Scandinavian Journal of Psychology, 2014, 55, 343–349
DOI: 10.1111/sjop.12131
Health and Disability Attention deficit hyperactivity disorder among inmates in Bergen Prison LISA STOKKELAND,1,2 OLE BERNT FASMER,3,4,5 LEIF WAAGE1 and ANITA L. HANSEN1,6 1
Centre for Research and Education in Forensic Psychiatry, Haukeland University Hospital, Bergen, Norway Unit for young adults with substance abuse and mental health problems, Department of Addiction medicine, Haukeland University Hospital, Bergen, Norway 3 Division of Psychiatry, Haukeland University Hospital, Bergen, Norway 4 Department of Clinical Medicine, Section for Psychiatry, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway 5 K.G. Jebsen Centre for Research on Neuropsychiatric Disorders, University of Bergen, Bergen, Norway 6 Department of Psychosocial Science, University of Bergen, Bergen, Norway 2
Stokkeland, L., Fasmer, O. B., Waage, L. & Hansen, A. L. (2014). Attention deficit hyperactivity disorder among inmates in Bergen Prison. Scandinavian Journal of Psychology 55, 343–349. The aim of this study was to investigate whether clinical findings are consistent with research indicating a high prevalence of attention deficit hyperactivity disorder (ADHD) among prison inmates. Forty-three male inmates who were referred for ADHD assessment at the health service in Bergen prison participated. Although most of them reported symptoms in accordance with ADHD both in childhood and adulthood, only 35% of the referred inmates fulfilled the criteria for ADHD when a comprehensive assessment was conducted. The results emphasize the importance of a comprehensive assessment when diagnosing ADHD among prison inmates. Key words: Prison inmates, ADHD, ASRS, MINI plus. Lisa Stokkeland, Unit for young adults with substance abuse and mental health problems, Department of Addiction medicine, Haukeland University Hospital, 5021 Bergen, Norway. Tel: +47 55970100; fax: +47 55970101; e-mail: [email protected]
INTRODUCTION Across the world, the most marginalized groups in society are over-represented in the prison inmate population, consisting of drug users, people with poor health, and those who engage in riskrelated activities (World Health Organization, 2003). International studies have indicated that prison inmates have high prevalence rates of serious psychiatric disorders such as personality disorders, major depression, and psychotic disorders (for a review of studies of serious mental disorders among prison inmates, see Fazel & Danesh, 2002). Another disorder that has been assumed to be of high prevalence among prison inmates, and to cause them serious problems, is attention deficit hyperactivity disorder (ADHD) (Rasmussen, Almvik & Levander, 2001). Considering that people with ADHD have an elevated risk for antisocial behavior and substance use disorder (Babinski, Hartsough & Lambert, 1999; Barkley, Fischer, Smallish & Fletcher, 2004), an elevated prevalence of ADHD among prison inmates could be expected. This expectation has been supported by research (Eyestone & Howell, 1994; Rasmussen et al., 2001; Young, Gudjonsson, Wells et al., 2008). Therefore, the current paper aimed to determine whether clinical findings are consistent with this expectation and whether a need exists for extra focus on ADHD among prison inmates. The aim was to identify how many of the prison inmates who were referred to the health service for ADHD assessment fulfilled the criteria for this diagnosis based on a comprehensive assessment by a clinical psychologist and a psychiatrist. ADHD: SYMPTOMS, PREVALENCE, AND COMORBIDITY ADHD is one of the most common psychiatric disorders of childhood. The primary symptoms of the disorder are inattention, hyperactivity, and impulsivity. ADHD is assumed to affect © 2014 Scandinavian Psychological Associations and John Wiley & Sons Ltd
approximately 3–7% of the childhood population (American Psychiatric Association, 2000). Approximately 70% to 80% of these children continue to have significant difficulties in adulthood. Comparatively few data are available on the prevalence of ADHD in the general adult population, but an estimated prevalence is 4.5% (Faraone, Biederman, Spencer et al., 2000; Kessler, Adler, Barkley et al., 2006). It is widely accepted that children with ADHD display a greater degree of difficulties with oppositional and defiant behavior, aggressiveness and conduct problems, and even antisocial behavior compared to other children (Barkley, 2006), and continued symptoms of ADHD in adolescence are highly correlated with the development of antisocial personality disorder (ASPD) and antisocial acts (Fischer, Barkley, Smallish & Fletcher, 2002; Gittelman, Mannuzza, Shenker & Bonagura, 1985; Rasmussen & Gillberg, 2000). This phenomenon is most apparent for those individuals who show aggressive and/or antisocial behavior as children (Claude & Firestone, 1995). ADHD among prison inmates It has been suggested that adults with ADHD who have the least favorable outcomes are among those who end up in prison (Rasmussen et al., 2001). Compared to controls, these individuals report a higher frequency of arrests and have committed a wider range of offenses. The severity of childhood ADHD has been found to contribute significantly to the frequency of drugrelated antisocial behavior in adulthood (Barkley et al., 2004). The incidence of ADHD in prison populations appears to far exceed the frequency found in the general adult population. In their sample of 102 prison inmates, Eyestone and Howell (1994) found that 25% of inmates fulfilled the criteria for ADHD, manifesting substantial symptoms both in childhood
344 L. Stokkeland et al. and adulthood. Nearly 7% of the total sample reported symptoms consistent with ADHD only in childhood, whereas another 7% of the sample reported symptoms consistent with this diagnosis only as adults. In a Norwegian study by Rasmussen et al. (2001), the results indicated that 46% of the prison inmates had difficulties that could be attributed to ADHD as children and that 30% also had symptoms as adults. Young et al. (2008) found that 24% of a Scottish prison population met the screening criteria for childhood ADHD, of whom 23% fulfilled the criteria for ADHD as adults, 33% were in partial remission, and 44% were in full remission. In a Swedish study, a prevalence rate of 40% was found among adult male longer-term prison inmates (Ginsberg, Hirvikoski & Lindefors, 2010), while an Australian study found that 17% of their prison sample met the criteria for adult ADHD (Moore, Sunjic, Kaye, Archer & Indig, 2013).
The difficulty of diagnosing ADHD ADHD is difficult to diagnose because the core symptoms of the disorder are also common in the normal population and the symptoms likely represent the extreme end of a continuum (Prince, Wilens, Spencer & Biederman, 2006). The symptoms of ADHD are also typical for a number of other diagnoses, including conduct disorder (CD) (Lindberg, Tani, PorkkaHeiskanen, Appelberg, Rimon & Virkkunen, 2004), anxiety disorders, depressive disorders, speech and learning disorders (Dulcan, 1997), and personality disorders (Murphy & Gordon, 2006). The diagnosing of ADHD is further complicated by the fact that the overlap in symptoms can be an accurate reflection of their co-occurrence (Babinski et al., 1999). For instance, the study by Rasmussen et al. (2001) suggests that persistent ADHD, comorbid with both personality disorders and reading disability, constitutes a problem of high magnitude among prisoners.
AIM OF THE STUDY Diagnosing ADHD among prison inmates is complex (Moore et al., 2013), and studies of ADHD among prison inmates have primarily relied on self-reported symptoms (Eyestone & Howell, 1994; Rasmussen et al., 2001; Young et al., 2008). Thus, the aim of the present study was to determine whether inmates who were referred to the health service for an assessment of possible ADHD met the criteria for an ADHD diagnosis based on a comprehensive assessment.
METHOD Participants The participants were 43 male inmates from Bergen Prison. They had all been referred to the mental health service for ADHD assessment by the prison physician due to reported symptoms consistent of ADHD. No instructions were given to the prison physician on how to assess symptoms consistent with ADHD as this assessment was a part of regular clinical practice. The age of the participants ranged from 20 to 52 years, with a mean of 32.1 years (SD = 8.5) (see Table 1). They were incarcerated for different criminal acts such as violence, murder, drugs, fraud, © 2014 Scandinavian Psychological Associations and John Wiley & Sons Ltd
Scand J Psychol 55 (2014) Table 1. Mean and Standard Deviations for Age, ASRS, WURS-25, MDQ, Cyclothymic temperament questionnaire, and HADS
Variables
Mean
Standard deviations
Age Total ASRS ASRS A ASRS B WURS-25 MDQ Cyclothymic temperament scale Total HADS HADS A HADS D
32.1 50.3 25.9 24.8 57.6 9.6 14.0
8.5 9.6 5.4 5.7 18.1 4.3 4.5
17.0 10.7 6.3
5.7 3.3 3.6
Notes: ASRS = Adult ADHD Self-Report Scale; WURS-25 = Wender Utah Rating Scale, 25 questions version; MDQ = Mood Disorder Questionnaire; HADS = Hospital Anxiety and Depression Scale. and robbery. The participants included both inmates serving custody and inmates who were sentenced.
Clinical data A standard clinical interview was used to obtain background information and past and present symptoms of mental illness. A specific emphasis was placed on gathering information that was relevant to diagnosing ADHD. This interview was supplemented with information from collateral sources. A clinical interview consisting of specific questions about developmental and medical history, school history, work history, psychiatric history, social adjustment, family history of ADHD or other psychiatric or medical conditions in the family, and current functioning, was conducted with parents and/or other significant individuals in the inmate’s past and/or present. When interviewing the participants and parents and/or other significant individuals, specific questions regarding symptoms consistent with ADHD was used and concrete examples of symptom expression was given. Since retrospective data can be vulnerable to historical inaccuracy, incompleteness, and distortions (Henry, Moffitt, Caspi, Langley & Silva, 1994; Hardt & Rutter, 2004), and to obtain a full picture of the patients functioning, reports were also collected from schools, educational psychological service, child psychiatry, child welfare, and contact with health care in adulthood. The following self-completion forms and rating scales were used: Adult ADHD Self-Report Scale (ASRS); Wender Utah Rating Scale, 25 questions version (WURS-25); Mood Disorder Questionnaire (MDQ); Cyclothymic temperament scale; Hospital Anxiety and Depression Scale (HADS); and the structured interview Mini-International Neuropsychiatric Interview (MINI plus). All of the patients also underwent neuropsychological testing. A description of the cognitive function of the patient was considered to be important for further treatment and advice concerning school or work, but the test results were not regarded as conclusive regarding the diagnostic decision. This assessment is in accordance with the recommendation that neuropsychological tests should not be oversold as a basis of ADHD diagnosis (Gordon, Barkley & Lovett, 2006). The results from the neuropsychological tests are, therefore, not included in the present report. WURS-25. This is a 25-item self-rating scale on which adults describe their childhood behavior retrospectively. The participants indicate how often symptoms occurred using a Likert scale of 0–4 (0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = very often). A score of 46 or higher has been shown to correctly identify 86% of adults with childhood ADHD and 99% of normal subjects (Ward, Wender &
ADHD among prison inmates 345
Scand J Psychol 55 (2014) Reimherr, 1993), and a score of 46 or higher was therefore chosen to indicate ADHD. ASRS. ASRS consists of 18 questions that follow the Diagnostic and Statistical Manual of Mental Disorders fourth edition, text revision [DSM-IV-TR] (American Psychiatric Association, 2000) criteria for ADHD and addresses the manifestations of ADHD symptoms in adults. The participants indicate how often symptoms occur using a Likert scale of 0–4 (0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = very often). The results may suggest the need for a more in-depth clinician interview (Adler, Kessler & Spencer, 2003; Kessler et al., 2005, 2006). MDQ. This is a self-report form that consists of 13 questions about symptoms consistent with bipolar disorders. Confirmation of at least seven questions and confirmation that the symptoms have occurred together and caused problems indicate bipolar disorder (Hirschfeld, Williams, Spitzer et al., 2000). Cyclothymic temperament questionnaire. This is a self-report form that consists of 21 questions that cover the cyclothymic temperament according to the definition of Akiskal. Confirmation of at least 11 questions indicates a cyclothymic temperament (Akiskal, Akiskal, Haykal, Manning & Connor, 2005).
All the gathered information was discussed according to DSM-IV (American Psychiatric Association, 1994) and the International Classification of mental and behavioural Disorders -10 [ICD-10] (World Health Organization, 1993) criteria for ADHD /hyperkinetic disorder. The diagnosis was, however, given according to the DSM-IV criteria. The clinical interview, administration of questionnaires, and collection of complete information were completed by a clinical psychologist (LS). The final diagnosis of ADHD and other mental disorders, development of conclusion, and the recommendations to the referring physician were conducted in cooperation with a psychiatrist (OBF).
Statistics The means and standard deviations for the WURS-25, ASRS, MDQ, Cyclothymic temperament questionnaire, and HADS were calculated. The MDQ and Cyclothymic temperament questionnaire scores were categorized in the described categories and the diagnoses of MINI plus were registered. The number of patients who were diagnosed with ADHD was also registered. SPSS version 15.0 (SSPS, Chicago, IL) was used for the statistical analyses.
RESULTS HADS. HADS is a self-assessment scale that is reliable for detecting states of depression and anxiety in the setting of a hospital medical outpatient clinic. The anxiety and depressive subscales are also valid measures of severity of the emotional disorder (Herrmann, 1997; Zigmond & Snaith, 1983). MINI plus. MINI plus is an instrument that allows for the coding of more than 60 variables, including 15 of the DSM-IV disorders (American Psychiatric Association, 1994). It employs different time frames for various disorders, including current, past, or lifetime (Sheehan, Lecrubier, Sheehan et al., 1998; Leiknes, Malt, Malt & Leganger, 2005).
Procedure The study was approved by the Regional Committee for Medical and Health Research Ethics in Western Norway. Data were collected for all of the patients referred to the mental health service in Bergen prison for assessment of ADHD in the period from 2007 to 2009. The self-report tests were administered individually to the participants, and the psychologist was present to answer questions and provide instructions. The tests were read to the participants when reading skills were not sufficient for self-completion. Both the self-report tests and MINI plus were scored according to the scoring and interview criteria, but the results regarding the diagnosis of somatization disorder, hypochondriasis, anorexia nervosa, bulimia nervosa, and somatoform disorders in MINI plus are not included in the current report. The final diagnostic assessment was made after an overall assessment and integration of all available information, including clinical interview, information from significant others, WURS-25, ASRS, MDQ, Cyclothymic temperament questionnaire, and MINI plus. This was done in order to underline the important work of integrating all the available data when doing a multimethod, multiinformant assessment (Hathaway, DoolingLitfin & Edwards, 2006). To be given the diagnosis of ADHD, the participants had to reach the cut-off levels for ADHD on WURS-25, ASRS and MINI plus, and they had to fulfill the criteria as defined in according to DSM-IV (American Psychiatric Association, 1994). To reach the final diagnostic conclusion, there had, as recommended by Murphy and Gordon (2006), to be credible evidence supporting that the patient had experienced ADHD-symptoms in early childhood, and that at least by the middle school years, these had led to substantial and chronic impairment across settings, and that the symptoms currently caused the patient substantial and consistent impairment across settings. Further, it was questioned whether there were other explanations other than ADHD that better could account for the clinical picture, and if there were comorbid conditions. © 2014 Scandinavian Psychological Associations and John Wiley & Sons Ltd
Means and standard deviations Means and standard deviations for age, WURS-25, ASRS, MDQ, Cyclothymic temperament questionnaire, and HADS are shown in Table 1.
Categorization of the WURS-25, ASRS, MDQ, and Cyclothymic temperament questionnaire scores The results showed that 74% (32 of 43) of the patients reported symptoms indicating ADHD as measured with WURS-25 and that 100% (43 of 43) reported symptoms in the ASRS category of “highly likely to have ADHD”. Of the patients, 81% (35 of 43 patients) had a score above 7 on MDQ, which indicates bipolar disorder, and 84% (36 of 43 patients) had a score above 11 on the cyclothymic temperament scale, indicating a cyclothymic temperament.
Diagnoses according to the MINI plus The diagnoses according to the MINI plus are shown in Table 2.
The diagnosis of ADHD based on all collected data The results showed that 35% (15 of 43) of the patients fulfilled the criteria for the diagnosis of ADHD after a comprehensive assessment was conducted. DISCUSSION The prison inmates who were referred to the mental health service in Bergen prison reported a high symptom level, reflected in high scores on the self-report forms used. We found that 74% (32 of 43) reported symptoms consistent with ADHD as measured with WURS-25, and 100% reported symptoms consistent with ADHD as measured with ASRS. As measured with the MINI plus, 74% (32 of 43) reported symptoms consistent with ADHD. However, following a comprehensive diagnostic assessment,
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Table 2. Diagnoses according to MINI plus Diagnosis Mood Disorders Major depression, Current Recurrent Dysthymia Current Manic episode, Current Past Hypomania, Current Past Panic disorder Current Lifetime Substance conditioned Agoraphobia Lifetime Current Social phobia Specific phobia Obsessive compulsive disorder Post traumatic stress disorder Substance use disorder Alcohol Dependence lifetime Dependence current Abuse lifetime Abuse current Drugs Dependence lifetime Dependence current Abuse and/or dependence Psychotic disorders General anxiety disorder Antisocial personality disorder ADHD
Frequency
Percent
7 26 3
16 60 7
2 3
5 7
4 18
9 41
1 11 1
2 26 2
14 9 14 6 3 1
33 21 33 14 7 2
28 9 30 13
65 21 70 30
40 22 41 1 4 32 32
93 51 95 2 9 74 74
including information from significant others and collateral sources, only 35% (15 of 43) were considered to meet the criteria for the diagnosis of ADHD. The WURS has been argued to be a sensitive instrument for identifying childhood ADHD (Ward et al., 1993). Its sensitivity in a prison population was not previously known (Rasmussen et al., 2001). Considering that 74% (32 of 43) of the prison inmates reported symptoms in accordance with ADHD in childhood as measured with WURS-25, but only 35% (15 of 43) were diagnosed with ADHD, the results indicate that WURS-25 scores alone, collected retrospectively, must be used with caution to assess the presence of ADHD symptoms in childhood. The WURS is not validated for patients with ASPD (Lindberg et al., 2004), which is the most frequently reported personality disorder among prison inmates (Fazel & Danesh, 2002). The diagnosis of ASPD is always preceded by CD before the age of 15. Because of high comorbidity between CD and ADHD, it is difficult to distinguish which of the retrospectively rated symptoms are associated with CD and which are markers of childhood ADHD (Lindberg et al., 2004). The MINI plus includes the diagnosis of ASPD, and 74% (32 of 43) of the patients reported symptoms in accordance with ASPD. It can be argued © 2014 Scandinavian Psychological Associations and John Wiley & Sons Ltd
that those individuals who were not diagnosed with ADHD might have outgrown their symptoms of ADHD as adults. However, considering the scores of ASRS, which showed that all of the patients reported symptoms in the category “highly likely to have ADHD,” the results indicate that 26% (11 of 43) reported that symptoms in accordance with ADHD as adults either worsened or emerged. Eyestone and Howell (1994) found that approximately 7% of their sample reported that ADHD had emerged or worsened. Those authors also found that a small subgroup of individuals reported having symptoms of ADHD as adults, but not as children. They questioned whether some of the ADHD symptoms manifested as adults could be attributed to anxiety or depression. The official diagnostic criteria for ADHD require that the symptoms of ADHD must be evident early in life, before age 7 (American Psychiatric Association, 2000), and the estimated prevalence of ADHD among adults is lower than that among children (Faraone et al., 2000). These factors support the assumption that the reported symptoms in accordance with ADHD are better explained by diagnoses or conditions other than ADHD. Results have indicated that patients and their parents have limited recall of childhood symptoms of ADHD (Miller, Newcorn & Halperin, 2010). It can therefore also be argued that the prison inmates have underestimated childhood symptoms consistent with ADHD due to poor memory. Other studies have, however, indicated that rather than underreporting symptoms consistent with ADHD in childhood, adults have a tendency to report a high frequency of symptoms consistent with ADHD as children (Mannuzza, Klein, Klein, Bessler & Shrout, 2002; Murphy & Gordon, 2006). Furthermore, the study by Miller et al. (2010) indicated that current ADHD symptoms seemed to improve the accuracy of symptom recall in childhood, and considering that all the participants in our study reported a high symptom level of ADHD as adults, this should then have reduced the risk for underestimating childhood symptoms. Examining the other self-report schemas for psychiatric symptoms and the diagnoses of MINI plus in addition to ADHD, mood disorders and alcohol and drug dependence and abuse primarily stand out as mental health problems. The results show that 81% (35 of 43 patients) had a score above 7 on MDQ, which indicates a bipolar spectrum disorder, and that 84% (36 of 43 patients) had a score above 11 on the Cyclothymic temperament questionnaire, which indicates a cyclothymic temperament. When considering the diagnoses of MINI plus, the results show that 60% (26 of 43) of the patients met the criteria for recurrent major depression, 9% (4 of 43) for current hypomania, 41% (18 of 43) for past hypomania, 5% (2 of 43) for current manic episode, and 7% (3 of 43) for past manic episode. It is well known that there is a high comorbidity between ADHD and mood disorders, especially bipolar illness (Kessler et al., 2006). Moreover, because attention problems, over activity/restlessness, and impulsivity are common symptoms in different phases of bipolar illness, it is often difficult to distinguish these disorders from one another (Murphy & Gordon, 2006). Regarding dependence and abuse of alcohol and drugs, the diagnosis of MINI plus shows that 65% (28 of 43) reported lifetime alcohol dependence, 70% (30 of 43) reported lifetime alcohol abuse, 93% (40 of 43) reported lifetime drug dependence,
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and 51% (22 of 43) reported current drug dependence. The high frequency of drug use among prison inmates is well known (see e.g. World Health Organization, 2003), and research results have shown a high frequency of drug use among prison inmates in Norway (Friestad & Kjelsberg, 2009) as well as among those with ADHD, especially those with ADHD comorbid with CD/ ASPD (Barkley et al., 2004; Claude & Firestone, 1995; Molina, Smith & Pelham, 1999). Although ADHD can be comorbid with substance use, they also have overlapping symptoms (Murphy & Gordon, 2006). It is, therefore, possible that the high frequency of reported dependence and abuse of alcohol and drugs contributed to the high reporting of symptoms consistent with ADHD. If we assume that the inmates developed dependence and abuse of alcohol and drugs in adolescence and/or adulthood, we can question whether dependence and abuse of alcohol and drugs contributed to the increase in symptoms consistent with ADHD from childhood to adulthood as indicated by the scores on the WURS-25 and ASRS. The low correlation between the self-report scales used and MINI plus, and the final ADHD diagnosis in our study can also indicate that we have been too strict regarding the criteria of documenting childhood history of ADHD considering that Ginsberg et al. (2010) found the screening instruments in diagnosing ADHD among prison inmates to be highly specific (88%). Including reports from schools, educational psychological service, child psychiatry and child welfare for documenting childhood history of ADHD might have lowered the specificity in our study. This is consistent with results indicating a more thorough assessments using clinical interviews typically yields lower prevalence rate compared with using self-report scales (Konstenius, Larsson, Lundholm et al., 2012; Mariani & Levin, 2007; Nutt, Fone, Asherson et al., 2007; Young et al., 2011). However, to qualify for the diagnosis of adult ADHD, it is a criterion that the person must have suffered from ADHD as a child. It is also possible that the high level of reported symptoms on WURS-25 and ASRS in our study is due to a collection bias. At the moment of the study, the possibility of getting an ADHD assessment was well known both among the prison inmates and the employees in the prison. This might have led to extra focus on ADHD which can have contributed to an increased knowledge about the symptoms of ADHD. This can have affected the accuracy of the information that the prison inmates presented, consciously or otherwise (Murphy & Gordon, 2006). This can also have contributed to prison inmates who otherwise would not have questioned if they had ADHD, got referred to the mental health service for ADHD assessment. Other studies has shown that screening of ADHD based on self-rating typically yields higher prevalence rates compared with more thorough assessments using clinical interviews (Mariani & Levin, 2007; Nutt et al., 2007; Young et al., 2011). In our study there is reason to believe that collecting collateral information from significant others and obtaining reports from schools, educational psychological service, child psychiatry, child welfare, and contact with health care in adulthood have reduced the number of inmates who were diagnosed with ADHD. Considering the difficulties with diagnosing ADHD in adulthood (Murphy & Gordon, 2006), future studies should examine the prevalence of ADHD among prison inmates using a collateral information, not © 2014 Scandinavian Psychological Associations and John Wiley & Sons Ltd
only from significant others, but also reports containing behavioral descriptions from childhood. A comprehensive diagnostic assessment increases the likelihood of ensuring that the symptoms attributed to ADHD are not better explained by other conditions such as other psychiatric diagnoses, personality factors, learning problems, situational stressors or drugs. Considering the high prevalence rates of serious psychiatric disorders among prison inmates (Fazel & Danesh, 2002), the results emphasize the importance of a comprehensive assessment and offering psychiatric health service to prison inmates, not only for ADHD, but for the broad spectrum of psychiatric illnesses. We expect a lower frequency of ADHD than that shown in previous research. Nevertheless, ADHD should be considered as a possible differential diagnosis in a psychiatric assessment (Haavik, Halmøy, Lundervold & Fasmer, 2010). In assessing ADHD among the prison inmates referred to assessment, we selected a comprehensive assessment including a standard clinical interview supplemented with information from collateral sources and self-completion forms, and rating scales. Although the self-report scales and the MINI plus diagnostics interview used are not sufficiently sensitive or specific for diagnostic assessment of ADHD in this population, they may have contributed to valuable information regarding differential diagnostic issues and psychological comorbidities. Considering the high frequency of personality disorders that has been found among prison inmates (Fazel & Danesh, 2002) and the substantial reported comorbidity between personality disorders and ADHD among prison inmates (Rasmussen et al., 2001), the inclusion of a specific diagnostic interview for personality disorders might contribute valuable information and should be considered in future assessments. The results from the neuropsychological testing were not included in the current report because they were not regarded as conclusive for the diagnostic decision. Nevertheless, we recommend including these results in ADHD assessment to obtain a description of the cognitive function of the patient. Such results may be important for further treatment and rehabilitation (Gordon et al., 2006).
Limitations There are several limitations with this study. To assess the presence of ADHD-symptoms in childhood, one has to rely on some historical data retrospectively when diagnosing adults. Most people are savvy about the formal characterizations of ADHD, and this can affect the accuracy of the information given. We have tried to compensate for this by including information from collateral sources as it is widely accepted that the diagnostic accuracy of assessing ADHD in adulthood is enhanced by obtaining information from parent or others (van de Glind, van den Brink, Koeter et al., 2013). We chose to collect the information from significant other using clinical interview. Supplementing this method with questionnaires might have contributed with valuable information and increased the certainty of the diagnosis given.
Conclusion Overall, the results indicate that the self-report scales and the MINI plus diagnostics interview used are not valid for diagnostic
348 L. Stokkeland et al. assessment of ADHD in the prison population. Although adults with ADHD, similar to those with other disorders, are considered to be appropriate reporters of their own condition (Prince et al., 2006), the results indicate that solely relying on self-report data results in an over-diagnosis of ADHD among inmates. The results, therefore, underline the importance of a comprehensive assessment that includes collecting information from significant others and collateral sources when diagnosing ADHD among prison inmates.
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ADHD among prison inmates 349 adult ADHD in treatment seeking substance use disorder patients. Drug and Alcohol Dependence, 132, 587–596. Ward, M. F., Wender, P. H. & Reimherr, F. W. (1993). The Wender Utah Rating Scale: An aid in the retrospective diagnosis of childhood attention deficit hyperactivity disorder. American Journal of Psychiatry, 150, 885–890. World Health Organization (1993). The ICD–10 Classification of Mental and Behavioural Disorders –10. Diagnostic criteria for research. Geneva: World Health Organization. World Health Organization (2003). Declaration on prison health as part of public health. Retrieved December 15, 2010, from http://www. euro.who.int/__data/assets/pdf_file/0007/98971/E94242.pdf. Young, S. J., Adamou, M., Bolea, B., Gudjonsson, G., M€ uller, U., Pitts, M., et al. (2011). The identification and management of ADHD in offenders within the criminal justice system: A consensus statement from the UK Adult ADHD Network and criminal justice agencies. BMC Psychiatry, 11, 32. doi:10.1186/1471-244X-11-32. Young, S., Gudjonsson, G. H., Wells, J., Asherson, P., Theobald, D., Oliver, B., et al. (2008). Attention deficit hyperactivity disorder and critical incidents in a Scottish prison population. Personality and Individual Differences, 46, 265–269. Zigmond, A. S. & Snaith, R. P. (1983). The hospital anxiety and depression scale. Acta Psychiatrica Scandinavica, 67, 361–370. Received 21 September 2013, accepted 7 March 2014
DOI: 10.1111/sjop.12131
Health and Disability Attention deficit hyperactivity disorder among inmates in Bergen Prison LISA STOKKELAND,1,2 OLE BERNT FASMER,3,4,5 LEIF WAAGE1 and ANITA L. HANSEN1,6 1
Centre for Research and Education in Forensic Psychiatry, Haukeland University Hospital, Bergen, Norway Unit for young adults with substance abuse and mental health problems, Department of Addiction medicine, Haukeland University Hospital, Bergen, Norway 3 Division of Psychiatry, Haukeland University Hospital, Bergen, Norway 4 Department of Clinical Medicine, Section for Psychiatry, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway 5 K.G. Jebsen Centre for Research on Neuropsychiatric Disorders, University of Bergen, Bergen, Norway 6 Department of Psychosocial Science, University of Bergen, Bergen, Norway 2
Stokkeland, L., Fasmer, O. B., Waage, L. & Hansen, A. L. (2014). Attention deficit hyperactivity disorder among inmates in Bergen Prison. Scandinavian Journal of Psychology 55, 343–349. The aim of this study was to investigate whether clinical findings are consistent with research indicating a high prevalence of attention deficit hyperactivity disorder (ADHD) among prison inmates. Forty-three male inmates who were referred for ADHD assessment at the health service in Bergen prison participated. Although most of them reported symptoms in accordance with ADHD both in childhood and adulthood, only 35% of the referred inmates fulfilled the criteria for ADHD when a comprehensive assessment was conducted. The results emphasize the importance of a comprehensive assessment when diagnosing ADHD among prison inmates. Key words: Prison inmates, ADHD, ASRS, MINI plus. Lisa Stokkeland, Unit for young adults with substance abuse and mental health problems, Department of Addiction medicine, Haukeland University Hospital, 5021 Bergen, Norway. Tel: +47 55970100; fax: +47 55970101; e-mail: [email protected]
INTRODUCTION Across the world, the most marginalized groups in society are over-represented in the prison inmate population, consisting of drug users, people with poor health, and those who engage in riskrelated activities (World Health Organization, 2003). International studies have indicated that prison inmates have high prevalence rates of serious psychiatric disorders such as personality disorders, major depression, and psychotic disorders (for a review of studies of serious mental disorders among prison inmates, see Fazel & Danesh, 2002). Another disorder that has been assumed to be of high prevalence among prison inmates, and to cause them serious problems, is attention deficit hyperactivity disorder (ADHD) (Rasmussen, Almvik & Levander, 2001). Considering that people with ADHD have an elevated risk for antisocial behavior and substance use disorder (Babinski, Hartsough & Lambert, 1999; Barkley, Fischer, Smallish & Fletcher, 2004), an elevated prevalence of ADHD among prison inmates could be expected. This expectation has been supported by research (Eyestone & Howell, 1994; Rasmussen et al., 2001; Young, Gudjonsson, Wells et al., 2008). Therefore, the current paper aimed to determine whether clinical findings are consistent with this expectation and whether a need exists for extra focus on ADHD among prison inmates. The aim was to identify how many of the prison inmates who were referred to the health service for ADHD assessment fulfilled the criteria for this diagnosis based on a comprehensive assessment by a clinical psychologist and a psychiatrist. ADHD: SYMPTOMS, PREVALENCE, AND COMORBIDITY ADHD is one of the most common psychiatric disorders of childhood. The primary symptoms of the disorder are inattention, hyperactivity, and impulsivity. ADHD is assumed to affect © 2014 Scandinavian Psychological Associations and John Wiley & Sons Ltd
approximately 3–7% of the childhood population (American Psychiatric Association, 2000). Approximately 70% to 80% of these children continue to have significant difficulties in adulthood. Comparatively few data are available on the prevalence of ADHD in the general adult population, but an estimated prevalence is 4.5% (Faraone, Biederman, Spencer et al., 2000; Kessler, Adler, Barkley et al., 2006). It is widely accepted that children with ADHD display a greater degree of difficulties with oppositional and defiant behavior, aggressiveness and conduct problems, and even antisocial behavior compared to other children (Barkley, 2006), and continued symptoms of ADHD in adolescence are highly correlated with the development of antisocial personality disorder (ASPD) and antisocial acts (Fischer, Barkley, Smallish & Fletcher, 2002; Gittelman, Mannuzza, Shenker & Bonagura, 1985; Rasmussen & Gillberg, 2000). This phenomenon is most apparent for those individuals who show aggressive and/or antisocial behavior as children (Claude & Firestone, 1995). ADHD among prison inmates It has been suggested that adults with ADHD who have the least favorable outcomes are among those who end up in prison (Rasmussen et al., 2001). Compared to controls, these individuals report a higher frequency of arrests and have committed a wider range of offenses. The severity of childhood ADHD has been found to contribute significantly to the frequency of drugrelated antisocial behavior in adulthood (Barkley et al., 2004). The incidence of ADHD in prison populations appears to far exceed the frequency found in the general adult population. In their sample of 102 prison inmates, Eyestone and Howell (1994) found that 25% of inmates fulfilled the criteria for ADHD, manifesting substantial symptoms both in childhood
344 L. Stokkeland et al. and adulthood. Nearly 7% of the total sample reported symptoms consistent with ADHD only in childhood, whereas another 7% of the sample reported symptoms consistent with this diagnosis only as adults. In a Norwegian study by Rasmussen et al. (2001), the results indicated that 46% of the prison inmates had difficulties that could be attributed to ADHD as children and that 30% also had symptoms as adults. Young et al. (2008) found that 24% of a Scottish prison population met the screening criteria for childhood ADHD, of whom 23% fulfilled the criteria for ADHD as adults, 33% were in partial remission, and 44% were in full remission. In a Swedish study, a prevalence rate of 40% was found among adult male longer-term prison inmates (Ginsberg, Hirvikoski & Lindefors, 2010), while an Australian study found that 17% of their prison sample met the criteria for adult ADHD (Moore, Sunjic, Kaye, Archer & Indig, 2013).
The difficulty of diagnosing ADHD ADHD is difficult to diagnose because the core symptoms of the disorder are also common in the normal population and the symptoms likely represent the extreme end of a continuum (Prince, Wilens, Spencer & Biederman, 2006). The symptoms of ADHD are also typical for a number of other diagnoses, including conduct disorder (CD) (Lindberg, Tani, PorkkaHeiskanen, Appelberg, Rimon & Virkkunen, 2004), anxiety disorders, depressive disorders, speech and learning disorders (Dulcan, 1997), and personality disorders (Murphy & Gordon, 2006). The diagnosing of ADHD is further complicated by the fact that the overlap in symptoms can be an accurate reflection of their co-occurrence (Babinski et al., 1999). For instance, the study by Rasmussen et al. (2001) suggests that persistent ADHD, comorbid with both personality disorders and reading disability, constitutes a problem of high magnitude among prisoners.
AIM OF THE STUDY Diagnosing ADHD among prison inmates is complex (Moore et al., 2013), and studies of ADHD among prison inmates have primarily relied on self-reported symptoms (Eyestone & Howell, 1994; Rasmussen et al., 2001; Young et al., 2008). Thus, the aim of the present study was to determine whether inmates who were referred to the health service for an assessment of possible ADHD met the criteria for an ADHD diagnosis based on a comprehensive assessment.
METHOD Participants The participants were 43 male inmates from Bergen Prison. They had all been referred to the mental health service for ADHD assessment by the prison physician due to reported symptoms consistent of ADHD. No instructions were given to the prison physician on how to assess symptoms consistent with ADHD as this assessment was a part of regular clinical practice. The age of the participants ranged from 20 to 52 years, with a mean of 32.1 years (SD = 8.5) (see Table 1). They were incarcerated for different criminal acts such as violence, murder, drugs, fraud, © 2014 Scandinavian Psychological Associations and John Wiley & Sons Ltd
Scand J Psychol 55 (2014) Table 1. Mean and Standard Deviations for Age, ASRS, WURS-25, MDQ, Cyclothymic temperament questionnaire, and HADS
Variables
Mean
Standard deviations
Age Total ASRS ASRS A ASRS B WURS-25 MDQ Cyclothymic temperament scale Total HADS HADS A HADS D
32.1 50.3 25.9 24.8 57.6 9.6 14.0
8.5 9.6 5.4 5.7 18.1 4.3 4.5
17.0 10.7 6.3
5.7 3.3 3.6
Notes: ASRS = Adult ADHD Self-Report Scale; WURS-25 = Wender Utah Rating Scale, 25 questions version; MDQ = Mood Disorder Questionnaire; HADS = Hospital Anxiety and Depression Scale. and robbery. The participants included both inmates serving custody and inmates who were sentenced.
Clinical data A standard clinical interview was used to obtain background information and past and present symptoms of mental illness. A specific emphasis was placed on gathering information that was relevant to diagnosing ADHD. This interview was supplemented with information from collateral sources. A clinical interview consisting of specific questions about developmental and medical history, school history, work history, psychiatric history, social adjustment, family history of ADHD or other psychiatric or medical conditions in the family, and current functioning, was conducted with parents and/or other significant individuals in the inmate’s past and/or present. When interviewing the participants and parents and/or other significant individuals, specific questions regarding symptoms consistent with ADHD was used and concrete examples of symptom expression was given. Since retrospective data can be vulnerable to historical inaccuracy, incompleteness, and distortions (Henry, Moffitt, Caspi, Langley & Silva, 1994; Hardt & Rutter, 2004), and to obtain a full picture of the patients functioning, reports were also collected from schools, educational psychological service, child psychiatry, child welfare, and contact with health care in adulthood. The following self-completion forms and rating scales were used: Adult ADHD Self-Report Scale (ASRS); Wender Utah Rating Scale, 25 questions version (WURS-25); Mood Disorder Questionnaire (MDQ); Cyclothymic temperament scale; Hospital Anxiety and Depression Scale (HADS); and the structured interview Mini-International Neuropsychiatric Interview (MINI plus). All of the patients also underwent neuropsychological testing. A description of the cognitive function of the patient was considered to be important for further treatment and advice concerning school or work, but the test results were not regarded as conclusive regarding the diagnostic decision. This assessment is in accordance with the recommendation that neuropsychological tests should not be oversold as a basis of ADHD diagnosis (Gordon, Barkley & Lovett, 2006). The results from the neuropsychological tests are, therefore, not included in the present report. WURS-25. This is a 25-item self-rating scale on which adults describe their childhood behavior retrospectively. The participants indicate how often symptoms occurred using a Likert scale of 0–4 (0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = very often). A score of 46 or higher has been shown to correctly identify 86% of adults with childhood ADHD and 99% of normal subjects (Ward, Wender &
ADHD among prison inmates 345
Scand J Psychol 55 (2014) Reimherr, 1993), and a score of 46 or higher was therefore chosen to indicate ADHD. ASRS. ASRS consists of 18 questions that follow the Diagnostic and Statistical Manual of Mental Disorders fourth edition, text revision [DSM-IV-TR] (American Psychiatric Association, 2000) criteria for ADHD and addresses the manifestations of ADHD symptoms in adults. The participants indicate how often symptoms occur using a Likert scale of 0–4 (0 = never, 1 = seldom, 2 = sometimes, 3 = often, 4 = very often). The results may suggest the need for a more in-depth clinician interview (Adler, Kessler & Spencer, 2003; Kessler et al., 2005, 2006). MDQ. This is a self-report form that consists of 13 questions about symptoms consistent with bipolar disorders. Confirmation of at least seven questions and confirmation that the symptoms have occurred together and caused problems indicate bipolar disorder (Hirschfeld, Williams, Spitzer et al., 2000). Cyclothymic temperament questionnaire. This is a self-report form that consists of 21 questions that cover the cyclothymic temperament according to the definition of Akiskal. Confirmation of at least 11 questions indicates a cyclothymic temperament (Akiskal, Akiskal, Haykal, Manning & Connor, 2005).
All the gathered information was discussed according to DSM-IV (American Psychiatric Association, 1994) and the International Classification of mental and behavioural Disorders -10 [ICD-10] (World Health Organization, 1993) criteria for ADHD /hyperkinetic disorder. The diagnosis was, however, given according to the DSM-IV criteria. The clinical interview, administration of questionnaires, and collection of complete information were completed by a clinical psychologist (LS). The final diagnosis of ADHD and other mental disorders, development of conclusion, and the recommendations to the referring physician were conducted in cooperation with a psychiatrist (OBF).
Statistics The means and standard deviations for the WURS-25, ASRS, MDQ, Cyclothymic temperament questionnaire, and HADS were calculated. The MDQ and Cyclothymic temperament questionnaire scores were categorized in the described categories and the diagnoses of MINI plus were registered. The number of patients who were diagnosed with ADHD was also registered. SPSS version 15.0 (SSPS, Chicago, IL) was used for the statistical analyses.
RESULTS HADS. HADS is a self-assessment scale that is reliable for detecting states of depression and anxiety in the setting of a hospital medical outpatient clinic. The anxiety and depressive subscales are also valid measures of severity of the emotional disorder (Herrmann, 1997; Zigmond & Snaith, 1983). MINI plus. MINI plus is an instrument that allows for the coding of more than 60 variables, including 15 of the DSM-IV disorders (American Psychiatric Association, 1994). It employs different time frames for various disorders, including current, past, or lifetime (Sheehan, Lecrubier, Sheehan et al., 1998; Leiknes, Malt, Malt & Leganger, 2005).
Procedure The study was approved by the Regional Committee for Medical and Health Research Ethics in Western Norway. Data were collected for all of the patients referred to the mental health service in Bergen prison for assessment of ADHD in the period from 2007 to 2009. The self-report tests were administered individually to the participants, and the psychologist was present to answer questions and provide instructions. The tests were read to the participants when reading skills were not sufficient for self-completion. Both the self-report tests and MINI plus were scored according to the scoring and interview criteria, but the results regarding the diagnosis of somatization disorder, hypochondriasis, anorexia nervosa, bulimia nervosa, and somatoform disorders in MINI plus are not included in the current report. The final diagnostic assessment was made after an overall assessment and integration of all available information, including clinical interview, information from significant others, WURS-25, ASRS, MDQ, Cyclothymic temperament questionnaire, and MINI plus. This was done in order to underline the important work of integrating all the available data when doing a multimethod, multiinformant assessment (Hathaway, DoolingLitfin & Edwards, 2006). To be given the diagnosis of ADHD, the participants had to reach the cut-off levels for ADHD on WURS-25, ASRS and MINI plus, and they had to fulfill the criteria as defined in according to DSM-IV (American Psychiatric Association, 1994). To reach the final diagnostic conclusion, there had, as recommended by Murphy and Gordon (2006), to be credible evidence supporting that the patient had experienced ADHD-symptoms in early childhood, and that at least by the middle school years, these had led to substantial and chronic impairment across settings, and that the symptoms currently caused the patient substantial and consistent impairment across settings. Further, it was questioned whether there were other explanations other than ADHD that better could account for the clinical picture, and if there were comorbid conditions. © 2014 Scandinavian Psychological Associations and John Wiley & Sons Ltd
Means and standard deviations Means and standard deviations for age, WURS-25, ASRS, MDQ, Cyclothymic temperament questionnaire, and HADS are shown in Table 1.
Categorization of the WURS-25, ASRS, MDQ, and Cyclothymic temperament questionnaire scores The results showed that 74% (32 of 43) of the patients reported symptoms indicating ADHD as measured with WURS-25 and that 100% (43 of 43) reported symptoms in the ASRS category of “highly likely to have ADHD”. Of the patients, 81% (35 of 43 patients) had a score above 7 on MDQ, which indicates bipolar disorder, and 84% (36 of 43 patients) had a score above 11 on the cyclothymic temperament scale, indicating a cyclothymic temperament.
Diagnoses according to the MINI plus The diagnoses according to the MINI plus are shown in Table 2.
The diagnosis of ADHD based on all collected data The results showed that 35% (15 of 43) of the patients fulfilled the criteria for the diagnosis of ADHD after a comprehensive assessment was conducted. DISCUSSION The prison inmates who were referred to the mental health service in Bergen prison reported a high symptom level, reflected in high scores on the self-report forms used. We found that 74% (32 of 43) reported symptoms consistent with ADHD as measured with WURS-25, and 100% reported symptoms consistent with ADHD as measured with ASRS. As measured with the MINI plus, 74% (32 of 43) reported symptoms consistent with ADHD. However, following a comprehensive diagnostic assessment,
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Table 2. Diagnoses according to MINI plus Diagnosis Mood Disorders Major depression, Current Recurrent Dysthymia Current Manic episode, Current Past Hypomania, Current Past Panic disorder Current Lifetime Substance conditioned Agoraphobia Lifetime Current Social phobia Specific phobia Obsessive compulsive disorder Post traumatic stress disorder Substance use disorder Alcohol Dependence lifetime Dependence current Abuse lifetime Abuse current Drugs Dependence lifetime Dependence current Abuse and/or dependence Psychotic disorders General anxiety disorder Antisocial personality disorder ADHD
Frequency
Percent
7 26 3
16 60 7
2 3
5 7
4 18
9 41
1 11 1
2 26 2
14 9 14 6 3 1
33 21 33 14 7 2
28 9 30 13
65 21 70 30
40 22 41 1 4 32 32
93 51 95 2 9 74 74
including information from significant others and collateral sources, only 35% (15 of 43) were considered to meet the criteria for the diagnosis of ADHD. The WURS has been argued to be a sensitive instrument for identifying childhood ADHD (Ward et al., 1993). Its sensitivity in a prison population was not previously known (Rasmussen et al., 2001). Considering that 74% (32 of 43) of the prison inmates reported symptoms in accordance with ADHD in childhood as measured with WURS-25, but only 35% (15 of 43) were diagnosed with ADHD, the results indicate that WURS-25 scores alone, collected retrospectively, must be used with caution to assess the presence of ADHD symptoms in childhood. The WURS is not validated for patients with ASPD (Lindberg et al., 2004), which is the most frequently reported personality disorder among prison inmates (Fazel & Danesh, 2002). The diagnosis of ASPD is always preceded by CD before the age of 15. Because of high comorbidity between CD and ADHD, it is difficult to distinguish which of the retrospectively rated symptoms are associated with CD and which are markers of childhood ADHD (Lindberg et al., 2004). The MINI plus includes the diagnosis of ASPD, and 74% (32 of 43) of the patients reported symptoms in accordance with ASPD. It can be argued © 2014 Scandinavian Psychological Associations and John Wiley & Sons Ltd
that those individuals who were not diagnosed with ADHD might have outgrown their symptoms of ADHD as adults. However, considering the scores of ASRS, which showed that all of the patients reported symptoms in the category “highly likely to have ADHD,” the results indicate that 26% (11 of 43) reported that symptoms in accordance with ADHD as adults either worsened or emerged. Eyestone and Howell (1994) found that approximately 7% of their sample reported that ADHD had emerged or worsened. Those authors also found that a small subgroup of individuals reported having symptoms of ADHD as adults, but not as children. They questioned whether some of the ADHD symptoms manifested as adults could be attributed to anxiety or depression. The official diagnostic criteria for ADHD require that the symptoms of ADHD must be evident early in life, before age 7 (American Psychiatric Association, 2000), and the estimated prevalence of ADHD among adults is lower than that among children (Faraone et al., 2000). These factors support the assumption that the reported symptoms in accordance with ADHD are better explained by diagnoses or conditions other than ADHD. Results have indicated that patients and their parents have limited recall of childhood symptoms of ADHD (Miller, Newcorn & Halperin, 2010). It can therefore also be argued that the prison inmates have underestimated childhood symptoms consistent with ADHD due to poor memory. Other studies have, however, indicated that rather than underreporting symptoms consistent with ADHD in childhood, adults have a tendency to report a high frequency of symptoms consistent with ADHD as children (Mannuzza, Klein, Klein, Bessler & Shrout, 2002; Murphy & Gordon, 2006). Furthermore, the study by Miller et al. (2010) indicated that current ADHD symptoms seemed to improve the accuracy of symptom recall in childhood, and considering that all the participants in our study reported a high symptom level of ADHD as adults, this should then have reduced the risk for underestimating childhood symptoms. Examining the other self-report schemas for psychiatric symptoms and the diagnoses of MINI plus in addition to ADHD, mood disorders and alcohol and drug dependence and abuse primarily stand out as mental health problems. The results show that 81% (35 of 43 patients) had a score above 7 on MDQ, which indicates a bipolar spectrum disorder, and that 84% (36 of 43 patients) had a score above 11 on the Cyclothymic temperament questionnaire, which indicates a cyclothymic temperament. When considering the diagnoses of MINI plus, the results show that 60% (26 of 43) of the patients met the criteria for recurrent major depression, 9% (4 of 43) for current hypomania, 41% (18 of 43) for past hypomania, 5% (2 of 43) for current manic episode, and 7% (3 of 43) for past manic episode. It is well known that there is a high comorbidity between ADHD and mood disorders, especially bipolar illness (Kessler et al., 2006). Moreover, because attention problems, over activity/restlessness, and impulsivity are common symptoms in different phases of bipolar illness, it is often difficult to distinguish these disorders from one another (Murphy & Gordon, 2006). Regarding dependence and abuse of alcohol and drugs, the diagnosis of MINI plus shows that 65% (28 of 43) reported lifetime alcohol dependence, 70% (30 of 43) reported lifetime alcohol abuse, 93% (40 of 43) reported lifetime drug dependence,
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and 51% (22 of 43) reported current drug dependence. The high frequency of drug use among prison inmates is well known (see e.g. World Health Organization, 2003), and research results have shown a high frequency of drug use among prison inmates in Norway (Friestad & Kjelsberg, 2009) as well as among those with ADHD, especially those with ADHD comorbid with CD/ ASPD (Barkley et al., 2004; Claude & Firestone, 1995; Molina, Smith & Pelham, 1999). Although ADHD can be comorbid with substance use, they also have overlapping symptoms (Murphy & Gordon, 2006). It is, therefore, possible that the high frequency of reported dependence and abuse of alcohol and drugs contributed to the high reporting of symptoms consistent with ADHD. If we assume that the inmates developed dependence and abuse of alcohol and drugs in adolescence and/or adulthood, we can question whether dependence and abuse of alcohol and drugs contributed to the increase in symptoms consistent with ADHD from childhood to adulthood as indicated by the scores on the WURS-25 and ASRS. The low correlation between the self-report scales used and MINI plus, and the final ADHD diagnosis in our study can also indicate that we have been too strict regarding the criteria of documenting childhood history of ADHD considering that Ginsberg et al. (2010) found the screening instruments in diagnosing ADHD among prison inmates to be highly specific (88%). Including reports from schools, educational psychological service, child psychiatry and child welfare for documenting childhood history of ADHD might have lowered the specificity in our study. This is consistent with results indicating a more thorough assessments using clinical interviews typically yields lower prevalence rate compared with using self-report scales (Konstenius, Larsson, Lundholm et al., 2012; Mariani & Levin, 2007; Nutt, Fone, Asherson et al., 2007; Young et al., 2011). However, to qualify for the diagnosis of adult ADHD, it is a criterion that the person must have suffered from ADHD as a child. It is also possible that the high level of reported symptoms on WURS-25 and ASRS in our study is due to a collection bias. At the moment of the study, the possibility of getting an ADHD assessment was well known both among the prison inmates and the employees in the prison. This might have led to extra focus on ADHD which can have contributed to an increased knowledge about the symptoms of ADHD. This can have affected the accuracy of the information that the prison inmates presented, consciously or otherwise (Murphy & Gordon, 2006). This can also have contributed to prison inmates who otherwise would not have questioned if they had ADHD, got referred to the mental health service for ADHD assessment. Other studies has shown that screening of ADHD based on self-rating typically yields higher prevalence rates compared with more thorough assessments using clinical interviews (Mariani & Levin, 2007; Nutt et al., 2007; Young et al., 2011). In our study there is reason to believe that collecting collateral information from significant others and obtaining reports from schools, educational psychological service, child psychiatry, child welfare, and contact with health care in adulthood have reduced the number of inmates who were diagnosed with ADHD. Considering the difficulties with diagnosing ADHD in adulthood (Murphy & Gordon, 2006), future studies should examine the prevalence of ADHD among prison inmates using a collateral information, not © 2014 Scandinavian Psychological Associations and John Wiley & Sons Ltd
only from significant others, but also reports containing behavioral descriptions from childhood. A comprehensive diagnostic assessment increases the likelihood of ensuring that the symptoms attributed to ADHD are not better explained by other conditions such as other psychiatric diagnoses, personality factors, learning problems, situational stressors or drugs. Considering the high prevalence rates of serious psychiatric disorders among prison inmates (Fazel & Danesh, 2002), the results emphasize the importance of a comprehensive assessment and offering psychiatric health service to prison inmates, not only for ADHD, but for the broad spectrum of psychiatric illnesses. We expect a lower frequency of ADHD than that shown in previous research. Nevertheless, ADHD should be considered as a possible differential diagnosis in a psychiatric assessment (Haavik, Halmøy, Lundervold & Fasmer, 2010). In assessing ADHD among the prison inmates referred to assessment, we selected a comprehensive assessment including a standard clinical interview supplemented with information from collateral sources and self-completion forms, and rating scales. Although the self-report scales and the MINI plus diagnostics interview used are not sufficiently sensitive or specific for diagnostic assessment of ADHD in this population, they may have contributed to valuable information regarding differential diagnostic issues and psychological comorbidities. Considering the high frequency of personality disorders that has been found among prison inmates (Fazel & Danesh, 2002) and the substantial reported comorbidity between personality disorders and ADHD among prison inmates (Rasmussen et al., 2001), the inclusion of a specific diagnostic interview for personality disorders might contribute valuable information and should be considered in future assessments. The results from the neuropsychological testing were not included in the current report because they were not regarded as conclusive for the diagnostic decision. Nevertheless, we recommend including these results in ADHD assessment to obtain a description of the cognitive function of the patient. Such results may be important for further treatment and rehabilitation (Gordon et al., 2006).
Limitations There are several limitations with this study. To assess the presence of ADHD-symptoms in childhood, one has to rely on some historical data retrospectively when diagnosing adults. Most people are savvy about the formal characterizations of ADHD, and this can affect the accuracy of the information given. We have tried to compensate for this by including information from collateral sources as it is widely accepted that the diagnostic accuracy of assessing ADHD in adulthood is enhanced by obtaining information from parent or others (van de Glind, van den Brink, Koeter et al., 2013). We chose to collect the information from significant other using clinical interview. Supplementing this method with questionnaires might have contributed with valuable information and increased the certainty of the diagnosis given.
Conclusion Overall, the results indicate that the self-report scales and the MINI plus diagnostics interview used are not valid for diagnostic
348 L. Stokkeland et al. assessment of ADHD in the prison population. Although adults with ADHD, similar to those with other disorders, are considered to be appropriate reporters of their own condition (Prince et al., 2006), the results indicate that solely relying on self-report data results in an over-diagnosis of ADHD among inmates. The results, therefore, underline the importance of a comprehensive assessment that includes collecting information from significant others and collateral sources when diagnosing ADHD among prison inmates.
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