The UK Adult ADHD Network has published a consensus statement on the identification and management of ADHD offenders within the criminal justice system (CJS).
The document claims that ADHD is currently not on the criminal justice agenda, which is a concern given the disproportionately high rates of ADHD offenders compared with the normal population and the association with violent, persistent offending. International studies 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 and 10% in adult female offenders. In young offenders rates are around 45%.
ADHD is a condition that the criminal justice system cannot afford to ignore.
The summary of key conclusions from the statement is as follows:
Screening and Assessment
- Screening tools are needed in police custody suites, courts, prison and probation services; while screening procedures exist across CJS services with a range of sensitivities and specificities, these exclude ADHD.
- ADHD screening tools exist for this purpose (e.g. the Barkley ADHD scales and the Adult ADHD Self-Report Scale however initial screens may need to be briefer.
- For diagnosis, of particular importance is the issue of comorbidity, which can complicate symptom presentation and hinder identification of adult ADHD. Differentiating between diagnoses (e.g. between ADHD and personality disorder) requires distinct, evidence-based diagnostic tools with ADHD criteria specific to adulthood.
- Advice is available and, as recognised by NICE, it will be necessary to include ADHD alongside other mental health conditions that currently have much greater awareness/training.
- ADHD can be effectively treated by a range of therapies providing many opportunities and benefits of treatment across the CJS.
- Psychosocial interventions have been specifically designed for this (e.g. adapted R&R2).
- It may not be easy to encourage service managers and policy-makers to embrace new developments into care pathways and crime reduction strategies, but systems must be put in place for those with health needs who remain in prison care.
- Evidence for ADHD treatment is needed and must link with health economic modelling.
- Little is known about the operational challenges of ADHD for prison staff and how these might be addressed.
- Greater understanding and awareness is key for improving assessment, diagnosis and treatment of adult ADHD, and continuity of care. This will require training across the CJS.
- Training in ADHD for medical staff is minimal, and needs to be increased.
- Training must extend beyond the medical discipline to all CJS agencies.
- PCT commissioning is the way forward in developing and modifying services, and a key issue in this regard is evidence.
- Establishing links between treatment and outcome is crucial (e.g. the direct correlation between methadone maintenance and reducing offending has demonstrated that detoxification programmes reduce both drug use and offending thus solving two problems).
- Both health and CJS commissioners will be attuned to interventions with the strongest evidence base. For ADHD this will require evidence of health and offence-related outcomes.
- Service provision is additionally determined by value for money, which further emphasises the need to demonstrate an economic argument for change within services.
Key areas of research
- Educational needs assessment across the CJS to determine knowledge, skills, attitudes and values, and identify training needs.
- Proof of principle studies to evaluate the use of screening measures across the CJS.
- Proof of principle studies to evaluate treatment efficacy; using health and offence-related outcomes.
- Cost-effectiveness studies using health economic modelling techniques to strengthen the case for ADHD treatment (e.g. each person prevented from entering prison saves £75,000p.a).
Young SJ, Adamou M, Bolea B, Gudjonsson G, Müller U, Pitts M, Thome J, Asherson P. The identification and management of ADHD offenders within the criminal justice system: a consensus statement from the UK Adult ADHD Network and criminal justice agencies. BMC Psychiatry. 2011 Feb 18;11:32.