The conclusion of NICE guidelines for the treatment and clinical management of adults with ADHD [1
] was that ADHD needed to be screened for and recognised, following which a referral to an expert in the diagnosis and treatment of ADHD should be made. The recommended first line treatment for adults with ADHD is methylphenidate, followed by second line treatments with either atomoxetine or dexamphetamine. In high risk populations consideration should be given to the use of atomoxetine as the first line choice, where abuse and/or diversion of stimulant medication are considered potential risks. Drug treatments for ADHD should always be considered as part of a comprehensive treatment programme addressing psychological, behavioural and educational or occupational needs.
The treatment of ADHD in the prison population is expected to have three main benefits. First, the reduction of symptoms of ADHD that impact adversely on behaviour within the prison setting, such as inattentiveness, physical restlessness, impulsive responding and mood instability. Second, the reduction of ADHD symptoms will enable individuals within the prison system to take better advantage of rehabilitation programs aimed at the reduction of recidivism and improved behavioural control. Third, the treatment of underlying ADHD may lead to improvements in comorbid disorders such as antisocial and borderline personality disorders, substance abuse disorders including addiction, and anxiety and depression including the risk for suicide.
We can therefore see that treatment of ADHD within offender populations fits well with the Risk-Needs-Responsivity principle, which proposes that treatment is targeted at the riskiest cases and at needs relevant to the service (e.g. treatment targeting criminogenic needs in offending populations). Programmes that adhere to the Risk-Needs-Responsivity principle, with strong strategies for reducing criminality, have been shown to be particularly effective in rehabilitating offenders and reducing recidivism [26
]. Working within this model, there are three broad aspects that relate to treatment for ADHD offenders:
1) Pharmacological treatments to alleviate ADHD symptoms.
2) Psychological treatments aimed at improving strategies for self-control and reduction of antisocial attitudes and behaviours.
3) Concurrent treatment of comorbid disorders.
Offenders with untreated ADHD can be particularly difficult to manage in prison/institutional environments. Individuals with high levels of ADHD symptoms were recently found to have an 8-fold greater number of critical incidents in a Scottish prison and a 6-fold greater number of critical incidents than inmates with Antisocial Personality Disorder [15
]; mainly consisting of verbal and physical aggression. Critical incidents of this type have also been found in personality disordered patients screening positive for ADHD and who are detained under the Mental Health Act [17
]. The Young study [15
] further found that the increased rate of critical incidents among prison inmates with ADHD could not be accounted for solely by co-occurring behavioural disorders, since the association with ADHD remained significant after controlling for Antisocial Personality Disorder. This suggests that there is something about ADHD itself that leads directly to an increased rate of critical incidents with prison/institutional settings, and these behavioural problems might therefore be expected to respond to treatments that reduce levels of ADHD symptoms.
The reasons for the particularly high rates of behavioural disturbance with prison inmates with ADHD are likely to stem from several sources related to the core syndrome of ADHD, including impulsive responding, mood instability, emotional dysregulation and low frustration tolerance [27
]. Gudjonsson and colleagues [31
] also found that prison inmates with ADHD have a particularly chaotic or disorganised style of behaviour that may also contribute to their behavioural problems. However, we also know that ADHD is associated with the development of conduct disorder during childhood and adolescence and this may lead to antisocial behaviours in adulthood. ADHD is therefore an important risk factor for the development of later antisocial behaviour. Left untreated, ADHD is likely to be an exacerbating factor that maintains antisocial behaviour and reduces the ability of an individual to alter their behavioural patterns.
Clearly ADHD has a greater impact on people than just the core symptoms of the disorder. In most cases the disorder starts during early childhood and has a negative impact in many areas of life throughout the lifespan [reviewed in 1]. One view of ADHD, supported by available data, is that children with ADHD are particularly susceptible to risk factors for the development of behavioural disorders, such as background social environment and genetic factors, and the often adverse negative events resulting from ADHD such as poor social interactions, poor engagement with education and exclusion from mainstream activities. Thus treatment within criminal justice settings will usually require the integration of interventions for comorbid mental illness, personality disorder, substance misuse, psychological problems, educational and occupational needs, criminogenic and other offence related factors. Treatment of ADHD is expected to enhance the effectiveness of these important interventions by reducing key symptoms and behaviours that act as a barrier to recovery and rehabilitation; including greater control over emotional and impulsive responses, reduced levels of restlessness, increased ability to focus and plan ahead and improved ability to take part in psychological treatment programs.
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
] 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
]. 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
]. 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
], 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.