out of the 'mixed bag' of individuals within forensic services has a diagnosis of ADHD and will benefit from ADHD treatment as a first-line primary intervention (rather than treatment targeting substance use or other mental health problems) is an important question.

Offender Health

A central tenet is that prisoners should be considered as part of the community and treated within mainstream services with access to the same standards of health and social care as the rest of the population. Nevertheless, it is recognised that there exists a sub-group of individuals who have particular difficulty navigating the system, perhaps due to poor educational ability, disturbed mental state, and/or substance misuse. By supporting these individuals in their care and through the provision of integrated services, the justice they receive will also be supported.

Offender Health now exists as a partnership between the Ministry of Justice and the DoH and, to date, the focus has been to:

1) Develop mental health transfer protocols to facilitate the transfer of those with severe mental illness to mental health settings.

2) Introduce an Integrated Treatment System, which draws together clinical interventions for prisoners (e.g. methadone maintenance and psychosocial interventions).

The Health and Criminal Justice Programme Board is supported by a National Advisory Group, which provides independent, evidence-based advice to the Board on the developing agenda, and highlights examples of good practice and the commissioning of in-depth studies in areas of interest. Thus this National Advisory Group will provide a mechanism for UKAAN to raise the profile of ADHD offenders at the highest level.

However, the volume and scale of activity within the CJS will influence what can realistically be achieved in terms of ADHD screening, assessment and treatment, and new developments must be integrated with existing protocols and run in a system at high capacity. Health inequality is common in the prison population for many reasons (e.g. personal and socio-economic, community, lack of continuity, failure to access general services), and the DoH has expressed commitment to raising standards for the benefit of prisoners and with a view to improving longer term outcomes such as a reduction in reoffending and positive integration into the community. However there is no 'quick fix' as most prison inmates are young men with complex healthcare needs, including alcohol and substance misuse problems and psychological problems. On the other hand health assessments and interventions often have to be rapidly implemented as approximately half of prison inmates stay in prison for an average of six months or less. Nevertheless there is room for innovation - screening at prison reception has improved and non-health staff are now involved in a preliminary screening process, which triggers a more comprehensive assessment, if required, conducted by health staff. The Integrated Treatment System is the appropriate pathway for introducing ADHD assessment and management as this will include after-care arrangements, e.g. for treatment post-discharge.

The Bradley Report

Police Services

The Criminal Intelligence System database includes mental health data and, once improved, screens will be standardised and introduced nationally providing an efficient and cost-effective way of sharing data and alerting staff to particular needs (in line with confidentiality legislation). Currently a Risk Assessment screen is given to every person received into custody and this includes questions about current mental state (e.g. risks posed by depression, suicidal ideation and self-harm). This triggers a follow-up primary care screen within 48 hours (to which ADHD items could be added) and/or contact with a forensic medical examiner to ensure that the individual is fit to be detained and interviewed. It also identifies individuals who require regular observations (e.g. to prevent suicide). For those fit for interview, other provisions can be made. In the UK for example, if a detainee is suspected of having a mental health need they must be supported by an appropriate adult (AA) during interview. The AA can give advice to all parties, furthers communication and ensures that the interview is fair, however even when ADHD is recognised, detainees will not necessarily be entitled to an AA unless triggered by some additional problem (e.g. learning disability). It is important to note that for many young offenders the AA will be a parent and, given the hereditary nature of ADHD, this in itself may have implications for the custody process. Furthermore, some countries do not have the AA system in place, in which case the vulnerability of detainees with ADHD (recognised or unrecognised) is more serious as they get no additional support. It is recognised that the introduction of improved screening may result in more detainees requiring an AA, and a revised AA scheme is due to be introduced, providing opportunities to introduce ADHD training and/or psychoeducational materials on ADHD recognition, treatment and management.

In completing any screen, detainees may be resistant to engage with officers who have arrested or detained them, thus it is important that screens are completed sensitively to avoid disclosure being limited if detainees perceive stigma associated with their endorsing mental health problems. Language barriers are routinely overcome by the use of interpreters who can attend the police station within two hours. Cultural barriers also need consideration, as does the perception that if a mental health need is disclosed or suspected, the criminal justice process will be lengthened.

Courts Services

Should ADHD be recognised at any stage of the court process, it could be referred as necessary to health professionals and/or the Probation Service to assist the court in its sentencing decisions. The National Probation Service provides pre-sentence reports to assist the judiciary with sentencing decisions. Some reports are described as 'Standard Delivery' taking up to three weeks (i.e. involving more serious offending and/or complexity of offender needs) and others are 'Fast Delivery' taking up to five days. Considerations necessitating the request of psychiatric reports arise from Section 157 of the Criminal Justice Act 2003 which places an obligation upon the court to consider a medical report in "any case where the offender is or appears to be mentally disordered" (s157 (1)) "unless the court is of the opinion it is unnecessary" (s157 (2)). Section 207 of the same Act also requires evidence of a registered medical practitioner if a mental health treatment requirement as part of a community order is required. Currently some court areas are developing service level agreements for the provision of such reports as suggested within the Bradley Report [19].

There is a Government expectation that the proportion of Fast Delivery Reports will increase to 70%, therefore ADHD screening needs to be built into initial screening processes (which vary across probation areas) in order to flag up whether the greater level of assessment provided by a Standard Delivery Report is required. With this in mind, probation staff would need training to screen for ADHD and learn how and from where to access diagnosis and treatment. The most likely procedure would be referral to a forensic psychiatric service for a comprehensive assessment. An area for development is for Local Criminal Justice Boards to establish effective protocols with health service providers to ensure that there are cost effective and practical arrangements for diversion and treatment for Court users with mental health problems and/or learning disabilities.

Probation Services

As part of the National Offender Management Service, the probation service is made up of 42 Probation Trusts that operate independently from each other to manage offenders and monitor them through the orders imposed by the courts (Sentences). Offender Managers provide interventions, (e.g. Accredited Programmes, Employment Training and Education and Community Payback) and monitor their clients' progress and, while there are national standards, each Trust and is encouraged to tailor responses to local needs and priorities and the offender profiles within their areas. Joint Needs Assessments are thus conducted between the National Offender Management Service and Primary Care Trusts (PCTs) resulting in targeted Offender Care Pathways that also reflect national initiatives (this is captured within the regional Offender Health Delivery Plan). One such initiative is the provision of mentoring/peer education services invested in by Probation Trusts and PCTs (e.g. the emergence of 'Peer Health Educators'). These initiatives are in the early stages of development (relatively speaking) but have a significant role to play in an offenders' journey as they provide continual support for the offender from custody to the community. Thus Peer Health Educators could develop their knowledge and skills about ADHD and prompt referrals from Offender Managers.

A useful tool for the identification of need is the Offender Assessment System (OASys), which has the potential to provide further determination of what barriers may exist for an offenders' ability to adhere to their rehabilitation requirements. OASys provides an opportunity for the identification of non-criminogenic needs with work ongoing to identify how Offender Managers can be made aware of issues such as ADHD, thus influencing the care pathway for an individual, and the use of OASys for this purpose could well be in addition to any local assessment tools that exist.

Whichever stage an offender is at (police, courts, prison, on licence) a protocol would need to be established for the effective identification of which offenders have ADHD so that this can be taken into account in terms of assessing offending behaviour (e.g. court reports, proposals made to sentencers) and ensuring that the interventions meet offender needs (in order to maximise their chances of compliance and successful completion). Any protocol would need to be established with each Probation Trust, ideally working in partnership with other agencies, including health, thus providing the best means of ensuring that the needs of offenders with ADHD are identified, diagnosed and met.

Prison Services

More informally, wing staff are the 'eyes and ears' of the prison. They interact with inmates on an intensive, daily basis and, whilst they usually lack the ability to describe perceived difficulties in medical terms, they are well placed to identify when a prisoner is 'different' or unwell.

Prison reception health screens are currently being reviewed. The current procedure (the 'Grubin' screen) is a two-part procedure comprising a brief screen for depression and suicidal ideation followed by a more comprehensive health screen to which ADHD items could be added. Currently around half of individuals entering the prison system complete both sections. While ADHD could be incorporated into this screen, it is important to maintain the brevity of the screen. Furthermore, several needs will compete with ADHD for inclusion (e.g. autism, learning disability, physical illness etc), however given the high rate of ADHD among prisoners involved in institutional critical incidents, we need to lobby for ADHD to be prioritised. A substantial barrier to the identification of ADHD and the delivery of mental health care in prison is the high turnover of inmates. The prison population nears 90,000 with around 200,000 new names introduced each year, and over 50% of prisoners serve less than six months before moving on to community supervision. In addition, the frequency of inter-prison transfers means that data-sharing protocols across authorities will be essential.

Forensic Mental Health Services

Rates of ADHD are disproportionately high in personality disorder wards in forensic mental health services (early data from an ongoing study at the high-secure Broadmoor Hospital indicate a prevalence of 25%), and addiction populations (20%) [25]. The persistence of ADHD symptoms has been associated with elevated rates of critical incidents (specifically verbal aggression and damage to property) within personality disordered patients detained under the Mental Health Act [17], and with the average length of stay in medium security being two to four years (and costing c.£170,000 per year) there is ample opportunity for a comprehensive screening and diagnostic programme to be introduced.

Within mental health services there is an existing infrastructure into which ADHD awareness will fit. In order to successfully build on this framework, two important factors were identified:

1) The development and provision of accessible information and resources for staff and patients and their families.

2) The development and provision of a monitoring checklist to record assessment and prescription information for the patient, which can be completed by multidisciplinary staff.

However, whilst routine screening is conducted on admission to forensic inpatient services, this is not routinely conducted in community services where the majority of ADHD offenders with mental disorder are likely to be found. Existing screening procedures, where provided, are unlikely to include ADHD, and in some cases ADHD may be misdiagnosed (e.g. as personality disorder), thus emphasising the importance of training for professionals in ADHD assessment and diagnosis, which does not currently feature in generic training curricula.

Pharmacological treatments for ADHD

The use of pharmacological treatments for ADHD in children is well established in the UK and across Europe, with approximately 1% of the child population receiving stimulants or atomoxetine for ADHD [32]. The pharmacological treatment of adults with ADHD is similar to that in children, since drug treatment trials have been found to be equally effective in adults as children [33]. Overall the effectiveness of stimulants or atomoxetine in adults compares well to other drug treatments for mental health disorders, such as the use of antidepressants to treat depression; and for this reason NICE [1] and other recent expert reviews [1, 34] conclude that drug treatments for ADHD in adults are the first line choice when considering treatment options. This is particularly true when treating people with ADHD with severe levels of impairment and/or associated behavioural problems, when implementing rapid and effective treatments is thought be most important [1]. In adults there is as yet insufficient evidence to recommend psychological approaches as first line treatments, although this might be suitable in less severe cases. It is however important to pay attention to the NICE recommendation that drug treatments for ADHD should always be considered as part of a comprehensive treatment programme addressing psychological, behavioural and educational or occupational needs.

The recommended first line treatment for ADHD in adults is methylphenidate, followed by dexamphetamine or atomoxetine. Currently none of the drugs available to treat ADHD in the UK are licensed for use in adults, although treatment trials required by the regulatory bodies are underway that are expected to lead to extension of current licensing to the adult population. Atomoxetine is licensed for use in adults but only as a continuation of treatment first initiated during childhood or adolescence (before the age of 18 years). This situation is an anomaly because in many cases pharmacological treatments are licensed for use in adults but not paediatric populations and the risks associated with stimulants are not thought to be greater in adults. Particular concerns in adults include cardiovascular changes such as increased pulse and blood pressure that need to be carefully monitored, although this is similar to many other drugs used in adults. Despite these potential problems, having fully reviewed available evidence, UK national guidelines from NICE [1] recommend that in most cases pharmacological treatments are used once the diagnosis of ADHD has been made in adults.

The main treatment effects recorded in drug treatment trials are improvements in levels of inattention, hyperactive and impulsive behaviours and symptoms. Studies have also documented a wider range of improvements on social and academic function and an individual's overall sense of well-being. Some studies have specifically reported on reductions in aggressive behaviour, with stimulant effect sizes being similar to those reported for core ADHD symptoms [35]. An important series of studies investigated mood symptoms in addition to core ADHD symptoms and found similar effect sizes for both sets of symptoms when treating adults with ADHD with either stimulants or atomoxetine [27, 28]. For example, in one study of methylphenidate it was found that there was a correlation in the improvement of mood symptoms with ADHD symptoms during the treatment process of around 0.8 [28].

The nature of the symptoms that improve with stimulant medication can best be understood from the descriptions given by patients being treated for ADHD [36]. The rapid onset and marked impact of stimulants on ADHD symptoms is widely reported by people with ADHD taking such treatments. Typically people say that within a short time of taking the medication they feel calmer, more focused and better able to initiate and complete tasks. They report improvements in their ability to focus their attention, greater motivation and reward from usual activities of daily life, improved ability to plan ahead with less forgetfulness and increased levels of self-organisation. Impulsive symptoms are reduced with less subjective and objective restlessness. Problems such as mood swings greatly reduce and they find that situations in which they were particularly prone to become irritable or aggressive, such as waiting turn in queues or being irritated by other peoples responses, are now far more easy to manage. Overall there is greater control over behaviour and people may find they can stop and think more easily, rather than acting in a more impulsive and unthinking way. Subjectively people find that their mind is much calmer, more relaxed and they are better able to focus their thoughts. This is often described as part of an overall reduction in both mental and physical overactivity. People with ADHD typically describe their mind as always on the go, a kind of ceaseless mental activity with multiple short lived or flitting thoughts going on at the same time. This kind of excessive and unfocused internal mental activity is often associated by people with the tendency to talk over or interrupt people or their difficulty in attending to what people are saying to them, including following simple instructions. Overall people treated for ADHD report numerous changes in their mental state and behaviour which can be best characterised as improved self-control over core processes such as attention, impulsive responding and emotional control.

Delivery of drug treatments within the prison setting and abuse potential

Prescribing stimulant medication in CJS settings may be perceived as unattractive due to the drug being (currently) off-licence, the controlled drug status for stimulants and abuse potential. The potential for abuse was recognised by NICE who suggest that atomoxetine may be a better option where this is a particular concern because it is not a controlled drug and is a non-stimulant. However the overall effectiveness of stimulants, which NICE consider to be greater than atomoxetine, means that stimulants should also be considered either as a first line or second line choice. The delivery of medication within the prison setting should not however be a problem, since many prisons already run medication-based programmes for controlled drugs (e.g. methadone maintenance) and successfully adhere to protocols and policies that aim to reduce the chances of mismanagement.

The abuse potential for stimulants is however often overstated and usually by professionals who are not familiar with the effects of stimulants in the treatment of ADHD. First, we know from follow-up studies that the use of prescribed stimulants is not associated with an overall increase in drug abuse problems and may be associated with a reduction in illicit drug use [37–39]. Second, one of the main problems in treating children with ADHD as they grow older is keeping them on stimulant medication, even when this thought to be important to their continued mental health. This is because many adolescents no longer wish to engage in the treatment program and prefer to stop medication, even when it is perceived by others (parents, teacher or professionals) to be beneficial. There is therefore no indication that stimulants are addictive when prescribed for the treatment of ADHD. Third, studies in the US where stimulants are more widely prescribed point towards the main misuse of stimulants being diversion to increase performance at work or in education, however the rates of stimulant prescriptions in the US is far higher than in the UK to high functioning individuals where academic performance is the main concern. Overall the potential benefits of treatment, particularly in highly impaired individuals, appear to greatly outweigh the potential risks. Risk assessments should however be carried out in each individual case and consideration given to the particular drug formulations prescribed.

Drugs with low abuse potential include atomoxetine which is a non-stimulant and long acting formulation, those where the stimulant cannot be easily extracted for injection, such as methylphenidate OROS in the UK or skin patches and long acting lisdexamphetamine in the USA.

Psychological treatments for ADHD

NICE recommends that drug treatment should always form part of a comprehensive treatment plan that includes psychological, behavioural and educational advice and interventions. Medication is likely to improve adherence to psychological treatments such as offender treatment programmes and other therapeutic, educational and occupational activities. Thus addressing ADHD may have a two-fold impact in crime reduction, first by directly treating the disorder (e.g. reducing symptoms) and secondly by improving engagement with rehabilitative programmes. Specific programmes have been developed that integrate the two, and there is some evidence from studies in children that psychological therapies, in combination with drug treatments lead to greater sustained effects and greater effects on comorbidity [40]. However, although recent research supports the use of cognitive behavioural methods for treating adult ADHD [41–43], treatment with psychological therapy remains an under-researched area and a priority for future research. Psychological and psycho-educational programmes are available that provide advice on how to adapt treatments to suit those with ADHD [e.g. 44, 45]. The R&R2 ADHD offender programme [45] for example, is currently being evaluated in a randomised controlled trial (RCT) in Iceland. Preliminary results from a community pilot study of R&R2 has shown it to be effective in treating ADHD adults with comorbid difficulties, with the effect continuing to improve at three-month follow-up [46].

The commissioning of treatment

Providing access to regular treatments of the right kind is generally a commissioning matter, however the evidence base needs to be expanded to evaluate newly developed, specialist programmes. A useful starting point might be to simply promote awareness of ADHD among those facilitating treatments.

Treatment protocols in prison are supported by PCT commissioning through links to care standards in the wider community, and it may be beneficial to take a phased approach. It may be sensible to target those with longer sentences, maximising opportunity for initiation and optimisation of treatment. Identification and treatment of ADHD inmates is likely to reduce behavioural disturbance within the prison setting but additionally improve engagement with therapeutic, education and occupational activities. Education is provided on a smaller scale in prison than in the community (e.g. two or three to a class) and one-to-one attention will optimise motivation, co-operation and learning. Greater understanding about ADHD and associated problems will maximise treatment benefit and increase the chance of successful rehabilitation and constructive skills acquisition.

The NHS is now responsible for the delivery of prison healthcare, however in the past practitioners in forensic mental health services have lacked confidence in prescribing stimulants, perhaps due to a lack of clinical guidelines. Thus, treatment plans need to be multidisciplinary and comprehensive, and need to recommend stimulant/drug therapy as a precursor to psychological work addressing criminogenic factors.

In the short-term, outcome needs to be assessed using symptom screens and staff measures to assess behavioural improvement (e.g. in treatment engagement, reduction in institutional disturbance). Longer-term effects may include transfer to a lower (and therefore less costly) level of security with greater opportunity to access rehabilitation, and reduction in antisocial and criminal behaviour.

In the community, after discharge from prison, some individuals will have contact with probation staff and/or be subject to a Multi Agency Public Protection Arrangements (MAPPA) review. This service provides psychosocial support for prisoners in the community, thus effective links with local mental health services and support agencies, and information sharing is necessary.