Identification and treatment of offenders with attention-deficit/hyperactivity disorder in the prison population: a practical approach based upon expert consensus

Primary screen

As is the case for many prisons, all youth offenders are subject to a reception screen upon admission. Screening preferences and practices vary greatly between institutions world-wide, and while no evident gold standard method exists, healthcare standards offer guidance for best practices for youth in secure settings [29]. Nurses with mental health experience usually administer the primary screen to assess the overall physical and mental health of the offenders.

The National Health Service England (NHSE) mandates using the comprehensive health assessment tool (CHAT) in youth offender institutions throughout England and Wales. Because of the NHSE requirements, we recommend using the CHAT as the primary screen in all youth offender institutions. The CHAT is a validated semi-structured interview designed to screen for health issues among all young offenders admitted to a secure facility [30]. CHAT is divided into four sections covering: physical health, mental health, substance abuse, and neurodisability. It is available in electronic format; however, the mental health section takes approximately one hour to complete.

Questions pertaining to ADHD symptoms are included in the mental health section of the CHAT, but because they focus on externalizing rather than internalizing symptoms the assessors will need to take extra care in considering all symptoms, including the inattention symptoms of ADHD. While we acknowledge the poor specificity of CHAT, it is a sensitive tool for detecting mental health problems that include ADHD. It is therefore important to emphasize that the CHAT should be used as a primary screen to flag potential mental health issues before going on to more detailed assessments.

If any chronic or serious mental health issue is suspected, then the offender should be referred for a secondary screen involving a more comprehensive assessment by a multidisciplinary mental health team including nurses, psychologists, and psychiatrists who are specially trained to recognize ADHD as well as other mental health conditions commonly seen in young offenders.

Secondary screen and clinical diagnosis

At the time of clinical assessment, we recommend that a trained clinician administer a standard validated rating scale such as the Swanson, Nolan, and Pelham teacher and parent rating scale (SNAP-IV) [31] and/or the Conners’ comprehensive behaviour rating scale (Conners’ CBRS) [32] to assist in making the diagnosis and to gather necessary collateral information. A diagnosis of ADHD usually requires supporting evidence from teacher, therapist, employer, or parent reports. In cases where screens indicate a possible ADHD diagnosis, we recommend that clinicians always conduct a full diagnostic interview for ADHD, as well as carefully assess for commonly occurring co-morbid conditions such as drug abuse, personality disorders, emotional problems, and learning difficulties. The ADHD Child Evaluation (ACE) [33] is one such tool used for assessing ADHD symptoms, possible co-morbid problems, and associated impairments. The ACE is a semi-structured diagnostic interview providing either DSM-5 or ICD-10 [7] criteria and is available in 19 languages free of charge in paper form. Those who are symptomatic on screening, but have a confirmed pre-existing diagnosis of ADHD may not require a diagnostic interview. This will largely depend on how long ago the diagnosis was made and is a matter of clinical judgment.

Primary screen

In adult prisons offenders are subject to a reception screen upon admission, to review their overall physical and mental health. In most institutions, however, the mental health section of the primary screen for adult offenders does not include questions pertaining to ADHD symptoms. For example, the screening tool Health & Wellbeing Needs Assessment Toolkit (HWBNA) published by the Public Health England Health & Justice Team, to be used in all 118 adult English Prisons, has no mention of ADHD. Screening preferences and practices vary greatly between adult institutions world-wide and while no evident gold standard method exists, several valid tools are available [25].

Some prisons have adopted the short screening version of the Adult ADHD Self Rating Scale (ASRS), [34] yet in our experience, because of the wording of the questions, this is less suitable for prison populations. We identify this as problematic and therefore suggest using the brief version of the Barkley Adult ADHD rating scale (B-BAARS) as part of the primary mental health screen. The B-BAARS is a short, six-item screen with excellent specificity and sensitivity for predicting a diagnosis of ADHD in the offender population, and is available free of charge [33, 35].

Ideally, nurses with mental health experience should administer the primary screen in adult institutions as this increases the validity of the screens by ensuring questions are understood and properly rated by the offenders [36]; however, this is usually not the case. Nurses in adult prisons and police stations tend to be physical health nurses without mental health experience. This may cause difficulties with identifying ADHD symptoms, as well as other mental health disorders, in the primary screen and may prevent triggering a secondary screen among adult offenders. Because of this, we recommend employing nurses with mental health experience throughout the criminal justice system offender pathway to adequately assess the overall physical and mental health of adult offenders.

If any co-morbid mental health disorder is suspected, then the offender should be referred for a secondary screen involving a more comprehensive assessment by a multidisciplinary mental health team including nurses, psychologists, and psychiatrists who are specially trained to recognize ADHD as well as other adult mental health conditions.

Secondary screen and clinical diagnosis

In cases where a B-BAARS score or results from another screen indicate a likely ADHD diagnosis, we recommend a clinician trained in the assessment of ADHD conduct a full diagnostic interview. This may include the full 18-item version of the BAARS to ascertain the severity of ADHD. Whenever possible, the interview should be supported by collateral reports (e.g., parent, therapist, and previous medical history) to gain a comprehensive description of their symptoms and impairments across the lifespan. While informant reports are not always required, they can be particularly useful as offenders with ADHD often have very poor recollections of their childhood behaviour and tend to minimise impairments arising from ADHD. Extra care is needed when evaluating all of the offenders’ symptoms to avoid focusing only on externalising behaviours.

We have identified three comprehensive semi-structured diagnostic interview tools that are suitable for adult prison populations: the Conners’ Adult ADHD Diagnostic Interview for DSM-IV (CAADID) [37], the Diagnostic Interview for ADHD in adults (DIVA-2) [38, 39], and the ACE+ (ACE for adults) [40]. While the CAADID and DIVA-2 are the more established methods, the ACE+ has an advantage because it includes a section that considers coexisting conditions and whether they are co-morbid or reflect a differential diagnosis. For this reason, the ACE+ may be preferred when establishing the diagnosis of ADHD in the presence of co-morbid disorders. The DIVA-2 is widely used throughout Europe and should be used in conjunction with a systematic assessment of co-morbidity because it does not include a prompt to evaluate the presence of common co-morbid conditions. Both the ACE+ and DIVA-2 are available in many languages other than English and are free of charge in paper form.

Each of these interviews provides age-appropriate examples of each of the ADHD symptoms that can be applied when evaluating adults. Relevant descriptions of adult ADHD symptoms include: internal restlessness; excessive mind wandering that interferes with tasks such as reading, writing and listening to TV or conversations; getting bored quickly then losing ability to focus; and feelings of irritability and impatience when waiting in queues. Clinicians also need to be aware that symptoms of emotional dysregulation such as frequent inappropriate levels of irritability, frustration, and anger (while not part of the formal diagnostic criteria) can be used to support the diagnosis [7].

While continuous performance tests (CPT) perform reasonably well at discriminating between people with ADHD from non-psychiatric controls, and may contribute to the diagnostic assessment, they are far less able to discriminate ADHD from other common psychiatric disorders seen in prison populations [38]. Given these validity issues and the logistical problems of bringing information technology equipment into prisons, we cannot recommend their use in prison populations.

Pharmacological treatments for offenders with co-morbid conditions

In the presence of co-morbid anxiety, autism spectrum disorder (ASD), aggressive behaviour, or mild affective symptoms, ADHD should usually be treated first, followed by a careful evaluation of the medication’s effect on the co-morbid symptoms. While adults with ADHD are reported to misuse drugs [50, 51], detoxification is provided by prison mental health services, and despite reports in the media about drug abuse in prison, there is no longer regular access to major drugs of abuse. Substance abuse is stabilised and under control in most cases in prison settings, so that diagnostic assessments and treatment for ADHD can proceed.

Symptoms commonly shared between ADHD and co-morbid disorders may be better managed with pharmacological treatments for ADHD rather than with pharmacological treatments for the co-morbid disorders themselves. For example, irritability and low mood symptoms secondary to ADHD are alleviated more effectively by ADHD medication than with antidepressants or antipsychotics. Similarly, we have observed that conditions such as post-traumatic stress disorder and borderline personality disorder sometimes improve following treatment of concurrent ADHD. Subsequent treatments for co-morbid disorders may be required and can be added one at a time to discriminate their effects. Conversely, in the presence of psychosis, bipolar disorder, and/or a clear depressive episode, ADHD should not be treated first. Care should be taken, however, to avoid mistaking the ADHD symptoms of emotional instability for the episodic mood changes of bipolar disorder or the chronic symptoms of a personality disorder.

In the case of co-morbid anxiety disorder, pharmacological treatment for the anxiety can be added if the stimulant exacerbates the anxiety. Alternatively, the stimulant can be discontinued and replaced by atomoxetine. In the case of co-morbid symptoms of aggressive behaviours, a low dose of quetiapine or risperidone may be added if the symptoms are not adequately treated by stimulants or atomoxetine. While high doses of quetiapine are sedative and are used to treat psychosis, low doses have a mildly sedative effect that can help reduce irritability and emotional liability associated with ADHD.

Unfortunately, there are insufficient studies of the treatment of ADHD in co-morbid cases, and offenders presenting with complex mix of co-morbidities. Our recommendations are therefore based on the experience of the authors, which are aligned with recommendations from guideline groups such as NICE [49]. In our experience, while a significant proportion of offenders with co-morbid conditions respond positively to the treatment of ADHD, there are cases that show limited or no response. Severe adverse effects on co-morbid conditions, including risk of psychosis, however appear to be extremely rare. The most common complaint is appetite loss. Overall, we conclude that while further work is needed to identify the predictors of good and poor response among patients with co-morbid conditions, the potential benefits of treatment outweigh the potential risks. The risks are minimised by careful monitoring of treatment effects during the titration phase of drug administration. In accordance with published guidelines [49], when titrating stimulants we recommend weekly assessments for 4–5 weeks, and less often for non-stimulants .

Offender psychoeducation

There is a need to change common misconceptions and stereotypes about ADHD symptoms and treatments. Young people and adults find it helpful to understand that ADHD is a neurobiological disorder evident early in life and distinct from other behavioural problems. It is especially important for offenders to understand that although ADHD is pervasive, treatment may help improve self-control and level of function. In our experience prisoners value improvements in attention span and reduced levels of physical restlessness and emotional impulsivity that would enable them to benefit from education. Mental health professionals working with prisoners with ADHD should provide a clear explanation of ADHD symptoms, treatments, and expected outcomes, and educate the offender on the potential risks of remaining untreated or discontinuing treatment. Additionally, we recommend giving offenders an easy-to-read pamphlet that briefly highlights some facts about ADHD.

Offender psychoeducation is an integral part of intervention that should be initiated during imprisonment to increase its efficacy and to avoid overwhelming the offender upon release. We commonly observe that offenders are not adequately educated about their condition and take a passive role in their treatment plan. Furthermore, we have observed that an offender’s increased understanding of their condition helps them to engage in their pharmacologic and psychological treatment programmes and increase their sense of self-empowerment.

Psychological treatment programmes

Many UK prisons implement offending behaviour programmes that focus on addressing the risk of future offending behaviour, but these do not provide treatment for clinical conditions for offenders with ADHD. We recommend implementing a neurocognitive intervention that addresses offending behaviour and ADHD related and other behavioural co-morbid executive function deficits such as: difficulty with time-keeping, organizing, planning, and self-regulating emotions and behaviour.

Given the logistical limitations inherent in correctional institutions (e.g. restrictions on movement and variations in sentencing), it is important that treatment programmes are suitable and feasible for the prison environment. Appropriate programmes include those that can be: completed in a relatively short amount of time (less than 4 months), delivered in a small group setting with about 10 to 12 inmates once or twice per week, and administered to all offenders irrespective of age and gender.

To augment and fortify interventions we recommend providing the offender with personal support from a mentor (i.e. coach or champion). Prison staff, officers, substance abuse staff, primary and secondary care clinicians, educators, volunteers, and when appropriate even fellow prisoners, can be trained to provide one-on-one skill-building sessions. These one-on-one sessions emphasize a personal approach and can help the offender bridge lessons from the therapy room to daily life.

To the best of our knowledge the only psychological treatment programme developed to address antisocial behaviour and executive functioning deficits is Reasoning and Rehabilitation 2 ADHD (R&R2ADHD). R&R2ADHD is a treatment programme based on cognitive behaviour therapy designed to build pro-social competence [18] and may be used in non-offender and prison populations. It can be administered to all offenders irrespective of age and gender and completed in approximately 2 months. The programme’s short duration, comprised of 15 treatment sessions deliverable up to 2 times per week, makes it favourable to ensure completion. R&R2ADHD has an additional advantage of being suitable for both youth and adult offenders. Furthermore, mentorship is embedded within the programme — whereof an assigned coach or mentor meets one-on-one with the offender between sessions to help them consolidate and apply newly learned skills in their daily life.

While the evidence for R&R2ADHD efficacy is predominantly community based with a majority of male samples [19–21], results from a pilot trial at Her Majesty’s Prison Youth Offender Institution (HMP/ YOI) Feltham (a level 3 youth offender institution in the UK) indicated high rates of completion and universally positive feedback from enrolled youth offenders. We observed that the positive impact of R&R2ADHD on the youth offenders with ADHD at HMP/YOI Feltham was even more significant when prison staff were involved in the treatment programme. Oftentimes prison staff and officers have an established rapport with offenders, and involving them seems to improve offender engagement in the treatment programme. According to the 2013 London Mayor’s Office for Policing and Crime (MOPAC) report, R&R2ADHD was mentioned as an example of good practice and has received the full support of London prison governors and lead staff [52].

Other psychological approaches that may be helpful include cognitive remediation therapy (CRT) [53] and dialectical behavioural therapy (DBT) [54]. CRT applies techniques historically used to treat individuals with traumatic brain injury (e.g. deficits in planning, time management, and attention, impulse control). DBT was developed for the treatment of borderline personality disorder. Ideally, psychological interventions should take an eclectic approach drawing on these paradigms as well as cognitive behaviour therapy (CBT). The Young-Bramham Programme, is one such CBT intervention that can be used for adolescents and adults with ADHD [55].

Educational and occupational treatment programmes

Children with ADHD are at an increased risk of academic underachievement [56] and repeating an academic year [57], therefore all prisoners should have numeracy and literacy assessments to identify academic impairments. An appropriate individualized education plan based upon academic assessments developed by the prison education department can be additionally informed by mental health screen results, and previous mental health and school records, pending prisoner consent to information sharing between departments. The CHAT screening tool assesses for learning difficulties in young people (in the neurodisability section, part 5). These results should be used in developing a young offender’s education plan, and will consequently inform overall holistic care.

It is important that the education plan addresses gaps in the offenders’ academic core skills, focuses on strengths, includes ADHD support strategies, and is appropriate for those disengaged from the education system. Education support workers and volunteers from outside private organizations can be helpful with implementing the education plan. While education services have information pertinent to learning difficulties, they do not automatically liaise with mental health services. We have observed that problems with information sharing are primary barriers that need to be to overcome. Therefore, we recommend an ad hoc liaison between mental health and education services to ensure effective intervention.

Prison rules most often require that offenders complete an academic course (related to reading and writing) before participating in technical skill-building workshops. Because symptoms of inattention, hyperactivity, and behavioural difficulties can prevent the offender from meaningful participation in academic courses, this requirement is inherently biased against them. Imposing this requirement upon offenders with ADHD who are at risk of disengaging from and failing the academic course may result in extended prison time. For example, in England and Wales, if an offender fails the Imprisonment for Public Protection (IPP) course they are subject to an increased prison sentence.

We recommend waiving the requirement to complete an academic course and directing offenders towards educational and occupational programmes that suit their strengths (e.g. creative, technical, and/or athletic skills). Focusing on their strengths may not only reduce the occurrence of extended sentencing, but also the rate of offenders with ADHD in solitary confinement. In cases where solitary confinement has not been averted, we recommend shortening the period(s) of isolation and giving the offender an activity to occupy them while confined.

Participation in technical skill-building workshops can provide hands on experience and the opportunity to learn occupational and technical skills useful for life during and after prison. In our experience, maintenance jobs throughout the prison (e.g., housekeeping, kitchen, and garden work) that provide the opportunity to be physically active and occupied, are highly sought after by ADHD offenders.

In addition to acquiring technical skills, it is important that offenders are taught necessary personal life skills to equip them to successfully navigate civilian life after prison and not re-offend. Given the likelihood of executive function deficits, offenders with ADHD most often need help planning how to attain their goals. Long-term desires and goals (e.g., health, wealth, and happiness) need to be broken down into realistic achievable short-term plans and goals (e.g., self-care and employment). R&R2ADHD [18] notably includes a module that focuses on offender needs of this nature.