The entire article may not be helpful to mentoring or juvenile justice practitioners; however, the connection between ADHD and the prison population is worthy of note. That connection action, if and when possible in a variety of ways.
From Medscape Education Psychiatry & Mental Health
ADHD
and Crime: Considering the Connections
Joel L. Young, MD
CME Released: 04/12/2010 ; Valid for credit
through 04/12/2011
Jim, age 18, was just
hanging out in the neighborhood with his younger cousin, when he happened upon
a very hot-looking red sports car a few blocks from home. Amazingly, the keys
were in the ignition, seemingly just waiting for someone to come along. Without
much thought, the adolescents jumped in the car and drove off. Several hours
later, the very chagrined Jim was apprehended by the police, who were entirely
unsympathetic to his explanation that he had just wanted to experience the
ride; he didn't think it counted as stealing. The Court was also
unconvinced, and although he had no prior criminal convictions, Jim was
sentenced to 9 months in jail and 2 years probation.
As part of his sentence,
the court demanded that Jim obtain a full mental health evaluation. The
psychiatrist learned of Jim's chronic struggles, including poor school
performance, intermittent marijuana use, and regular conflicts with
authorities. After a thorough examination, the psychiatrist diagnosed
attention-deficit/hyperactivity disorder (ADHD), predominantly
hyperactive-impulsive type, and prescribed treatment. Within weeks, Jim noted
improvements in his focus and concentration. Jim's family reported that he was
decidedly less moody and impulsive. After a few months on treatment, Jim's
gains solidified, and the family was convinced the intervention had averted
further encounters with the criminal justice system. This case highlights the
complicated relationship that individuals with ADHD have with their impulsivity
and the criminal and societal implications of this disorder.
People with ADHD commit
crimes for many of the same reasons as those without ADHD: Some want money or
property that belongs to others and have little motivation to acquire the loot
honestly. Those with ADHD also have other triggers for crimes; adolescents and
adults with untreated ADHD are often bored, sensation seeking, or simply
impulsive, and this combination of attributes leads them to react with poor
judgment. A desired item appears, they want it, so they take it.[1] It
also appears that when individuals with ADHD commit violent crimes, these acts
are more likely to be crimes of spontaneous and "reactive" aggression
rather than carefully plotted out offenses. Such crimes are generally impulsive
acts driven by a provocation or conflict that triggers an outburst. Research
with adult male offenders seems to bear out this hypothesis.[2]
Studies show that at
least 25% of prisoners in the United States have ADHD. The recidivism rate
among all felons is high, and an estimated two thirds are rearrested within
about 3 years.[3] These statistics have important implications for society at
large.
WHY SHOULD WE CARE ABOUT UNTREATED
CRIMINALS WITH ADHD?
ADHD among prisoners is
a problem, not only for the offenders with ADHD but also for their victims who
were misused violently and nonviolently. Evidence suggests that the diagnosis
and treatment of ADHD could have an impact on crime rates. In 2009, the
National Bureau of Economic Research[4] sought an explanation for a decline in violent crimes
starting in the 1990s; they hypothesized that there was a relationship between
the increase in prescribing of newer-generation antidepressants for depression
(such as bupropion) and also in the prescribing of stimulants for ADHD.
The researchers compared
the rates of prescriptions for these psychiatric medications to rates of
violent crimes in the United States from 1997-2004 with a statistical regression
analysis.[4] They found a significant inverse correlation; that is, as
prescriptions went up, violent crimes came down. As a comparison, the authors
also looked at the prescription rate of statins for cholesterol treatment and
found no relationship between the number of prescriptions for statins and the
crime rate.
The researchers stated,
"Our evidence suggests that, in particular, sales of new-generation
antidepressants and stimulants used to treat ADHD are negatively associated
with rates of violent crime." They added, "To put this in
perspective, doubling the prescription rate [of antidepressants] would reduce
violent crimes by 6%, or by 27 crimes per 100,000, at the average rate of 446.5
crimes per 100,000 population. A similar calculation with stimulants would
decrease crimes by a range of 30-38 crimes per 100,000. While doubling the
prescription rates seems like a large change, it has been estimated that 28% of
the US adult population in any year has a diagnosable mental or addictive
disorder, yet only 8% seeks treatment."[4]
The researchers noted
that the crime rate in Canada also fell during the same time period.[4] As
in the United States, Canada was among the world leaders in treatment with new
psychiatric medications. This finding asserts that identifying and treating
ADHD is a win-win situation: Individuals with the condition experience the
benefit of treatment, and the public is less likely to become their victims.
STUDIES ON ADHD AND CRIMINAL BEHAVIOR
In ADHD in
Adults: What the Science Says,[5] Russell
Barkley and colleagues report on the Milwaukee Study, a longitudinal outcome
assessment of crime and other activities of hyperactive children through the
life cycle. According to Barkley, there were too many medication variations to
account for treatment, but the majority had not received medication treatment
for their ADHD (Barkley RA, personal communication, 2008). The authors reported
on 2 separate groups of adults with hyperactivity: those diagnosed with ADHD
with hyperactivity as children (H+ADHD; n=55) and those not diagnosed with ADHD
until adulthood (H-ADHD; n=80). These groups were compared with a community
control group (n=73). In most cases, the 2 groups of adults with ADHD had
significantly higher rates of crime than the community control group, although
the H+ADHD group fared worse than both other groups in terms of stealing
property, selling drugs, assaulting others, and several other categories. For
example, 40% of the H+ADHD group had carried a weapon illegally, compared with
20% of the H-ADHD group and 8% of the control group. Among the H+ADHD group,
58% had ever been jailed, compared with 46% of the H-ADHD group and 24% of the
control group (Table 1).[5] Clearly,
ADHD is a factor in the commission of crimes.
Table 1. Crime
Categories for Each Group in the Milwaukee Study
|
H+ADHD
(%) (n=55)
|
H-ADHD
(%) (n=80)
|
Community
(%) (n=73)
|
P Value
|
|
|
|
|
Stole others' property
|
74
|
58
|
45
|
.004
|
Stole others' money
|
47
|
42
|
28
|
NS
|
Robbed someone of money
|
7
|
2
|
1
|
NS
|
Breaking and entering
|
14
|
15
|
3
|
.021
|
Assaulted with fists
|
42
|
33
|
16
|
.004
|
Assaulted with a weapon
|
29
|
6
|
3
|
<
.001
|
Set fires intentionally
|
11
|
9
|
5
|
NS
|
Carried a weapon illegally
|
40
|
20
|
8
|
<
.001
|
Forced sexual activity
|
2
|
0
|
0
|
NS
|
Possessed illegal drugs
|
67
|
61
|
48
|
NS
|
Sold drugs illegally
|
40
|
27
|
19
|
.026
|
Engaged in disorderly conduct
|
47
|
34
|
24
|
.022
|
Arrested
|
73
|
52
|
33
|
<
.001
|
Jailed
|
58
|
46
|
24
|
<
.001
|
H+ADHD = adults
diagnosed with ADHD with hyperactivity as children; H-ADHD = adults not diagnosed
with ADHD until adulthood; NS = not significant
Adapted from Barkley RA, Murphy KR, Fischer M. ADHD in Adults: What the
Science Says. New York, NY: Guilford Press; 2008:313.
In a study of 198
prisoners in a Scottish prison,[6] Young and colleagues found that 48 subjects (24%) met the
criteria for childhood ADHD. Of these 48 prisoners, 11 (23%) still exhibited
fully active ADHD symptoms as adults, while 16 (33%) had partial symptoms.
Thus, 55% (27 inmates) had identifiable symptoms of ADHD that persisted from
their childhood into adulthood. The researchers found that these 27 prisoners
with continued ADHD symptoms had perpetrated significantly more aggressive
incidents than the other prisoners.[6] Nonsymptomatic
prisoners averaged 0.46 acts of physical aggression compared with 2.48
incidents among those with ADHD symptoms. The symptomatic group was also more
verbally aggressive and was responsible for more incidents of property damage
(Table 2). The researchers noted that the severity of aggression was nearly 12
times greater for the ADHD group.[6]
Of interest, adults in
the ADHD group appeared to externalize their anger and were less likely to be
self-injurious than their non-ADHD cohorts. The study did not control for
treatment, and it is unknown if appropriate intervention could have altered the
findings.
Table 2. Means, Standard
Deviations, Medians, and Range of Scores for Critical Incidents Within the
Prison for the Nonsymptomatic and the ADHD Symptomatic Group
Critical Incidents
|
Nonsymptomatic
Group (n=171)
|
Symptomatic
Group (n=27)
|
Mean
No. of Incidents
|
SD
|
Median
No. of Incidents
|
Range
|
Mean No.
of Incidents
|
SD
|
Median
No. of Incidents
|
Range
|
Verbal aggression
|
5.05
|
13.2
|
1.00
|
0-90
|
18.26
|
28.1
|
4.00
|
0-100
|
Physical aggression
|
0.46
|
0.95
|
0.00
|
0-6
|
2.48
|
5.8
|
1.00
|
0-30
|
Damage to property
|
0.39
|
1.2
|
0.00
|
0-7
|
1.59
|
4.7
|
0.00
|
0-20
|
Self-injury
|
0.09
|
0.55
|
0.00
|
0-5
|
0.15
|
0.4
|
0.00
|
0-1
|
Total critical incidents
|
6.41
|
13.9
|
2.00
|
0-95
|
23.5
|
33.8
|
8.00
|
0-120
|
Severity of aggression
|
0.68
|
1.5
|
0.00
|
0-10
|
4.7
|
12.1
|
1.00
|
0-62
|
SD = standard deviation
Adapted with permission from Young S, et al. Personality Individual Differences. 2009;46:267.[6]
Adolescents and Children
and Criminal Acts
Children and adolescents
derive their self-esteem through succeeding in school and pleasing the adults
around them. Children with ADHD are struggling with chronic symptoms of
inattention, distractibility, hyperactivity, and impulsivity and frequently do
not realize this satisfaction. They can become alienated or friendless, and to
avoid this outcome, they learn that outlandish behavior can earn them the respect
of their peers. To them, negative attention is more desirable than no attention
whatsoever, and befriending "bad kids" is preferable to having no
friends.
Punishment for impulsive
and criminal actions can begin a cascade of decline. A young offender's
introduction to the juvenile justice system exposes them to increasingly
troubled adolescents who can readily offer further education about wayward
activities. Preventing this destructive cycle is the fundamental reason for
early identification and treatment of this population.
ADHD That Persists Into
Adulthood
Until recently, ADHD was
thought to be "outgrown" by the time children reached adulthood; we
now know that for many, ADHD symptoms persist. Indeed, the National Comorbidity
Survey Replication found that 4.4% of American adults have ADHD.[7]
In a longitudinal study,
Mannuzza and colleagues[8] studied 207 white boys (ages 6-12 years) with
ADHD.[8] Follow-up visits were obtained at ages 18, 25, and 38 years.
The analysis compared subjects with ADHD vs non-ADHD probands, revealing
trouble for the afflicted group. Men with ADHD were nearly twice as likely to
have been arrested (47% for the ADHD subjects vs 24% for the probands) and more
than 3 times more likely to be convicted for crimes (42% for the men with ADHD
vs 14% for the probands). Their rates of incarceration (15% vs 1%) were also
pronounced.[8]
Mannuzza reported other
disturbing trends. Seventeen percent of the men with ADHD had committed
aggressive violent offenses such as murder, rape, robbery, and arson whereas none
of the probands had committed any violent acts. Given the long duration of the
study, the researchers were unable to control for treatment exposure.
In a retrospective study
of more than 14,000 subjects with ADHD,[9] Fletcher and Wolfe analyzed the relationship between
childhood ADHD and the commission of crimes in adulthood. The previous
treatment status of the subjects, now young adults ages 18-28, was not known.
Subjects were separated into the 3 subtypes of ADHD: hyperactive, inattentive,
and combined. The findings were clear: compared with the general non-ADHD
population, the likelihood of committing any crime was 11 points higher for
those with hyperactive ADHD, 6.5 points higher for those with inattentive ADHD,
and 5 points higher for those with the combined subtype.[9]
ADHD symptoms presenting
early in life carry an ominous prognosis. Individuals with ADHD symptoms
evident between ages 5 and 12 years, regardless of subtype, were significantly
more likely to engage in criminal activities as adults compared with those
without ADHD.[9] Individuals with the hyperactive subtype were the most
likely to be arrested and convicted of a crime.[9] Robbery
and theft were associated with this subtype. By contrast, those with the
inattentive subtype of ADHD were more likely than those without ADHD to commit
crimes that required planning, such as burglary or selling drugs. For unknown
reasons, individuals with the combined subtype had the weakest links to adult
criminal behavior.[9]
Female Criminals With
ADHD
The prevalence of ADHD
among incarcerated men and women far exceeds the rates among men and women in
the general population. A study of 320 prisoners in Iowa found that 14.3% of
the female prisoners and 23.1% of the male prisoners met the diagnostic
criteria for ADHD.[10]
In an analysis of 110
female offenders with ADHD in a German prison,[11] Rösler and colleagues found a 24.5%
lifetime prevalence of ADHD and a 10% prevalence of persistent ADHD. The
inmates with ADHD were significantly younger at their first conviction (19.2
years, compared with 27 years for the non-ADHD women). In addition, the rate of
diagnosis of ADHD was higher with younger age; for example, the prevalence of
ADHD was 17.9% among the female inmates ages 25 and below and fell to just 10%
among inmates ages 26-45 years.[11] Why
the older inmates were less symptomatic is unclear. Perhaps they were more
experienced at dealing with their symptoms.
IMPLICATIONS FOR MENTAL HEALTH
PROFESSIONALS
The presumption that
treatment for ADHD will positively affect outcomes drives clinicians to address
this population. In a meta-analysis of studies of adolescents followed for 4
years,[12] Wilens and colleagues showed that treating
adolescents with ADHD with methylphenidate significantly reduced their risk of
developing a substance use disorder. Similar data regarding risk reduction are
sparse in the ADHD/crime literature, but some preliminary findings are
encouraging.
A Norwegian study of
adults with ADHD determined the subjects' "index of burden" (IOB).[13] The
IOB is a composite of scores evaluating alcohol abuse, substance abuse,
criminality, and other items. Stimulant treatment in childhood and adolescence
was found to contribute significantly to a higher level of psychological and
social functioning in adulthood. For example, 48% of the group that had
received treatment had a 0 score on the IOB (lower scores are better). This
compares favorably with the 18% of the untreated group that scored 0. This
trend continues if criminality is assessed alone. Two out of 14 of the
treatment group (14%) had criminal records, compared with 14 out of 59 of the
nontreatment group (24%).[13]
The Need for Continued
Treatment of ADHD
While the need for
chronic treatment is apparent, many factors contribute to the fall off in
treatment rates as patients age. Adolescents often lack the ability to assess
the positive impact that treatment offers, and they tend to devalue parental
input. Adolescents and young adults have less contact with their pediatricians
and suffer from this professional void. As the individual transitions into the
third and fourth decades of life, Medicaid and private insurance benefits are
less well-protected, and cost becomes an obstacle to access to ADHD medications
and treatment. All evidence suggests that the absence of treatment is
correlated with increased rates of criminal behavior.[5,6,8-10]These findings have clear implications for public policy makers
interested in criminality.
Our collective
ambivalence extends to the issue of how to treat incarcerated individuals with
ADHD. Prison officials may find it logically inconsistent that, on one hand,
some prisoners are incarcerated for their misuse of addictive or illicit
substances while, on the other hand, controlled agents are indicated for ADHD
treatment. Despite this inherent paradox, more prison officials are recognizing
the importance of treatment, if for no other reason than maintaining calm among
closely quartered, impulsive inmates. The introduction of the nonstimulant
atomoxetine, a US Food and Drug Administration-approved agent for treating
adult ADHD,[14] has also been helpful. The long-acting
OROS (osmotic-release oral system) methylphenidate also has a low risk for
abuse.[15] Most recently, the introduction of the pro-drug
lisdexamfetamine offers an effective, long-acting amphetamine that is activated
after absorption in the gastrointestinal tract and has little potential for
nasal or intravenous abuse.[16] These
novel agents and delivery systems significantly reduce the risk for stimulant
misuse.
ADHD is a significant
factor relating to both crime and punishment. The condition increases the risk
of committing a crime, and once the individual is incarcerated, the conundrum
develops regarding appropriate treatment. Evidence suggests that proper
treatment may reduce the risk for criminal behavior and the rate of recidivism
among afflicted criminals.
Coherent approaches to
treating youth with ADHD both in and out of the criminal justice system need to
be developed. Additional study will further enlighten these difficult issues.
For the present, it is important for psychiatrists to consider ADHD as a valid
factor in crime and the treatment of ADHD as a potentially preventive measure
against the commission of violent and nonviolent criminal acts. Resolving or
improving ADHD symptoms can bring relief to the individual as well as to
society at large.
Supported by an
independent educational grant from Shire.
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