Profile and outcomes of male offenders with ADHD (Full Report)

Acknowledgements

The authors would like to thank Colette Cousineau for her help with the data for this report and Dianne Zakaria for her helpful guidance throughout the analysis phase of the project. We would also like to thank Jenelle Power and Brian Grant for their thoughtful comments on earlier drafts of the report. A very special thanks to the team at the Regional Reception and Assessment Centre in the Pacific region (RRAC) that so conscientiously collected the data that form the basis of this research.

Executive Summary

Attention Deficit Hyperactivity Disorder (ADHD) is a neurobiological disorder characterized by difficulties regulating attention, activity, and impulsivity. Predominantly diagnosed in childhood and adolescence, ADHD is increasingly being recognized as a disorder that continues to affect individuals into adulthood. ADHD is associated with a number of adverse outcomes including aggression, criminality, substance abuse, and low educational attainment, and it is thought to be more prevalent in forensic populations. Currently there is no information on the level of ADHD among federal offenders, and it is hypothesized that high rates of ADHD would present challenges for CSC in terms of offender behaviour management and community reintegration. To study the relationship between ADHD and a number of variables related to correctional outcomes, the Adult ADHD Self-Report Scale (ASRS) was administered to a sample of offenders newly admitted to CSC.

Over a 14 month period, 497 male offenders completed the ASRS at the Regional Reception Centre in the Pacific region (RRAC). It was determined that 16.5% of offenders met the clinical criteria for ADHD, while a further 25% scored in moderate range for this disorder. A significant relationship was discovered between ADHD and a number of demographic and profile variables. ADHD was found to be associated with unstable job history, presence of a learning disability, lower educational attainment, substance abuse, higher risk and need levels, and other mental health problems. ADHD was also found to predict institutional misconduct; offenders with the highest levels of ADHD were 2.5 times more likely to receive an institutional charge than offenders without these symptoms. Additionally, offenders with high levels of ADHD fared poorly on release to the community. Within six months of release, they were more likely to have returned to custody than offenders with no symptoms of ADHD.

The current study improves our understanding of the impact of ADHD in forensic populations. The rate of the disorder found in this study was considerably higher than prevalence rates cited in the general population, but in line with estimates from other correctional jurisdictions. Results indicate that high levels of ADHD can present challenges for CSC in terms of offender institutional management and transition into the community. A secondary purpose of this study was to evaluate the ASRS as a screening tool for ADHD in offenders. Findings indicate that the ASRS is a brief measure that can easily be administered at intake to identify offenders who may need additional services or adapted interventions because of this disorder.

Introduction

The effective management and reintegration of federal offenders is a priority for the Correctional Service of Canada (CSC). Integral to this process is the accurate assessment and accommodation of offenders who present with unique needs relating to psychological and learning difficulties. Attention Deficit Hyperactivity Disorder (ADHD) is thought to be more prevalent in forensic populations and is associated with disruptive behaviour, aggression, criminality, substance abuse, and the development of antisocial and other personality disorders (Westmoreland et al, 2010; Gunter, Arndt, Riggins-Capsers, Wenman & Cadoret, 2006). Potentially, high rates of ADHD in CSC's offender population would present a challenge with respect to management of offenders' impulsive and aggressive behaviours, as well as their decreased ability to participate and succeed in correctional and educational programs.

ADHD is a neurobiological disorder characterized by difficulties in regulating attention, activity and impulsivity. ADHD is defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) as a "persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequently displayed and more severe than is typically observed in individuals at a comparable level of development" (APA, 2000, p.85). It is one of the most commonly diagnosed psychiatric disorders among children and adolescents, with symptoms persisting into adulthood for a large proportion of individuals. A clinical diagnosis of adult ADHD requires current and persistent symptoms originating in childhood (Pary et al, 2004; Wilens, Bierderman & Spencer, 2002). Research has recently established that while high levels of ADHD are required to reach threshold for a clinical diagnosis of the disorder, problems associated with ADHD are evident with lower levels of symptomology as well. This suggests that the disorder actually exists on a continuum, with severe symptoms at the upper end of the spectrum (Levy, Hay, McStephen, Wood, & Waldman, 1997; Lubke, Hudziak, Derks, van Bijsterveldt, & Boomsa, 2009).

Despite the fact that ADHD is thought to affect a significant proportion of adults, it has only recently been the focus of adult clinical research (Kessler et al, 2006; Pary et al, 2004). Recent epidemiological studies estimate the adult prevalence rate of ADHD in the general population to be 2-5% (Faraone, Sergeant, Gillberg, & Biederman, 2003; Kessler et al. 2006; Rosler et al, 2004; Simon, Czobor, Balint, Meszaros & Bitter, 2009). Rates are typically higher for males than for females; it is estimated that approximately 5% of the adult male population has ADHD as compared to 3% of adult women (Kessler et al., 2006). There is currently no information on the prevalence of ADHD in CSC's offender population; however, research on offenders in other jurisdictions report rates of ADHD ranging from 17% to 40% (Eme, 2009; Eyeston & Howell, 1994; Rassmussen, Almvik & Levander, 2001; Retz et al, 2004; Westmoreland et al., 2010).

There are a number of potential explanations for why the incidence of ADHD is much higher in the offender population. Low self-control has been theoretically and empirically linked to criminal behaviour. Failure to inhibit impulses and general poor self regulation is the basis of Gottfredson and Hirschi's (1990) explanation of the underpinnings of criminal behaviour. Subsequent research has confirmed that low levels of self-control were predictive of a variety of anti-social and criminal behaviours (Longshore, 1998; Vazsonyi, Pickering, Junger & Hessing, 2001). A meta-analysis conducted by Pratt and Cullen (2000) found that low self-control was consistently one of the strongest correlates of crime, regardless of how self-control was measured. Studies specifically measuring ADHD in relation to criminal behaviour have found similar results. Given that impulsivity and low self-control are symptoms of ADHD, it is not surprising that the disorder has been empirically linked to delinquency. A recent meta-analysis found ADHD to be an important risk factor in crime with the authors concluding that there is a broad trend in the literature supporting the general impact of ADHD on criminal behaviour (Pratt, Cullen, Blevins & Unnever, 2002).

A strong association has also been documented between ADHD and antisocial personality disorder (Westmoreland et al., 2010; Young et al., 2009). Collins and White (2002) report that studies have found rates of antisocial personality disorder to be ten times higher in adults with a childhood diagnosis of ADHD as compared to controls. An Icelandic study found antisocial personality disorder to be the best predictor of current ADHD symptoms in male inmates (Einarsson, Sigurdsson, Gudjonsson, Newton & Bragason, 2009). Similarly, a prospective study of 158 males found that participants who had been diagnosed with ADHD in childhood were significantly more likely to be diagnosed with antisocial personality disorder in adulthood (Mannuzza, Klein, Bessler, Malloy & LaPadula, 1998).

High rates of psychiatric comorbidity have also been found in the literature. A German study with a sample of 70 adults with ADHD reported that at 77%, psychiatric comorbidity rates were significantly higher than in a control group. Other studies have confirmed this high rate of lifetime psychiatric comorbidity (Biederman, 2004; Kessler et al., 2006). Research with offenders also demonstrates similar results. A study involving 319 randomly selected offenders found higher rates of psychiatric comorbidity among offenders with ADHD compared to a control group (Westmoreland et al., 2010). Comorbidity rates were highest for mood disorders (87%) and anxiety disorders (68%).

Research has generally shown a link between ADHD and substance abuse, although some conflicting findings exist. Mannuzza et al (1998) reported that adults who had been diagnosed with ADHD in childhood were more likely to have non-alcoholic substance use disorder than a control group. Similarly, Biederman, Wilens, Mick, Faraone and Spencer (1998) reported that adults with ADHD were twice as likely to have psychoactive substance use disorder. Increased risk for nicotine, alcohol and drug dependence was reported by Sullivan and Rudnik-Levin (2001). A recent study with offenders did not find any difference in substance abuse between offenders with and without ADHD, although this result could be due to the generally high prevalence of substance use disorders among offenders in general (Westmoreland et al, 2010).

There is a lack of research on the precise relationship between adult ADHD and recidivism. Studies in this area have focused predominantly on young offenders, with results generally supporting the finding that ADHD is a risk factor for recidivism in youth (Putnins, 2005). However, there is some evidence that ADHD is only predictive of recidivism in the presence of conduct disorder (Soderstrom, Sjodin, Carlstedt & Forsman, 2004). Although few studies have been conducted with adult offenders, it is possible that ADHD increases the risk of reincarceration, particularly when combined with antisocial personality disorder.

It is also unclear what the impact of ADHD might be on participation in correctional programming. No studies to date have examined the relationship between the disorder and level of participation or success in correctional programs. Based on the literature correlating ADHD with learning disabilities and low educational attainment (Barkley, 2002; Einat & Einat, 2008; Loe & Feldman, 2007), it may be inferred that offenders with ADHD are likely to have higher rates of program drop out and poorer performance on measures of treatment change due to difficulties with attention and learning. There is evidence, however, that individuals with ADHD respond well to interventions based on cognitive behaviour principles (Safren et al., 2004). The majority of programming delivered by CSC is based on a cognitive behavioural model.

Given the indication that rates of ADHD are higher in correctional populations, ADHD could present challenges within CSC in terms of population management and offender rehabilitation. Although it has been well-established in the literature that ADHD is prevalent in correctional populations, few studies to date have examined the influence of ADHD on a range of correctional outcomes for adult offenders as well as its implications for institutional management. Offenders with ADHD may have more trouble adjusting to the constraints of incarceration as well as increased difficulty following the rules of the institution and managing relationships with other offenders (Pratt et al., 2002). A recent study of incarcerated male offenders in the UK found that ADHD had a significant effect on the total number of critical incidents as well as the severity of incidents occurring in a Scottish prison (Young et al., 2009).

The purpose of the present study is to examine the relationship between ADHD and a number of correctional outcomes including institutional misconducts, performance in correctional programming, and returns to custody in adult male offenders. Based on the literature examined to date, it is hypothesized that offenders with high levels of ADHD symptoms will have poorer outcomes with respect to program participation, institutional behaviour, and success upon release. It is also hypothesized that high levels of ADHD symptoms will be associated with a number of profiling characteristics such as younger age, lower educational attainment, job instability, increased substance abuse, and mental illness. In addition, this research report presents results of the Adult ADHD Self-Report Scale (ASRS) as a screening tool for ADHD in male offenders. Prevalence rate, demographic profile, and outcomes are presented based on level of ADHD symptom endorsement. A discussion of the recommended scoring of this instrument is also included.

Discussion

The purpose of the present study was to create a profile of male offenders with ADHD and examine the impact that the disorder might have on institutional behaviour, program completion, and success after release. As hypothesized, results indicate that there is a significant relationship between ADHD and a number of important outcomes and variables relevant to corrections.

With respect to prevalence, 16.5% of the sample had scores on the ASRS that would meet the clinical criteria for ADHD. This is considerably higher than rates for the general adult population. Literature on prevalence of ADHD in adult incarcerated populations is inconsistent, with a wide range of prevalence rates being reported, possibly due to a variety of tools and cut off scores being used to measure the presence of the disorder. The rate found in the present study is consistent with estimates in the lower end of this spectrum (Eme, 2009; Retz et al., 2007). Nevertheless, this represents approximately 1 in 6 federal male offenders reporting a large number of ADHD symptoms. This has implications for the management of these offenders and their prospects for success upon release.

A profile of offenders with high levels of ADHD symptoms demonstrated that they were more likely to have lower educational attainment, unstable job histories and the presence of a learning disability than offenders with low or no ADHD symptoms. The strength of the associations was small but the pattern was consistent, suggesting that ADHD contributes, probably in combination with other factors, to problems that have an impact on reintegration in the community.

An examination of the relationship between ADHD level and index offence indicated that offenders with higher levels of ADHD were more likely to be currently incarcerated for robbery than offenders without ADHD. Given the impulsive nature of most robbery offences, this result is not surprising. Offenders with high levels of ADHD were less likely to be convicted for drug offences. This might be explained by the fact that the types of drug offences typically receiving a federal sentence include trafficking and exportation, offences which require a certain degree of planning. Additionally, offenders with high levels of ADHD symptoms were more likely to have substance abuse and other mental health problems. This is consistent with literature indicating a relationship between ADHD and substance abuse, as well as psychiatric comorbidity.

As hypothesized, ADHD was associated with an increased likelihood of receiving an institutional charge while incarcerated, with offenders with the highest ADHD rating being 2.5 times more likely to be given an institutional charge. Even moderate levels of ADHD significantly predicted the probability of receiving an institutional charge. This indicates that behaviour management is more difficult for offenders who are highly impulsive and inattentive. Interestingly, these behavioural traits were not associated with an increased likelihood of being sent to segregation. The implications of these results suggest that correctional staff can expect a potential increase in behaviour management issues with these offenders.

Contrary to expectation, ADHD did not have a significant impact on program completion. Offenders with high levels of ADHD were equally as likely to successfully complete their correctional programs as offenders without ADHD symptoms. This finding is somewhat counterintuitive given that these same offenders were found to have lower levels of educational attainment and a higher risk of learning disability. The fact that they were equally as successful as their non-ADHD counterparts in remaining in programs may be explained by the accommodations already put in place by many of CSC's program facilitators. In fact, ADHD has been recognized by CSC as a special need in the context of program delivery. To that end, facilitators are provided with information on recommended accommodations for offenders who may be exhibiting ADHD-like symptoms in the Responsivity Portal, an on-line resource guide with links to more in-depth information. It is possible that even though no formal screening for ADHD has yet taken place, program facilitators are already providing appropriate accommodations for offenders who need additional support.

Another significant finding was the impact of ADHD on returns to custody. At six months post-release, offenders with high levels of ADHD had returned to custody in greater numbers than offender with lower levels of ADHD. This difference remained significant at one year post-release. This indicates that offenders with ADHD are likely to return to custody and to do so more quickly than their non-ADHD counterparts, which was confirmed by the survival analysis. Given that the rate of return for offenders with ADHD is higher than for those without ADHD, it would be beneficial for CSC to be able to identify ADHD as a potential factor for increased risk of return to custody. Identification of offenders more likely to recidivate because of problems with impulsivity and inattention can allow parole staff, correctional educators, shop instructors and program officers to facilitate the reintegration process through targeted coaching strategies. These strategies have been shown to be effective in mitigating the most serious effects of ADHD (Solanto, Marks, Mitchell, Wasserstein & Kofman, 2008). Such interventions include coaching on self-management skills, problem solving, goal setting, and guided self-talk, all of which are included in existing CSC correctional programming and can be incorporated into individual counseling or educational sessions.

A secondary purpose for this study was to determine the usefulness of screening for ADHD upon admission to CSC, and whether the ASRS would be an appropriate tool for conducting this screening. The results of this research indicate that ADHD has an impact on success upon release as well as implications for institutional offender management. While the magnitude of the relationship of ADHD to delinquency and crime is not large, knowledge of the presence of the disorder does provide an additional piece of information for the complex task of offender case management within CSC. Although offenders with high ADHD were found to be equally successful in completing programs as those with low or no symptoms, the study did not assess the actual progress of the offenders in treatment or their outcomes as a result of program participation. We do know that offenders with high levels of ADHD had more institutional misconducts and were more likely to return to custody after release. This suggests that while program facilitators are currently able to accommodate offenders with impulsivity and attentional difficulties to the extent that they do not drop out of programs more than other offenders, their outcomes remain poorer than their non-ADHD counterparts. The evidence suggests that it would be worthwhile to screen for this disorder in order to make the appropriate accommodations for those offenders in need of extra support, particularly for those who may have ADHD in combination with other mental health problems or substance abuse issues. If information on offenders' level of symptoms of ADHD could be provided to program facilitators, educators and case management team members through CoMHISS reports, a more targeted correctional plan and intervention strategies could be developed. Current guidelines on the use of information from CoMHISS specify that its results should be included in psychologists' reports and be made accessible to those working with the offenders on a "need to know" basis.^{Footnote 1}

The ASRS is a brief and easy to administer measure that has been used in international studies of ADHD. Further research would need to be conducted in order to validate it on CSC's offender population (including women offenders); however, given that it is a screening tool, it could be a useful addition to the Computerized Mental Health Intake Screening System (CoMHISS) battery. Ease of administration makes the ASRS useful for this purpose, especially given that it can be used as either the full scale or as a 6-item version. Results of the current study indicated that the full scale and the shorter screener version were highly correlated. In addition, the results of our analyses did not change when using the screener as opposed to the full scale (see Appendix A). Depending on the situation, it could be advantageous to use the shorter version if administration time is a concern.

Conclusions

From an operational point of view, these results indicate that offenders with high levels of ADHD symptoms present a challenge in terms of institutional management and success upon release. Practically speaking, there would be a benefit to addressing the symptoms of impulsivity and inattention that are the features of the disorder in order to assist these offenders to adjust to an institutional environment and make a more successful transition into the community. Currently, correctional programs in CSC use a treatment model well suited to addressing the symptoms of ADHD. Although no specific ADHD intervention is in place, the Responsivity Portal developed through Reintegration Programs provides a description of intervention strategies for working with individuals with ADHD that have some evidenced-based support.

With respect to the measurement of ADHD, the ASRS is a quick measure that has been shown to be a valid measure of the disorder and could easily be incorporated into the mental health screening system already in place at intake (i.e. CoMHISS). Through CoMHISS reports, results of the ADHD screening could be relayed to the case management team, mental health professionals, and facilitators working with the offenders who are in a position to provide the necessary specialized support.

Preliminary estimates of rates of co-occurring ADHD and substance abuse indicate a strong link between the two confirming the literature on high rates of co-morbidity with various psychiatric diagnoses. Future research should explore the extent to which co-occurring substance abuse and mental health problems might further impede the rehabilitation of offenders with ADHD and identify methods to assist ADHD offenders and mitigate the impact of the disorder.

Finally, it should be pointed out that the picture for those with significant symptoms of ADHD is not entirely negative. While high rates of ADHD, particularly in combination with conduct disorder and substance abuse, can increase the chance of a variety of adverse outcomes, many adults with symptoms of ADHD are high functioning, creative, and lead prosocial and productive lives (Adler, 2004; Rad, Constantinescu, Nicolae, & Dobrescu, 2008). There is also some indication that ADHD may serve a protective factor for some adults. Ohan and Johnston (2002) note that individuals with ADHD are likely to project high self-esteem creating a positive impression in social situations. These individuals also tend to be overly optimistic when estimating their performance in future endeavors which is a factor linked to persistence and resilience (Diener & Milich, 1997).

Individuals who are high functioning despite their ADHD symptoms have discovered strategies or been provided with the assistance required to channel their high energy levels and focus their attention. These are the types of strategies that could be part of interventions that assist in mediating the effects of ADHD among offenders.

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Appendices

Appendix A: Results of analyses using the 6-item ASRS screener

Figure A1. Proportion of Offenders Remaining in the Community According to ASRS Rating