Attention Deficit Hyperactivity Disorder in Offenders and the Need for Early Intervention

Risk Factors in Childhood and Adolescence

ADHD has long been studied as a developmental pathway to prison (Trentacosta, Hyde, Shaw, & Cheong, 2009). There is an increased risk of incarceration for those juveniles and adults with the combination of ADHD and CD (Young, Misch, Collins, & Gudjonsson, 2011).

Children and adolescents who have difficulty regulating emotion in response to significant stimuli are at risk for negative behaviors, such as testing limits and experimentation with drugs and alcohol and social norms (Lahey et al., 2008). Emotional liability includes such symptoms as hot temper, low frustration tolerance, “and sudden un-predictable shifts towards negative emotions, such as sadness” (Sobanski et al., 2010, p. 916). Children with ADHD manifest an overabundance of externalizing problems, which can result in them being fearless and more likely to break social norms (Eisenberg, Hofer, & Vaughn, 2007). S. Jones and Lynam (2009) found children with ADHD engage in “thrill and adventure seeking” behaviors. These behaviors, when correlated in neighborhoods with poor supervision often lead to offending (S. Jones & Lynam, 2009). The combination of these factors can place children and adolescents at risk for engaging in high risk taking that violates societal norms and frequently victimizes others (Farrington & West, 1993).

D. E. Jones and Foster (2009) found that one of the most important indicators of eventual delinquency is the comorbid diagnosis of CD. The risk of offending is particularly high if the onset of CD was made prior to age 10 (Harvard Mental Health Letter, 2011). Young, Misch, et al. (2011) note,

Conduct disorder and ADHD are found to coexist and they occur together at a level greater than chance. (p. 74)

Young, Misch, et al. (2011) note that when this “double deficit” exists, “a more severe variant of ADHD” is present (p. 74). Young, Misch, et al. also found that the added factors of “substance misuse and violent cognitions are important in relation to community offending” (p. 74). Other research, however, notes that the presence of ADHD-only and ADHD and oppositional defiant disorder also place children at risk for later offending behavior (Sibley et al., 2011).

Children with ADHD generally create difficulties for parents, for example, by creating strained family relationships and “increased parental stress” (Young & Amarasinghe, 2010). Parents may blame the child with ADHD for their inappropriate behaviors; however, “parent blame behaviors” can worsen behaviors in children with ADHD (Mukolo & Hefilnger, 2011). Children with ADHD frequently exhibit anticipatory anxiety and fear, which correlates with a high degree of novelty seeking (Gomez, Woodworth, Waugh, & Corr, 2012). These behaviors manifest as a negative attitude toward authority figures, which places the child at risk for conflict with adults and institutions (Pliszka, 1998). Many of these children will experiment with alcohol/drugs, which increases their risk of offending (Crowley, Mikulich, MacDonald, Young, & Zerbe, 1998).

Shannon, Sauder, Beauchaine, and Gatzke-Koop (2009) found that children with ADHD generally exhibit deficiencies in frontostriatal functioning, which generally results in a more difficult time responding to rewards and/or nonrewards. These behaviors can create a kind of defiance in children with ADHD, which can lead to the breaking of social norms.

A seldom realized factor in ADHD and its contribution to crime are the desire in these children to want to belong (Litner, 2003). Gudjonsson and Sigurdsson (2007) found that “high compliance” behaviors led to people feeling pressured to offend. Gudjonsson, Young, and Bramham (2007) found that people with ADHD frequently say “don’t know” when interrogated, which can lead to officials assuming that they are guilty of an alleged crime. More recent research by Gudjonsson, Sigurdsson, Bragason, Newton, and Eomarsson (2008) found that, while people with ADHD may be more susceptible to suggestion when under police interrogation, “they may be psychologically vulnerable during police questioning” (p. 1041). These studies confirmed that people with ADHD are vulnerable to peer pressure and false confessions because of their “general restlessness, poor concentration, and impulsiveness” (Gudjonsson & Young, 2006). Paradoxically, these children have difficulty in controlling their behaviors, yet they are sometimes able to focus on the needs of the group to which they want to belong. Unfortunately, the group they seek to join may manifest negative behaviors, for example, those with violent cognitions. Some of these children will manifest violent cognitions, which “correlates well with offending behavior” (Walker & Gudjonsson, 2006; Young, Misch, et al., 2011, p. 73).

Parental and Community Attempts to Intervene

Although there is effective treatment for children with ADHD and many families do adjust to meet the needs of their child with ADHD (Firmin & Phillips, 2009), there are high rates of heritability reported and many parents have ADHD themselves (Franke, Neale, & Faraone, 2009) leading them to have poor parenting skills, which often prevents them from seeking appropriate treatment (Biderman, Faraone, Mounteaux, Bober, & Cadogen, 2004; Schachar, 2009). Thus, many parents exhibit poor parenting coping skills, nonauthoritative parenting styles, inconsistent discipline, and low involvement (Ellis & Nigg, 2009).

Many preschool children are not properly diagnosed, which can result in delayed treatment (Greenhill, Posner, Vaughan, & Kratochvil, 2008). Child intervention generally means multimodal treatments that include medication management and family intervention (Young & Amarasinghe, 2010). It is also important to train teachers and obtain a teacher’s input as a program of learning is developed for a child with ADHD (Polderman, Boomsma, Bartels, Verhulst, & Huizink, 2010).

Most practitioners agree that it is important to begin medication management as a child enters elementary school (Wigal, 2009); however, early pharmacological intervention as young as age 3 has also been indicated (Satterfield et al., 2007). Early intervention is important for reducing substance abuse and delinquent behavior (Connor, Glatt, Lopez, Jackson, & Melloni, 2002). It may also enable the child to achieve greater educational attainment because of the increased ability to concentrate. Latimer et al. (2003) argue that later academic achievement and frustration are the result of a “failure to develop basic skills during the preschool years.”

One of the greatest challenges that prohibit appropriate treatment for these children is that psychotropic medications for ADHD can be very expensive. Matza, Paramore, and Prasad (2005) found that the costs to families with a child with ADHD were two to three times higher than a family without a child with ADHD. This finding was also confirmed in a study by (Kleinman, Durkin, Melkonian, & Markosyan, 2009). A significant number of parents in the United States do not have pharmacy coverage, which would enable them to afford ADHD medications. Medication options for people with ADHD have increased, and pharmacological treatment is no longer limited to Ritalin. Newer formulations include long-acting stimulants, such as Concerta and Adderall XR, and nonstimulant medications, such as Strattera.

Parent training has long been recognized as important in improving “parent-child relationships” (Young & Amarasinghe, p. 120). The goal of these efforts is to

increase one-on-one positive parent-child contact and teach them specific management strategies (i.e., behavioral modification techniques) to cope with problem behaviors. (Young & Amarasinghe, p. 121)

One effort is called the Triple P program, and research found that it

brought about clinically reliably reductions in disruptive behaviors and hyperactive/inattentive difficulties in comparison to the waitlist group. (Young & Amarasinghe, p. 121)

Other research has focused on a therapist working with mothers of children with ADHD to teach them behavioral strategies (Sonuga-Barke, Daley, Thompson, Laver-Bradbury, & Weeks, 2001). A pilot of a direct group intervention with children aged 8 to 12 has also received support.

Parenting children with ADHD is particularly difficult for poor and depressed mothers who frequently use harsh discipline and are not able to respond emotionally to their children (Milkie, 2008). Because schools reflect the surrounding community, poor and minority children are less likely to get needed resources that might mitigate the effects of their mental health problems. For example, teachers in poorer schools are sometimes less supportive than in higher resource schools. Ryan and Patrick (2001) found that when middle school teachers perceive a supportive attitude from their teacher, they are less likely to engage in disruptive behavior. Children with ADHD are likely to act out in a nonsupportive classroom where they sense that they can “get away” with more aberrant behaviors. One of the greatest challenges for children with ADHD is they are generally “tracked” into curriculum for low achievers, which may lead many of these children to identify themselves as underachievers and live up to this negative expectation through negative social and academic behavior (Carbonaro, 2005). One study suggested,

It may be that children in such classrooms have on average less academic work to engage them on their own level so that it leaves them time to fidget and fuss. Teachers with high numbers of below level children may not adequately challenge all students, thus losing students’ attention and concentration. (Milkie, 2008, p. 20)

Among intervention models, teacher consultation models have been noted to support the academic success of students with ADHD (Nadeem & Jensen, 2009). These models develop a cooperative relationship between students and teachers, which help to develop a supportive relationship that is problem specific. Middle school can present a challenge for many children because of a combination of factors including the child’s puberty, increased peer group pressure, the transition from elementary school, and growing demands of adolescence. Students with ADHD in middle school can experience academic decline (Schultz, Evans, & Serpell, 2009). Because of their inability to control their behavior and their increasingly poor academic achievement, these children are at increased risk for higher rates of suspension, expulsions, and school dropout when compared with their non-ADHD peers (Latimer et al., 2003).

Even with medication, some children with ADHD show greater levels of verbal aggression (Harty, Miller, Newcorn, & Halperin, 2009). Failure to limit the emotional dysregulation in children with ADHD can create problems for them in later adolescence as they tend to engage in more socially repugnant behaviors.

Some schools have implemented the Challenging Horizons Program–Consultation Model, which targets the academic and social impairments associated with ADHD during the first 2 years of middle school (Evans, Serpell, Schultz, & Pastor, 2007). The strength of this program lies in its diagnostic specificity and identification, which then enables educators to find children who need extra help with their education. One of the important strategies of this program is that it helps to increase self-esteem by enabling the children to increase their academic potential. Another method to help older children with ADHD is to use audiotaped chimes and a student checklist to improve on-task behaviors (Graham-Day, 2010). It is also important to implement intensive behavioral intervention (Jensen, Hinshaw, & Swanson, 2001). The combination of these interventions is referred to as multimodal interventions. Research shows that juveniles that experienced multimodal interventions showed lower rates of arrest and incarceration (Satterfield, Satterfield, & Schell, 1987).

Behavioral interventions tend to focus on improving self-monitoring, self-regulation, and positive self-reinforcement, which together have been found to encourage children to learn to limit their risky and nonconforming behaviors (Reid, Trout, & Schartz, 2005). However, it is also important to work with adolescents and young adults to improve their academic performance, which can act as a protective factor against delinquency (Heilbrun, Cottle, & Lee, 2000). Interventions need to include a psychoeducational component so parents and children understand that ADHD may be a lifelong condition that requires long-term intervention (Fabiano et al., 2007).

Entry Into the Criminal Justice System: Juvenile and Adult Systems

Sibley et al. (2011) note,

There is currently consensus that the progression to serious delinquency begins early, with problems at school, at home, and with peers. Most agree with the hypothesis that this troubling path begins with impulsivity, ADHD, under-controlled temperament, or some other variant thereof. (p. 22)

Despite the best efforts of families, communities, and professionals, research shows that approximately 30% of children with ADHD either show no improvement or their condition worsens (Lopez, Masana, Marti, Acosta, & Gaviria, 2011). Another study showed that boys with ADHD-only and ADHD and oppositional defiant disorder “displayed worse delinquency outcomes” than boys without these diagnoses (Sibley et al., 2011).

The challenge is that many of the “core” symptoms of ADHD correspond to delinquent offending (Loeber, Pardini, Stoouthammer-Loeber, & Raine, 2007). Sibley et al. (2011) suggests that children with ADHD initiate mild delinquency at earlier ages than children without ADHD.

The combination of these behaviors is referred to as an externalizing spectrum model (ESM), which places juveniles at risk for substance abuse and CD (Krueger, Markon, Patrick, Benning, & Kramer, 2007). Some of these juveniles will only develop CD and later antisocial disorder. Many children with ADHD who enter the juvenile justice system (JJS) have not been properly diagnosed and provided with early intervention, such as medical management of symptoms. This is particularly a problem in communities of poverty, which tend to expend few resources for troubled children (Rodriguez, 2007).

Once placed in the (JJS), children with ADHD become labeled as delinquents, and the focus of attention changes from education to supervision. Many (JJS) programs recognize the need for increased parental monitoring because increased monitoring can sometimes interrupt aggressive parental behavior. The challenge for adolescents with ADHD in the JJS is that so many offenders exhibit mental health problems that it can make it difficult to accurately diagnosis ADHD (Mitchell & Shaw, 2011). Young, Adamou, et al. (2011) note the importance of identification and management of ADHD offenders within the criminal justice system.

The general progression of ADHD suggests that the majority of youth in the JJS will have developed comorbid mental health disorders, such as mood and/or CD, and substance abuse. Similar to most mental health interventions, it is important to provide appropriate services in the community (Grisso, 2008). Mental health disorders, such as ADHD, are frequent, ranging from 60% to 400% in the JJS, which is more frequent than in the general population (Catlin, 2006). Unfortunately, many adolescents diagnosed with ADHD move from the JJS to the Adult Correctional System.

One of the challenges to treating inmates with ADHD is the high prevalence of substance abuse in prisons (Burns, 2009). Thus, interventions that include stimulant medication, which is frequently prescribed for ADHD, pose the risk that some inmates may sell the medications to other prisoners. Because of their propensity to gravitate toward people that engage in risk behavior, inmates with ADHD quickly become absorbed with the “wrong crowd.”

Drinkwater and Gudjonsson (1989) noted that offenders with ADHD in institutional settings are not provided with enough planned activities and have poor staff–inmate interactions. Young, Gudjonsson, et al. (2009) also found that young people, in particular, may find it difficult to articulate their distress and anxiety.

Model Programs and Advocacy

Young, Gudjonsson, et al. (2009) note that inmates with ADHD represent management challenges and pose increased costs for correctional facilities. In 2004, the University of Massachusetts Correctional Health (UMCH) program developed a set of protocols for treatment of ADHD in the Massachusetts correctional system (Appelbaum, 2009). The program worked to establish two basic protocols; first, create more diagnostic and treatment consistency within the system, and two, create appropriate prescription practices. One of the hallmarks of this approach was to require psychological testing by a psychologist, a self-report instrument, assessment of cognition and attention, and assessment for malingering. In general, the program was widely accepted among staff and inmates.

The Massachusetts program emphasized the importance of standard diagnostic rigor. A review of mental health services in the New York Prison system also highlighted the importance of standard assessment tools (Gebbie et al., 2008). Israel has taken the lead in identifying comorbidity between ADHD and learning disability (LD) (Einat & Einat, 2008). By recognizing the comorbidity between ADHD and LD, Israel also recognized that ADHD, LD, low intelligence, challenging behavior, and inadequate adaptive behavior are risk factors for antisocial personality disorder (APD). In addition to these attributes, dyslexia is also comorbid with ADHD, which can lead to frustration, violence, and depression (Daderman, Lindgren, & Lidberg, 2004).

Ginsberg and Lindefors (2012) found that osmotic-release oral system methylphenidate was effective treatment for adult inmates with ADHD. The challenge is that adult inmates with ADHD also present with comorbid conditions, such as a “lifetime history of substance abuse” and learning disorders (Ginsberg et al., 2010, p. 10). Medication management in prison may reduce symptoms for inmates with ADHD, but it will not likely change “lifelong patterns of poor behavioral control and anti-social behavior” (Young et al., 2009, p. 46).

Specific programs have been developed for youths and adults with ADHD and antisocial behavior. Evaluations indicate that such programs are effective in reducing symptoms and improving compliance with rules and regulations. These evaluation studies show medium to large treatment effects when delivered in the community and inpatient settings (Emilsson et al., 2011; Young et al., 2012).

Although it is important to address the needs of inmates with ADHD, it is also important to continue to provide treatment for inmates about to be released on parole. Sweden, for example, screens inmates about to be released and, if diagnosed with ADHD, prescribes methylphenidate (Lindqvist, 2007). The importance of providing postrelease intervention was also supported by research done with American prisons (Eme, 2009).

Conclusion

American policy makers are generally reluctant to invest in long-term programs and prefer short-term solutions (Belcher & DeForge, 2005). Thus, it is important to show lawmakers that untreated and poorly treated ADHD can lead to future challenges, such as incarceration. Much research suggests that treatment is possible for people with ADHD (Young, Misch, et al., 2011). Criminal justice systems need to campaign with state legislatures to adopt a model that involves early assessment, diagnosis, and treatment of ADHD with children and provides for appropriate services. Early intervention in the school systems can identify children with ADHD and begin to address some of the comorbid challenges, such as CD, oppositional defiant disorder, LD, and emotional problems. A life span approach to treatment is important (Young & Amarasinghe, 2010).

The pathway is very clear for many children and adolescents with ADHD; they will enter the JJS and later, the adult correctional system. Parents need support and assistance in managing these children. The educational system could better assist with screening assessments and school interventions. Indeed, early identification and the provision of multimodal interventions, involving both home and school domains, may direct young people toward constructive employment as opposed to a criminal career. This early investment in the child’s developmental pathway is likely to reap large rewards in the longer term by reducing demands on the criminal justice and health service systems.