Providing appropriate pharmacological and non-pharmacological interventions in prison populations is a process reliant on prison staff and offender self-awareness of ADHD symptoms and treatments, the availability of trained mental health clinicians, and the administration of specifically targeted multimodal treatments. Although female offenders often present with a more complex profile due to pregnancy, motherhood, and high levels of co-morbidity [13], all pharmacological and non-pharmacological treatments can be administered irrespective of age and gender. During pregnancy, ADHD pharmacological treatments can be used, but should be restricted to cases where treatment is required to reduce significant distress and behavioural problems, where the potential risks of no treatment outweigh risks of treatment [41].
It will be necessary to educate offenders on the efficacy of multimodal treatments and expected outcomes and to obtain informed consent for permission to treat. Following a new or confirmed previous diagnosis of ADHD and a careful evaluation of possible co-morbid conditions, we recommended the following multi-modal treatment for incarcerated offenders, as summarized in Fig. 1.
We have observed that staff support in pharmacological treatment and involvement in psychological treatment programmes has a positive and direct impact on offender adherence to and engagement in the prescribed treatment plan. Staff lack of knowledge about ADHD can interfere with medication administration and offender engagement in psychological treatment programmes. Conversely, staff awareness of ADHD symptoms, and observation of positive treatment effects, usually increases engagement with and support for the treatment process, and makes it much more likely they become involved in the delivery of offenders’ psychological treatments.
According to principle and law, punishment for criminal offence is the loss of liberty, and prisoners’ human rights are fully protected unless restrictions are unavoidably and demonstrably ‘necessitated by the fact of incarceration’ [42]. The Mandela Rules expressly state the fundamental prohibitions on torture and inhumane treatment, and emphasize that imprisonment is itself the punishment and should not carry additional ‘pains’ [42]. Solitary confinement is arguably considered to be an additional ‘pain’, with especially significant adverse effects for people with serious mental illness; it has negative psychological consequences and restricts the inmates access to mental health services [43, 44]. Although ADHD is often un-recognized as a serious mental illness, we contend that severe cases should be recognized as such, and particularly when ADHD related behaviours are severe enough to lead to isolation of sentenced prisoners. We have observed that solitary confinement exacerbates prisoners’ ADHD symptoms [45], and recommend increasing efforts to ensure that offenders with ADHD are prevented from receiving this punishment. The same argument can be applied to severe cases of other mental health disorders, so it not unique to ADHD. This may require prisons to reduce the use of solitary confinement for all prisoners and to ensure that it is only used as a last resort, for short periods of time to manage acute situations, and never as a punishment.
Given the high prevalence of neurodevelopmental disorders (traumatic brain injury, communication disorders, dyslexia, learning disabilities, autistic spectrum disorder, and ADHD) among young offenders [46], it is especially important to staff the prisons appropriately with educational psychologists and speech/language therapists to meet their needs adequately. Currently, prisoners with these needs are either inadequately supported or receive these necessary services only upon release.
Pharmacological treatments for offenders
Treatment with ADHD medication is effective in reducing symptoms of inattention, hyperactivity, and impulsiveness [47] and is also reported to be associated with a significant reduction in violent reoffending (around 42%) on release from prison [22] and similarly in criminal convictions [23]. By reducing their ADHD symptoms, the offender is likely better equipped to engage in and benefit from psychological, educational, and occupational interventions. It is important for offenders and prison staff to understand that, although ADHD medication reduces ADHD symptoms, it does not cure the disorder, and concomitant non-pharmacological treatments are nearly always necessary to help the offender manage ADHD related problems and improve their behaviour.
Given the lack of sufficient high quality evidence from randomized-control trials for treatment among prisoners, it is important to emphasize that clinicians trained in the diagnosis and treatment of ADHD should administer ADHD medications, to carefully asses for risks of abuse potential and possible risks of exacerbating other co-morbid conditions. Medication can be administered to all offenders irrespective of age and gender, but type and dosage should be made on an individual basis, especially in the case of pregnancy.
With respect to psychoeducation, the offender needs to be educated on the benefits and side effects of pharmacological treatment and the implications of remaining untreated or discontinuing treatment. This education is not only necessary in obtaining informed consent to treat, but is important in engaging them in their own treatment. Such engagement will encourage offenders to take an active role in their treatment and can cause them to perceive some control over their situation, which can have an empowering effect. Offenders need to be given adequate opportunities to provide feedback on the medication’s effect and to titrate for therapeutic doses. Support during the early stage of treatment is critical in helping offenders take full advantage of the reductions in ADHD symptoms and in helping manage the medication's side effects.
We recommend prescribing stimulant medications first line because these have a quicker response than non-stimulants and a greater average effect size. Drugs with a high risk of abuse, such as immediate release preparations of methylphenidate (MPH) and dexamfetamine (DEX), should be avoided in prison populations due to the potential for abuse. Injected or insufflated (snorted) MPH and DEX cause a rapid release of dopamine that can give the user a ‘high’. This does not occur, however, when these medications are taken orally. The oral administration of therapeutic doses of MPH or DEX is therefore essential in reducing the abuse potential of stimulant medications [48].
We recommend prescribing long acting or modified release preparations of methylphenidate (MR MPH) that are difficult to take in any other way than by mouth (e.g. Concerta XL). Lisdexamfetamine (Elvanse) is a long acting preparation that has a unique advantage, because even if injected, the active drug is released slowly at a similar rate in to the brain as when taken by mouth. These extended release formulations are usually taken in the morning and give active control of symptoms for 8–14 h in most cases.
MR MPH, lisdexamfetamine, along with all other stimulants, are controlled substances and thus subject to strict dispensary logistics that often interfere with treatment compliance and efficacy. Restrictions on movements within the prison can limit the regular and timely administration of stimulant (and other) medications. In some cases, staff are needed to escort prisoners to the healthcare unit to receive medication, although in most cases prisoners can take themselves to a dispensary, or receive medication from a wheeled cart. Escorting not only over burdens the staff, but stigmatizes the offender and further complicates adherence. Although stimulants are controlled substances, they can usually be dispensed in the same manner as other non-stimulant medications that are not kept in possession, which improves adherence. The practice of dispensing drugs varies by prison, but non-stimulants are easier to dispense as there are less procedures for nursing staff to follow.
Preliminary results of a pilot study of Concerta XL in adult offenders with ADHD (CIAO) indicated a significant reduction in total critical incidents (assaults, fights, property damage, self-harm, drug use, and acts of disobedience) among prisoners in the UK who were treated for 12 weeks. In relation to dose, over half of the prisoners took 18-36 mg and only 4% took the maximum dose of 90 mg, indicating a lack of drug seeking behaviour with regard to Concerta XL in this population. This was in line with our clinical experience that suggests greater abuse potential for sedative antidepressants and antipsychotics than stimulants within the prison population. The findings from this study were successfully used to secure further funding the National Institute of Health Research (NIHR) for an ongoing randomised controlled trial in 200 young adult offenders following a similar study design. We anticipate that the reports from these studies will inform optimal medical treatment of ADHD in prisons and raise public awareness for the need for effective treatment of offenders with ADHD (unpublished report for pilot study available from PA).
In alignment with national guidelines [49], we recommend prescribing non-stimulants, such as atomoxetine in adolescents under 18 and adults, and/or long-acting guanfacine in adolescents under 18: when stimulants do not adequately treat symptoms or cause adverse effects, when a sustained 24-h effect is required, or there is clear drug seeking behaviour for stimulant medications (a rare event in our experience). In adults there is no data for the use of guanfacine, so atomoxetine is the non-stimulant of choice. Non-stimulants are easy to administer as they are not a controlled substance and would therefore bypass dispensary logistics and potentially improve treatment compliance. Although atomoxetine and long-acting guanfacine take several weeks to reach optimal effect, they have a significantly longer effect on symptom control over a 24-h period and can maintain their effect when individual doses are missed. They are particularly useful for patients who have a rapid return of severe ADHD symptoms once stimulant effects wear off during the day. Additionally, non-stimulants are the medication of choice for patients with a previous history of stimulant abuse.
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 .
Non-pharmacological treatments for offenders
Non-pharmacological treatments in the prison setting consist of psychological, educational, and occupational treatment programmes. These interventions should aim to: facilitate changes in life-long patterns of poor behavioural control, increase life satisfaction, build useful skills, and help the offender plan for civilian life after release. Mentorship programmes embedded in the treatment plan are likely to be additionally beneficial. Pharmacological treatment of ADHD symptoms will enable offenders who respond to such treatments to better engage in and benefit from non-pharmacological interventions in this setting. It is important to emphasize that, although ADHD medication can improve symptoms, concomitant non-pharmacological treatments are nearly always necessary to help the offender manage ADHD related problems and improve their behaviour.
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 [19,20,21], 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.
