Identification and support of autistic individuals within the UK Criminal Justice System: a practical approach based upon professional consensus with input from lived experience.

BACKGROUND: Autism spectrum disorder (hereafter referred to as autism) is characterised by difficulties with (i) social communication, social interaction, and (ii) restricted and repetitive interests and behaviours. Estimates of autism prevalence within the criminal justice system (CJS) vary considerably, but there is evidence to suggest that the condition can be missed or misidentified within this population. Autism has implications for an individual's journey through the CJS, from police questioning and engagement in court proceedings through to risk assessment, formulation, therapeutic approaches, engagement with support services, and long-term social and legal outcomes. METHODS: This consensus based on professional opinion with input from lived experience aims to provide general principles for consideration by United Kingdom (UK) CJS personnel when working with autistic individuals, focusing on autistic offenders and those suspected of offences. Principles may be transferable to countries beyond the UK. Multidisciplinary professionals and two service users were approached for their input to address the effective identification and support strategies for autistic individuals within the CJS. RESULTS: The authors provide a consensus statement including recommendations on the general principles of effective identification, and support strategies for autistic individuals across different levels of the CJS. CONCLUSION: Greater attention needs to be given to this population as they navigate the CJS.

Psychometric properties of the Chinese version of the Gudjonsson compliance scale: scale validation and associations with mental health.

BACKGROUND: Trait compliance involves people reacting favorably to demands made by others across different situations. This may lead to susceptibility to external pressures, exploitation, and manipulation. Moreover, trait compliance was found to correlate with various mental health outcomes, such as depression and anxiety. The Gudjonsson Compliance Scale (GCS) is an efficient tool for assessing trait compliance in Western contexts. To date, no study has validated the psychometric properties of the GCS in Chinese populations. METHODS: Two college student samples from China were recruited. The first sample (N = 4,276) was used to conduct exploratory factor analysis. The second (N = 4,356) was used to perform a confirmatory factor analysis. The reliability, measurement invariance, and correlational tests were conducted on the two combined samples. RESULTS: The Chinese GCS showed a 3-factor structure, with two items deleted. Reliability was supported by moderate-to-good internal consistency of the three-factor scales and good internal consistency on the full scale. Strong measurement invariance across sex, ethnicity, and group recruitment was supported. Scores of the total scale and factor scales were found to significantly associated with several mental health problems. CONCLUSIONS: The Chinese version of the GCS appears to be a valid and reliable instrument for measuring trait compliance and could promote both the assessment and research on compliance in Chinese population.

Identification and treatment of individuals with attention-deficit/hyperactivity disorder and substance use disorder: An expert consensus statement.

Attention-deficit/hyperactivity disorder (ADHD) often co-occurs with substance use (SU) and/or substance use disorder (SUD). Individuals with concurrent ADHD and SU/SUD can have complex presentations that may complicate diagnosis and treatment. This can be further complicated by the context in which services are delivered. Also, when working with young people and adults with co-existing ADHD and SU/SUD, there is uncertainty among healthcare practitioners on how best to meet their needs. In February 2022, the United Kingdom ADHD Partnership hosted a meeting attended by multidisciplinary experts to address these issues. Following presentations providing attendees with an overview of the literature, group discussions were held synthesizing research evidence and clinical experience. Topics included: (1) A review of substances and reasons for use/misuse; (2) identification, assessment and treatment of illicit SU/SUD in young people and adults with ADHD presenting in community services; and (3) identification, assessment and treatment of ADHD in adults presenting in SU/SUD community and inpatient services. Dis-cussions highlighted inter-service barriers and fragmentation of care. It was concluded that a multimodal and multi-agency approach is needed. The consensus group generated a table of practice recommendations providing guidance on: identification and assessment; pharmacological and psychological treatment; and multi-agency interventions.

Let's Talk about Sex and ADHD: Findings from an Anonymous Online Survey.

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by inattention, hyperactivity and impulsivity. A dearth of studies have investigated psychosexuality in this population, often with few (predominantly male) participants. We recruited individuals with and without ADHD via an anonymous online survey distributed electronically by ADHD support organizations and social media. We investigated sexual history; interests and practices; and relationships. Of 1392 respondents, we classified an 'ADHD' group (n = 541; 30.5% male) and compared them to individuals of similar ages without ADHD, ('Other' group; n = 851; 37.6% male). The ADHD group (both males and females) had a significantly higher preference for same-sex or either-sex partners; and higher rates of electronic sexual exchanges, masturbation, and sexually transmitted diseases. They were more adventurous in sexual interests and practices and substantially less satisfied with their partners, both sexually and generally. Within the ADHD group, significant sex differences emerged: females had younger onset of sexual activities, used contraception less frequently, had more sexual partners and practiced more infidelity. Sexual interests differed between the sexes, but females more commonly acted on them, whereas males did not. Findings suggest both sexes engage in risky sexual behaviors, perhaps driven by impulsivity, but risk is substantially greater for females with ADHD.

Sex differences in conduct and emotional outcomes for young people with hyperactive/inattentive traits and social communication difficulties between 9 and 16 years of age: a growth curve analysis.

BACKGROUND: The purpose of this paper is to identify the trajectory of conduct and emotional problems for young people within the general population at four time points (between 9 years 7 months and 16 years 6 months), investigate their relationship with hyperactive/inattentive traits and explore the moderating effect of autistic social traits (ASTs). METHODS: Data from 9305 individuals involved in The Avon Longitudinal Study of Parents and Children (ALSPAC) study were included. Conduct and emotional problems and hyperactive/inattentive traits were measured by the Strengths and Difficulties Questionnaire. ASTs were assessed using the Social Communication Disorder Checklist. Individual trajectories for conduct and emotional problems were identified via growth curve modelling. Hyperactive/inattentive traits were included within the growth curve model as a time-varying covariate to determine their effect on these outcomes. Finally, participants were split into two groups (below and above clinical threshold ASTs Groups) and multi-group invariance testing was conducted on the data to identify the moderating effect of ASTs on the relationship between hyperactive/inattentive traits and outcomes (i.e. conduct and emotional problems). RESULTS: Hyperactive/inattentive traits were associated with higher rates of conduct and emotional problems for both boys and girls. The presence of ASTs moderated these relationships for boys, but not for girls, by increasing the risk of boys with hyperactive/inattentive traits developing greater conduct and emotional problems. CONCLUSIONS: These findings underscore the importance of identifying hyperactive/inattentive traits and ASTs in young people and addressing the increased risk of conduct and emotional problems. Research and clinical implications are explored.

What does current science tell us about the accuracy, reliability, and completeness of intoxicated witnesses? A case example of the murder of a prime minister.

Generally, the testimony of intoxicated witnesses has been considered relatively unreliable, but recent research has nuanced the knowledge base regarding these vulnerable witnesses. Purpose: To demonstrate the application of recent research findings regarding intoxicated witnesses to the statements made by a key witness to the murder of Olof Palme, Sweden's prime minister, in 1986. An additional purpose was to illustrate the use of a nuanced calculation of blood alcohol concentration (BAC) for researchers. Methods: The Palme murder has been debated since the crime was committed and no one has yet been sentenced. One of the witnesses was intoxicated and to estimate a range for his BAC at the time, a comprehensive BAC calculation was conducted in this study to illustrate important factors to consider in these types of cases. Results: Through the demonstration of the use of a nuanced BAC formula and by applying recent research results from studies on intoxicated witnesses, it was estimated that the possible BAC of the witness in the Palme-case at the time of the witnessed crime ranged between BAC = 0 to BAC = 0.13, depending on the type of alcoholic beverage consumed and whether the witness was a social or heavy drinker. This puts the witness either well within the span of maintained completeness as well as maintained accuracy rate (if considering: lowest dose and heavy drinker), or slightly exceeding this span into the BAC-range of reduced completeness but maintained accuracy rate (if considering: highest dose and social drinker). He was questioned immediately, and thereafter repeatedly, and he reported similar information throughout the interviews, which is in line with previous results on information maintenance over repeated interviews among intoxicated witnesses. Conclusion: The current case example shows how recent research on intoxicated witnesses can be applied in praxis, illustrating important factors for legal practitioners to consider when interpreting information from intoxicated witnesses. It also provides legal practitioners and researchers with an example of a structured approach to more nuanced BAC-calculations.

COVID-19 infection, vaccine status, and avoidance behaviors in adults with attention deficit and hyperactivity disorder: A cross-sectional study.

Objective: We aim to examine infection risk and vaccine status of COVID-19 in attention deficit and hyperactivity disorder and evaluate the impact of demographic, clinical, and COVID-19-related factors on the infection status and behavioral avoidance of COVID-19. Methods: This cross-sectional study assessed adults with attention deficit and hyperactivity disorder recruited from an outpatient psychiatry clinic. Patients and healthy controls completed a survey on sociodemographic data, COVID-19 infection status, and vaccine status. COVID-19 Disease Perception Scale, COVID-19 Avoidance Attitudes Scale, Attitudes toward COVID-19 Vaccine Scale, Adult Attention Deficit and Hyperactivity Disorder Self-report Screening Scale for DSM-5, Adult Attention Deficit and Hyperactivity Disorder Self-Report Scale Symptoms Checklist, Patient Health Questionnaire-9, and State-Trait Anxiety Inventory were applied. Results: Ninety patients and 40 healthy controls participated. Patients did not differ from controls in COVID-19 infection and vaccine status, and behavioral avoidance of COVID-19. No demographic and clinical factor significantly affected the COVID-19 infection status. Patients scored higher than controls in the perception of COVID-19 as contagious (p = 0.038), cognitive avoidance of COVID-19 (p = 0.008), and positive attitudes toward the COVID-19 vaccine (p = 0.024). After adjustment of possible factors, a positive perception of the COVID-19 vaccine and a perception of COVID-19 as dangerous were the two factors significantly affecting behavioral avoidance of COVID-19 [R 2 = 0. 17, F(2) = 13.189, p < 0.0001]. Conclusion: Infection and vaccine status of COVID-19 in patients did not significantly differ from controls. No demographic and clinical factor significantly affected the COVID-19 infection status. Approximately four-fifths of the patients were fully vaccinated as recommended by national and global health organizations. This has increased the knowledge base showing that the COVID-19 vaccine is acceptable and receiving the vaccine is endorsed by ADHD patients. Attention deficit and hyperactivity disorder itself may provoke no kind of mental disturbance in sense of perception of the danger of this disease. Our findings have increased the knowledge base showing that the COVID-19 vaccine is acceptable and the actual practice of receiving the vaccine is endorsed in this population. Our message for practice would be to take into account not only the core symptoms and the comorbidities of the disorder but also the perception of the disease while exploring its link with COVID-19.

University students with attention deficit hyperactivity disorder (ADHD): a consensus statement from the UK Adult ADHD Network (UKAAN).

BACKGROUND: Attention deficit hyperactivity disorder (ADHD) is associated with poor educational outcomes that can have long-term negative effects on the mental health, wellbeing, and socio-economic outcomes of university students. Mental health provision for university students with ADHD is often inadequate due to long waiting times for access to diagnosis and treatment in specialist National Health Service (NHS) clinics. ADHD is a hidden and marginalised disability, and within higher education in the UK, the categorisation of ADHD as a specific learning difference (or difficulty) may be contributing to this. AIMS: This consensus aims to provide an informed understanding of the impact of ADHD on the educational (or academic) outcomes of university students and highlight an urgent need for timely access to treatment and management. METHODS: The UK Adult ADHD Network (UKAAN) convened a meeting of practitioners and experts from England, Wales, and Scotland, to discuss issues that university students with ADHD can experience or present with during their programme of studies and how best to address them. A report on the collective analysis, evaluation, and opinions of the expert panel and published literature about the impact of ADHD on the educational outcomes of university students is presented. RESULTS: A consensus was reached that offers expert advice, practical guidance, and recommendations to support the medical, education, and disability practitioners working with university students with ADHD. CONCLUSIONS: Practical advice, guidance, and recommendations based on expert consensus can inform the identification of ADHD in university students, personalised interventions, and educational support, as well as contribute to existing research in this topic area. There is a need to move away from prevailing notions within higher education about ADHD being a specific learning difference (or difficulty) and attend to the urgent need for university students with ADHD to have timely access to treatment and support. A multimodal approach can be adapted to support university students with ADHD. This approach would view timely access to treatment, including reasonable adjustments and educational support, as having a positive impact on the academic performance and achievement of university students with ADHD.

Failure of Healthcare Provision for Attention-Deficit/Hyperactivity Disorder in the United Kingdom: A Consensus Statement.

Background: Despite evidence-based national guidelines for ADHD in the United Kingdom (UK), ADHD is under-identified, under-diagnosed, and under-treated. Many seeking help for ADHD face prejudice, long waiting lists, and patchy or unavailable services, and are turning to service-user support groups and/or private healthcare for help. Methods: A group of UK experts representing clinical and healthcare providers from public and private healthcare, academia, ADHD patient groups, educational, and occupational specialists, met to discuss shortfalls in ADHD service provision in the UK. Discussions explored causes of under-diagnosis, examined biases operating across referral, diagnosis and treatment, together with recommendations for resolving these matters. Results: Cultural and structural barriers operate at all levels of the healthcare system, resulting in a de-prioritization of ADHD. Services for ADHD are insufficient in many regions, and problems with service provision have intensified as a result of the response to the COVID-19 pandemic. Research has established a range of adverse outcomes of untreated ADHD, and associated long-term personal, social, health and economic costs are high. The consensus group called for training of professionals who come into contact with people with ADHD, increased funding, commissioning and monitoring to improve service provision, and streamlined communication between health services to support better outcomes for people with ADHD. Conclusions: Evidence-based national clinical guidelines for ADHD are not being met. People with ADHD should have access to healthcare free from discrimination, and in line with their legal rights. UK Governments and clinical and regulatory bodies must act urgently on this important public health issue.

The Science-Based Pathways to Understanding False Confessions and Wrongful Convictions.

This review shows that there is now a solid scientific evidence base for the "expert" evaluation of disputed confession cases in judicial proceedings. Real-life cases have driven the science by stimulating research into "coercive" police questioning techniques, psychological vulnerabilities to false confession, and the development and validation of psychometric tests of interrogative suggestibility and compliance. Mandatory electronic recording of police interviews has helped with identifying the situational and personal "risk factors" involved in false confessions and how these interact. It is the combination of a detailed evaluation and analysis of real-life cases, experimental work, and community (and prison/police station) studies that have greatly advanced the science over the past 40 years. In this review, the story of the development of the science during this "golden era" is told through the three established error pathways to false confessions and wrongful convictions: misclassification, coercion, and contamination. A case study of a major miscarriage of justice is used to highlight the key issues at each stage of the error pathways and it shows the continued resistance of the judiciary to admit mistakes and learn from them. Science is a powerful platform from which to educate the police and the judiciary.

Recommendations for occupational therapy interventions for adults with ADHD: a consensus statement from the UK adult ADHD network.

BACKGROUND: ADHD is neurodevelopmental disorder which persists into adulthood. Presently, therapeutic approaches are mainly pharmacological and psychological whilst the role, scope and approaches of occupational therapists have not been adequately described. RESULTS: In this consensus statement we propose that by assessing specific aspects of a person's occupation, occupational therapists can deploy their unique skills in providing specialist interventions for adults with ADHD. We also propose a framework with areas where occupational therapists can focus their assessments and give practice examples of specific interventions. CONCLUSIONS: Occupational therapists have much to offer in providing interventions for adults with ADHD. A unified and flexible approach when working with adults with ADHD is most appropriate and further research on occupational therapy interventions is needed.

The Risk of Making False Confessions: The Role of Developmental Disorders, Conduct Disorder, Psychiatric Symptoms, and Compliance.

Objective: To investigate salient predictors of self-reported false confessions. The conditions included mild intellectual disability (ID), autism spectrum disorder (ASD), ADHD, conduct disorder (CD), psychiatric symptoms, and compliance. Method: The sample consisted of 386 male Scottish prisoners, who completed a diagnostic ADHD interview, psychometric tests, and a questionnaire about false confessions they had given to police over their lifetime. Results: There was a high rate of reported false confessions (33.4%); the reason for the majority (62.2%) being to "cover up for somebody else." CD, ADHD, psychological distress and psychiatric symptoms, and compliance were all significant predictors of false confession. When examining the influence of underlying domains of ADHD, it was found that hyperactivity/impulsivity drove the association with false confession after adjusting for coexisting CD. Conclusion: CD and ADHD were the two most powerful predictors of false confessions, with CD mediating some of the effects of ADHD.

Time and Alcohol Do Not Change Everything: How Intoxicated Witnesses Perceive Aggression in Intimate Partner Violence.

Although alcohol-intoxicated witnesses to violent crimes are common, research on how alcohol affects witnesses' perception of aggression is sparse. In the present study, it was investigated whether different levels of intoxication altered how severe witnesses perceived aggression displayed by involved parties in an intimate partner violence (IPV) scenario to be. An experimental mixed-groups design 3 (sober vs. moderate vs. high breath alcohol concentration [BAC]) x 2 (immediate vs. one week delayed interview) was used. Socially drinking men and women (n = 137; 67 and 70, respectively) were randomized to an alcohol condition (0.8 g/kg adjusted to 0.75 g/kg for women, divided into two intoxication groups: moderate ≤0.08 and high ≥0.08) or a control condition (juice). They were also randomized into a direct interview condition or a delayed interview condition. In a laboratory setting, they consumed drinks and viewed an IPV scenario on film. During their interview, the participants rated how severe they perceived the involved parties' aggression to be. Inter alia, participants in the high BAC group perceived both parties' physically aggressive behavior as comparatively less severe than the sober and moderately intoxicated witnesses did. The high BAC group also perceived the IPV scenario as less unpleasant than the other two groups, and they maintained this perception over time and repeated interviews. A BAC level of ≥0.08 was required to significantly lower witnesses' perceived severity of physical aggression, possibly caused by alcohol's anxiety-dampening effect as well as its impairing effect on cognitive processing capacity over this level of intoxication. That alcohol intoxication at (or over) such a BAC level makes witnesses perceive physical aggression as less severe and less unpleasant, and also that such an altered perception holds over time and repeated interviews, is important for legal practitioners to be aware of when handling intoxicated witnesses to violence. Therefore, this issue warrants further investigation.

Females with ADHD: An expert consensus statement taking a lifespan approach providing guidance for the identification and treatment of attention-deficit/ hyperactivity disorder in girls and women.

BACKGROUND: There is evidence to suggest that the broad discrepancy in the ratio of males to females with diagnosed ADHD is due, at least in part, to lack of recognition and/or referral bias in females. Studies suggest that females with ADHD present with differences in their profile of symptoms, comorbidity and associated functioning compared with males. This consensus aims to provide a better understanding of females with ADHD in order to improve recognition and referral. Comprehensive assessment and appropriate treatment is hoped to enhance longer-term clinical outcomes and patient wellbeing for females with ADHD. METHODS: The United Kingdom ADHD Partnership hosted a meeting of experts to discuss symptom presentation, triggers for referral, assessment, treatment and multi-agency liaison for females with ADHD across the lifespan. RESULTS: A consensus was reached offering practical guidance to support medical and mental health practitioners working with females with ADHD. The potential challenges of working with this patient group were identified, as well as specific barriers that may hinder recognition. These included symptomatic differences, gender biases, comorbidities and the compensatory strategies that may mask or overshadow underlying symptoms of ADHD. Furthermore, we determined the broader needs of these patients and considered how multi-agency liaison may provide the support to meet them. CONCLUSIONS: This practical approach based upon expert consensus will inform effective identification, treatment and support of girls and women with ADHD. It is important to move away from the prevalent perspective that ADHD is a behavioural disorder and attend to the more subtle and/or internalised presentation that is common in females. It is essential to adopt a lifespan model of care to support the complex transitions experienced by females that occur in parallel to change in clinical presentation and social circumstances. Treatment with pharmacological and psychological interventions is expected to have a positive impact leading to increased productivity, decreased resource utilization and most importantly, improved long-term outcomes for girls and women.

Guidance for identification and treatment of individuals with attention deficit/hyperactivity disorder and autism spectrum disorder based upon expert consensus.

BACKGROUND: Individuals with co-occurring hyperactivity disorder/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) can have complex presentations that may complicate diagnosis and treatment. There are established guidelines with regard to the identification and treatment of ADHD and ASD as independent conditions. However, ADHD and ASD were not formally recognised diagnostically as co-occurring conditions until the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5) was published in 2013. Hence, awareness and understanding of both conditions when they co-occur is less established and there is little guidance in the clinical literature. This has led to uncertainty among healthcare practitioners when working with children, young people and adults who present with co-existing ADHD and ASD. The United Kingdom ADHD Partnership (UKAP) therefore convened a meeting of professional experts that aimed to address this gap and reach expert consensus on the topic that will aid healthcare practitioners and allied professionals when working with this complex and vulnerable population. METHOD: UK experts from multiple disciplines in the fields of ADHD and ASD convened in London in December 2017. The meeting provided the opportunity to address the complexities of ADHD and ASD as a co-occurring presentation from different perspectives and included presentations, discussion and group work. The authors considered the clinical challenges of working with this complex group of individuals, producing a consensus for a unified approach when working with male and female, children, adolescents and adults with co-occurring ADHD and ASD. This was written up, circulated and endorsed by all authors. RESULTS: The authors reached a consensus of practical recommendations for working across the lifespan with males and females with ADHD and ASD. Consensus was reached on topics of (1) identification and assessment using rating scales, clinical diagnostic interviews and objective supporting assessments; outcomes of assessment, including standards of clinical reporting; (2) non-pharmacological interventions and care management, including psychoeducation, carer interventions/carer training, behavioural/environmental and Cognitive Behavioural Therapy (CBT) approaches; and multi-agency liaison, including educational interventions, career advice, occupational skills and training, and (3) pharmacological treatments. CONCLUSIONS: The guidance and practice recommendations (Tables 1, 4, 5, 7, 8 and 10) will support healthcare practitioners and allied professionals to meet the needs of this complex group from a multidisciplinary perspective. Further research is needed to enhance our understanding of the diagnosis, treatment and management of individuals presenting with comorbid ADHD and ASD.

Substance and Alcohol Misuse, Drug Pathways, and Offending Behaviors in Association With ADHD in Prison Inmates.

Objective: The objective of the study is to quantify the extent of specific polysubstance use, drug transitions to current substances, and describe the association with alcohol use disorders among inmates with ADHD. We also examined health risk behaviors and patterns of offending in relation with ADHD. Method: A total of 387 male British prison inmates were screened and interviewed via the Diagnostic Interview for ADHD in Adults 2.0 (DIVA-2). Results: Male prisoners with ADHD endorse more methadone and amphetamine use. There was a significantly higher linear trend among those with ADHD for the number of substances ever used. ADHD was positively associated with increasing levels of alcohol use disorder severity, and with alcohol dependence. Transition along the pathways of substance misuse and persistence of drug misuse was better explained by the presence of conduct disorder/antisocial personality traits. Conclusion: Higher rates of alcohol dependence and stimulant-cocaine misuse suggest these inmates have maladaptive coping mechanisms, such as self-medication behaviors.

Attention Problems Predict Risk of Violence and Rehabilitative Engagement in Mentally Disordered Offenders.

Mentally disordered offenders (MDOs) endorse difficulties with attention, impulsivity, and hyperactivity. Assessing these difficulties among MDOs may confer practical benefits for the management and provision of care for this population, by informing strategies to improve rehabilitative engagement and risk assessments for violence. However, there is a dearth of literature exploring these cognitive problems in MDOs in relation to outcome factors. Forty-eight MDOs from a high-security hospital completed the QbTest, which measures the domains of inattention, impulsivity, and hyperactivity. Comprehensive file review of clinical and occupational/vocational rehabilitative engagement and Historical Clinical Risk Management-20 (HCR-20) were used as outcome measures of interest. Participants displayed greater cognitive deficits in attention, impulsivity, and hyperactivity compared to the general population. The domain of inattention and omission errors was related to occupational/vocational therapy engagement as well as a higher risk of present and future violence as measured by the HCR-20. The findings suggest that QbTest is a helpful objective tool that could be incorporated into the assessment of MDOs. Specifically, inattention emerged as a strong predictor of patients' risk of violence as well as patient's vocational therapy engagement. Therefore, cognitive skills programs targeting attention problems should be introduced to improve outcomes for this population.

Identification and treatment of offenders with attention-deficit/hyperactivity disorder in the prison population: a practical approach based upon expert consensus.

BACKGROUND: Around 25% of prisoners meet diagnostic criteria for attention-deficit/hyperactivity disorder (ADHD). Because ADHD is associated with increased recidivism and other functional and behavioural problems, appropriate diagnosis and treatment can be a critical intervention to improve outcomes. While ADHD is a treatable condition, best managed by a combination of medication and psychological treatments, among individuals in the criminal justice system ADHD remains both mis- and under-diagnosed and consequently inadequately treated. We aimed to identify barriers within the prison system that prevent appropriate intervention, and provide a practical approach to identify and treat incarcerated offenders with ADHD. METHODS: The United Kingdom ADHD Partnership hosted a consensus meeting to discuss practical interventions for youth (< 18 years) and adult (≥18 years) offenders with ADHD. Experts at the meeting addressed prisoners' needs for effective identification, treatment, and multiagency liaison, and considered the requirement of different approaches based on age or gender. RESULTS: The authors developed a consensus statement that offers practical advice to anyone working with prison populations. We identified specific barriers within the prison and criminal justice system such as the lack of adequate: staff and offender awareness of ADHD symptoms and treatments; trained mental health staff; use of appropriate screening and diagnostic tools; appropriate multimodal interventions; care management; supportive services; multiagency liaison; and preparation for prison release. Through discussion, a consensus was reached regarding prisoners' needs, effective identification, treatment and multiagency liaison and considered how this may differ for age and gender. CONCLUSIONS: This practical approach based upon expert consensus will inform effective identification and treatment of offenders with ADHD. Appropriate intervention is expected to have a positive impact on the offender and society and lead to increased productivity, decreased resource utilization, and most importantly reduced rates of re-offending. Research is still needed, however, to identify optimal clinical operating models and to monitor their implementation and measure their success. Furthermore, government support will likely be required to effect change in criminal justice and mental health service policies.

Health-related quality of life in prisoners with attention-deficit hyperactivity disorder and head injury.

BACKGROUND: Attention-deficit hyperactivity disorder (ADHD) and head injury (including traumatic brain injury (TBI)) manifest in high levels across prison samples and guidance from the National Institute for Health and Care Excellence notes that people with acquired brain injury may have increased prevalence of ADHD. We aimed to examine the association of ADHD with TBI and the impact of the association upon health-related quality of life (HRQoL) and service use among imprisoned adults. METHODS: An observational study was performed in 2011-2013, at Porterfield Prison, Inverness, United Kingdom (UK). The all male sample included 390 adult prison inmates with capacity to consent and no history of moderate or severe intellectual disability. Head injury was measured with a series of self-reported questions, addressing history of hits to the head: frequency, severity, loss of consciousness (LOC), and sequelae. Participants were interviewed using the Diagnostic Interview for ADHD in Adults 2.0. The Health Utilities Index Mark 3 was used to measure health status, and to calculate attribute specific HRQoL and Quality-Adjusted Life Year (QALY) scores. RESULTS: 72% of prisoners sampled reported at least one head injury in their lifetime. Among those, 70% of head injuries occurred before age 16 and 70% experienced LOC. Prisoners with ADHD were nearly twice more likely to have TBI. Prisoners with ADHD-only and ADHD with co-morbid TBI had significantly lower scores in several HRQoL attributes, compared with TBI only or the absence of either condition. Adjusted logistic regression models indicated an average reduction of 0.20 QALYs in inmates with ADHD-only and 0.30 QALY loss in those with ADHD with co-morbid TBI compared with inmates with neither condition. CONCLUSIONS: There is a robust association between ADHD and TBI, and ADHD with co-morbid TBI confers significantly greater impairment in terms of HRQoL. Managing the short and long-term consequences of TBI is essential to improving care for prisoners and to addressing the criminogenic factors related to them.

The economic consequences of attention-deficit hyperactivity disorder in the Scottish prison system.

BACKGROUND: Attention-deficit hyperactivity disorder (ADHD) is highly prevalent amongst prison inmates and the criminal justice system (CJS) likely bears considerable costs for offenders with ADHD. We aimed to examine the relationship between ADHD and health-related quality of life (HRQoL) and quality-adjusted life years (QALY) amongst imprisoned adults; and to estimate the annual expenditure associated with ADHD status in prison. METHODS: An observational study was performed in 2011-2013, at Porterfield Prison, Inverness, United Kingdom (UK). The all male sample included 390 adult prison inmates with capacity to consent and no history of moderate or severe intellectual disability. Participants were interviewed using the Diagnostic Interview for ADHD in Adults 2.0. The Health Utilities Index Mark 3 (HUI3) was used to measure health status, and to calculate attribute specific HRQoL scores and QALY. Health service utilisation was obtained through inspection of medical prison records. Inmates with ADHD were compared with inmates without ADHD. RESULTS: Inmates with ADHD had significantly lower QALYs, with a clinically significant adjusted difference of 0.13. Psychiatric co-morbidity accounted for the variation of ADHD on the HUI3 emotion domain only. Medical costs for inmates with ADHD were significantly higher; and behaviour-related prison costs were similar to prisoners without ADHD, reflecting a low frequency of recorded critical incidents. CONCLUSIONS: ADHD may directly contribute to adverse health and quality of life through cognitive and executive function deficits, and co-morbid disorders. The extrapolation of conservative cost estimates suggests that the financial burden of medical and behavior-related prison care for inmates with ADHD in the UK is approximately £11.7 million annually. The reported cost estimates are conservative as there is great variability in recorded critical incidents in prisons. In turn, for some prison establishments the prison care costs associated with prisoners with ADHD may be considerably greater.