ADHD in the Justice System: underdiagnosed and underserved

Individuals with Attention-Deficit/Hyperactivity Disorder (ADHD) may deal with symptoms such as inattention, disorganization, hyperactivity (often seen as restlessness in adults), and/or impulsivity. Symptoms of ADHD often continue into adulthood, causing challenges in social, academic, and professional functioning (American Psychiatric Association, 2022). Research suggests that ADHD occurs in most cultures in about 5% of children and 2.5% of adults (American Psychiatric Association, 2022).

How can ADHD relate to involvement with the justice system?

Personality factors and symptoms that relate to ADHD such as recklessness, sensation-seeking behavior, poor impulse control, inattention, and a confrontational interpersonal style have been linked to unlawful behavior (Young & Gudjonsson, 2010). Additionally, these behaviors can lead to vulnerability and disadvantage in the criminal justice system, as symptoms of ADHD may be misattributed to “defiance” or more generally “bad behavior” (Young & Cocallis, 2019). ADHD can affect how successful individuals are in their experiences in court, during imprisonment, and with probation. This observation is particularly true for individuals who have never been formally diagnosed or whose ADHD diagnosis is unknown to the criminal justice system (Berryessa, 2017). For example, dysfunctional coping strategies, problems with paying attention, impulsive responses to questions or a lack of confidence in one’s memory can lead to a high number of “don’t know” answers during interviews, which can be interpreted as evasive or misleading (Gudjonsson, Young, & Bramham, 2007).

What is the prevalence of ADHD in justice and corrections systems?

There is a disproportionately high concentration of individuals with ADHD within the criminal justice system. International studies suggest that up to two-thirds of youth who have offended and up to half of the adult prison population screen positive for childhood ADHD, and many justice-involved individuals continue to experience symptoms into adulthood, with rates reported at 14% in adult males and 10% in adult females (Young et al., 2011). A meta-analysis that combined the findings of multiple scientific studies showed a five to tenfold higher prevalence of ADHD in prison compared to general population rates (Young et al., 2015).

Even though ADHD is known to be highly prevalent in the correctional system, it is also likely to be underdiagnosed and undertreated (Young & Cocallis, 2019), which is problematic because understanding that (at least some of) an individual’s behavior may be related to ADHD can help provide better recommendations for sentencing, probation, and treatment (Berryessa, 2017). Particularly little is known about the prevalence of ADHD in justice involved individuals managed in the community, although research in England and Wales shows that probation staff tend to underestimate the prevalence of ADHD (Young et al., 2014).

As previously mentioned, there is a risk that symptoms of ADHD may be misattributed to “defiance” or “bad behavior” (Young & Cocallis, 2019). Additionally, the diagnosis of ADHD is often complicated by the presence of other co-occurring psychiatric and neurodevelopmental disorders that can mask the symptoms of ADHD, such as substance use disorder and depression (CADDAC, 2019; Young & Cocallis, 2019). Effective treatment of ADHD improves outcomes, including those related to co-occurring disorders (Young & Cocallis, 2019), and can alleviate functional impairments associated with ADHD symptoms. In other words, the treatment of co-occurring disorders is more likely to fail if ADHD is not treated well. Screening for ADHD, therefore, leads to more efficient use of resources and better clinical outcomes.

What’s different for youth with ADHD in the justice system?

There is an increased awareness of the number of young people with ADHD who come into contact with the criminal justice system. Research shows that youth with ADHD enter the criminal justice system at a younger age (based on the age of first arrest and conviction), they are four to five times more likely to be arrested, and they are more likely to have multiple arrests and convictions than those without ADHD (Young et al., 2014). In custody, youth with ADHD are also more likely to present with demanding and/or violent behaviors (Young et al., 2011). This finding has led researchers to conclude that early detection of ADHD in young offenders could help disrupt an antisocial trajectory (Young & Cocallis, 2019).

The urgent need for ADHD screening in the justice and corrections systems

There is an urgent need for ADHD screening in the criminal justice system as early detection and treatment can reduce substance use, criminal behavior, and recidivism (CADDAC, 2019; Young & Gudjonsson, 2010; Young & Cocallis, 2019). Improved screening provisions and training may help address under-detection and misdiagnosis to achieve a greater awareness of the prevalence of ADHD in the criminal justice system (Young et al., 2014), as well as identify proper interventions and care.
To accomplish this goal, experts recommend screening for childhood and current symptoms. One could use checklists or standardized behavior rating scales for screening purposes, such as the Conners 4 ^TM for youth or the Conners’ Adult ADHD Rating Scales (CAARS^TM) for adults, which meet best-practice guidelines for screening for ADHD symptoms and related impairments. Afterwards, those who screen positive should receive a semi-structured diagnostic interview, using, for example, the Conner’s Adult ADHD Diagnostic Interview for DSM-IV (Young & Gudjonsson, 2010; with consideration to any changes described in the DSM-5-TR). It is important to use psychometric assessments with strong evidence of reliability, validity, and fairness to support diagnostic decision-making (e.g., pairing assessment results with clinical interviews, perspectives from multiple informants, and findings from a records review). Upon diagnosis, the key challenge for management in institutional settings is to accept that specific pharmacological and psychological treatment may be necessary to help individuals manage ADHD symptoms and improve pro-social behavior (Young & Gudjonsson, 2010). In the long run, this thorough assessment process is in everyone’s best interest.

As per Young and Cocallis, “…due to the disproportionate[ly] high rate of ADHD compared with the general population and the pervasive and long-lasting impact ADHD may manifest among prisoners, ADHD is a condition that the prison system cannot afford to ignore. Effective interventions exist and have the potential to significantly decrease disruption in the prison system, increase the impact of rehabilitation programmes, reduce recidivism, and ultimately change the trajectory of offenders. In the context of data from recent health economic analyses and the prospective savings that may be realized, attending to the needs of this at-risk group would seem to offer ‘win-win’ solutions for all stakeholders in the longer term” (2019, p. 6).

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