J Forensic Sci, July 2014, Vol. 59, No. 4 doi: 10.1111/1556-4029.12444 Available online at: onlinelibrary.wiley.com
PAPER PSYCHIATRY & BEHAVIORAL SCIENCES
Anne Ga€ıffas,1,2 M.D., M.Sc.; Cedric Galera,1,3 M.D., Ph.D.; Virginie Mandon,1 M.D.; and Manuel P. Bouvard,1,2,4 M.D., Ph.D.
Attention-Deficit/Hyperactivity Disorder in Young French Male Prisoners
ABSTRACT: While forensic studies have reported higher than community rates of mental disorders in imprisoned populations, few studies
have focused on attention-deficit/hyperactivity disorder (ADHD) in these subjects. The aim of this study was to investigate ADHD prevalence among young French male prisoners. A specific diagnostic interview (Conners’ Adult ADHD Diagnostic Interview for DSM-IV, CAADID) was used. Correlations between ADHD, subsyndromal ADHD, and criminal features were investigated. 11% of young male prisoners among 93 male subjects aged 18–35 years met the criteria for actual ADHD, and 17% met those for childhood ADHD. Considering ADHD and subsyndromal ADHD, prevalence was about 43% in adulthood. ADHD and subsyndromal ADHD in adulthood were significantly associated with a higher number of imprisonments and a younger age at first arrest. It could be advisable to better identify subjects with ADHD symptoms among prison populations.
KEYWORDS: forensic science, forensic psychiatry, prevalence, attention-deficit/hyperactivity disorder, prison, Conners’ adult ADHD diagnostic interview for DSM-IV
Attention-deficit/hyperactivity disorder (ADHD) is an impairing clinical syndrome with childhood onset and persisting features in adulthood. Adult ADHD prevalence has been estimated at about 3.4% (1). Several studies of children with ADHD followed up into adulthood have shown the possibility of full or partial persistence, thereby defining a subsyndromal ADHD in adulthood (2,3). ADHD is highly comorbid with psychiatric disorders, including substance use disorder, conduct disorder, and antisocial personality. As antisocial behaviors associated with ADHD may contribute to criminality and subsequently increase involvement with the legal system (4), it is important to study ADHD in criminal populations. Numerous studies across a wide spectrum of forensic settings have reported higher than community rates of mental disorders in imprisoned populations (5–8), particularly juveniles (9). In the past 10 years, a few studies have focused on ADHD in prison populations (10–18). Forensic studies have shown ADHD to be common among prison inmates with a prevalence ranging from 21% (18) to 45% (12). Surveys to date have used heterogeneous procedures and measures. Most of the research on childhood ADHD diagnosis until now has most relied on the Wender Utah Rating Scale (WURS) (19). However, a limitation of this scale is that it spuriously identifies subjects with antisocial conducts as ADHD, 1
Department of child and adolescent psychiatry, Charles Perrens Hospital, 121 rue de la Bechade, 33076 Bordeaux, France. 2 University Bordeaux Segalen, 146 rue Leo Saignat, 33076 Bordeaux Cedex, France. 3 INSERM U 897, 146 rue Leo Saignat, 33076 Bordeaux Cedex, France. 4 CNRS UMR 5287, 146 rue Leo Saignat, 33076 Bordeaux Cedex, France. Received 14 Feb. 2013; and in revised form 23 May 2013; accepted 13 June 2013.
1016
leading to inflated ADHD prevalence rates due to false positives (20). In addition, there is no French study regarding ADHD prevalence in the prison population. The main objective of this study was to estimate the prevalence of ADHD among a population of young French male prisoners using a comprehensive and accurate diagnostic DSM-IV procedure (21). A secondary objective was to investigate the correlation between ADHD, subsyndromal ADHD, and criminal features. Method This cross-sectional study was conducted between November 2007 and July 2008 in the “Maison d’Arr^et” in Bordeaux-Gradignan in France. The “Maisons d’Arr^et” are intended for remand prisoners and/or for prisoners with short sentences who have been convicted for a wide range of offenses. The study was proposed to all male remand and convicted prisoners, aged 18–35 years who were imprisoned between November 2007 and February 2008. Interviews and questionnaires were administered at the prisoner medical and psychological department, which is a psycho-medical unit inside the prison (“Service Medico-Psychologique Regional,” SMPR). Subjects were received at the SMPR by a psychiatrist between 2 weeks and 3 months after beginning their imprisonment. All subjects received full information about the study. Informed consent was obtained before inclusion. Data collection lasted about 90 mins for each subject and concerned sociodemographic and criminal data and psychiatric history. Psychiatric diagnoses were recorded using the Mini-International Neuropsychiatric Interview (MINI) (22), a short structured diagnostic interview for DSM-IV (21) and ICD-10 (23) psychiatric disorders. Past and actual diagnoses were collected, including © 2014 American Academy of Forensic Sciences
GA€IFFAS ET AL.
mood disorders, anxiety disorders, psychotic disorders, eating disorders, conduct disorder, substance-related disorders, and antisocial personality disorder. Adult and childhood ADHD diagnoses were evaluated using the Conners’Adult ADHD Diagnostic Interview for DSM-IV (CAADID) (24,25). The CAADID is a semi-structured interview for diagnosing ADHD in adults. It was designed to assess DSMIV criteria for adult ADHD in order to establish an accurate and appropriate ADHD diagnosis. The CAADID questions assess DSM-IV ADHD symptoms (inattention symptoms, hyperactive/ impulsive symptoms) as follows: the presence or absence at onset, pervasiveness, and impairment caused by the symptoms during childhood and adulthood. The ADHD diagnosis is established when the subject presents at least six of the nine symptoms on at least one dimension (inattention and/or hyperactivity/ impulsivity). Subsyndromal ADHD is established when the subjects present at least four symptoms on any dimension (inattention or hyperactivity/impulsivity). Descriptive statistics were provided (percentages and means with standard deviations). Comparative statistics (using v², t test, and nonparametric statistics when applicable) were then conducted. The study was conducted in accordance with penitentiary administration rules and conformed to the French bioethics and clinical research and data protection legislation. All data were de-identified.
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Prevalence of ADHD and Comorbidities Among the 93 subjects, 13% had a history of hospitalization for psychiatric reasons, and 35% were under psychotropic medication at the time of the study. No subject was receiving any prescription for stimulants, and only one subject had received stimulant in childhood. Table 2 presents the estimated prevalence of ADHD diagnosis and subsyndromal ADHD diagnosis according to the CAADID questionnaire. 11% of young male prisoners met the criteria for actual ADHD, and 17% met those for childhood ADHD. 43% presented ADHD or subsyndromal ADHD. ADHD diagnosis in childhood persisted in adulthood in 62.5%. Concerning subtypes of ADHD, hyperactive/impulsive type (50%) or combined type (44%) were more frequent in childhood. ADHD comorbidities (internalized and externalized disorders) are presented in Table 3. Subjects with psychotic disorder (n = 6) were excluded from this analysis because they all presented a positive symptomatology or severe cognitive impairment that ruled out an ADHD diagnosis. Assessment of “severe cognitive impairment” was based on judgment by the clinician. Conduct disorder and antisocial personality disorder were significantly associated with ADHD. ADHD and Criminal Features ADHD and subsyndromal ADHD in childhood were significantly associated with a young age at first arrest. ADHD and
Results Between November 2007 and July 2008, 126 inmates were received among the eligible inmates. A total of 16 inmates refused to participate in the study, 14 subjects were excluded, nine because they did not speak French fluently, and five because they presented mental retardation and could not understand and/or give their consent for the study. During the study, two subjects were lost to follow-up and one withdrew his consent. Ninety-three males on remand, that is, pretrial men (41%) or convicted (59%) subjects aged 18–35 years were included; mean age was 26 years. Sociodemographic and criminal characteristics of the study population are presented in Table 1. Their educational status was low. Most of the offenses committed involved violence to persons or property.
TABLE 2––Attention-deficit/hyperactivity disorder (ADHD) prevalence (n = 93). ADHD
n
%
ADHD diagnosis in childhood IN type HA/I type combined type ADHD diagnosis in adulthood IN type HA/I type combined type ADHD + subsyndromal ADHD In childhood In adulthood
16 1 8 7 10 3 6 1
17 1 9 7 11 3 6 2
41 40
44 43
TABLE 3––Attention-deficit/hyperactivity disorder (ADHD) comorbidities. TABLE 1––Sociodemographic and criminal features (n = 93). n Age Educational level secondary school or lower high school or lower higher education Job at imprisonment Criminal status Remand Convicted Reason for actual imprisonment attack on property attack on persons sexual offense illegal drugs road traffic offenses Prior sentences
%
38 50 5 68
41 54 5 73
38 55
41 59
38 26 3 14 11 82
41 28 3 15 12 88
Infancy and Adulthood ADHD
Average
SD
26
4.38
Internalized disorders Major depression (lifetime) Major depression (actual diagnosis) Suicide attempt Suicidal risk Anxiety disorder (lifetime) Anxiety disorder (actual diagnosis) Externalized disorders Conduct disorder Antisocial personality *p < 0.05. † p < 0.10.
ADHD (n = 10) (%)
No ADHD (n = 77) (%)
5 (50) 4 (40)
29 (38) 17 (22)
NS NS
2 (20) 3 (30) 5 (50)
16 (21) 32 (42) 22 (29)
NS NS NS
2 (20)
15 (20)
NS
8 (80) 7 (70)
39 (49) 28 (36)
0.067† 0.04*
p
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JOURNAL OF FORENSIC SCIENCES
subsyndromal ADHD in adulthood were significantly associated with a higher number of imprisonments and younger age at first arrest (Table 4). Discussion In the present study, 11% of young male prisoners met the criteria for actual ADHD, and 17% met the childhood ADHD criteria. This is fewer than in previous inmates studies using less stringent evaluation tools. However, if we compare this result to the cross-national prevalence of adult ADHD published in 2007 by Fayyad et al. (1) (3,4%), the prevalence among young male prisoners is still three times greatest. Among the 17% of subjects meeting the criteria for childhood ADHD, 63% had symptoms both in childhood and adulthood. In the study by Faraone et al. (2), 15% of subjects with childhood ADHD still met ADHD criteria in adulthood, suggesting a higher adult persistence of ADHD among imprisoned populations. Einarsson et al. (13) found a similar result (60%) for the number of prisoners fully symptomatic or in partial remission of their ADHD symptoms. In the present study, ADHD was highly comorbid with conduct disorder (80%) and antisocial personality disorder (70%). ADHD and subsyndromal ADHD in adulthood were significantly associated with a higher number of imprisonments and younger age at first arrest. Previous studies in various Western countries have also revealed a higher-than-expected prevalence of actual ADHD among adult prisoners. Although ADHD is common among prison inmates, prevalence rates are inconsistent, probably because of the heterogeneity of the criteria used. Westmoreland et al. (18) found a prevalence of 21.3% for ADHD among 319 offenders using a version of the Mini-International Neuropsychiatric Interview, while Ginsberg et al. (11) estimated the prevalence of adult ADHD among long-term inmates to be 40%. Our results are consistent with those published by Fazel et al. (26) in a recent meta-analysis. They found a prevalence of 18.5% for ADHD among populations of imprisoned adolescents, although the subjects were aged 18 years or under in that study. In various studies conducted in prisons in the past 10 years, childhood ADHD prevalence has been estimated to be around 50% (12,13,16,17). These studies differed from ours in several aspects. First, most of them used the Wender Utah Rating Scale (WURS), but the cutoff was different. The WURS can lead to false-positive diagnoses of ADHD. It is sensitive in detecting ADHD, but it misclassifies approximately half of those who do not have ADHD (27). In fact, it can lead to misclassifying as ADHD other subjects with major depression or with conduct disorder symptoms, which are very common symptoms among imprisoned individuals. For this reason, we used the CAADID to be more specific.
Second, the French prison population might differ from those of other countries owing to legal differences. The main study conducted in French prisons, and evaluating the prevalence of mental disorders (28) did not assess ADHD. Our study was conducted in a “Maison d’Arr^et,” so our subjects had not yet been convicted (remand prisoners) or had been convicted only for short sentences. The other studies concerned longer-term prison inmates. The literature concerning long-term outcomes in individuals diagnosed with ADHD underlines the possible evolution to subsyndromal ADHD in adulthood, with a reduction in the number and intensity of symptoms and behaviors associated with ADHD. In the present study, prevalence of ADHD and subsyndromal ADHD was about 43% in adulthood, which is consistent with previous studies. The difficulty, however, is to determine the influence of each single disorder on social outcome and delinquency. Some follow-up studies of hyperactive children have explored the relationship between childhood ADHD and subsequent criminality by considering ADHD and its comorbidities separately. Manuzza et al.(4) found that even in the absence of comorbid substance disorder in childhood, ADHD increases the risk of developing antisocial personality and substance use disorders in adolescence, which, in turn increases the risk of criminal behavior in adolescence and adulthood. Galera et al. (29) showed an association between childhood attention problems and socioeconomic disadvantage in adulthood, which could constitute a confounding factor. ADHD and subsyndromal ADHD were associated in this study with younger age at first arrest (before 13 years old). At present, studies on predictors of persistence among childhood onset offenders have been scarce. In a recent study, Cohn et al. (30) compared three groups of offenders among a sample of 192 first-time arrestees aged under 12: persistent high, occasional, and persistent low offenders. After logistic regression analyses, only comorbid ADHD and ODD/CD significantly predicted persistent high offending as compared to occasional and low offending. The present study has several limitations. First, the results need to be extended to cover larger prison populations over a longer period. Second, childhood ADHD is often diagnosed using parent and teacher reports, neither of which was available here. Third, owing to self-report measures, our study ran the risk of an information bias, which should be considered when interpreting the results. This study is the first to screen ADHD in a French prison population using specific measures. Our results are consistent with those of previous studies underlining a higher-than-expected prevalence of ADHD among young adult prisoners and suggesting that ADHD is a diagnosis that should be borne in mind in adolescent and adult forensic evaluations. The relationship between childhood ADHD and delinquency should be examined
TABLE 4––Comparison between attention-deficit/hyperactivity disorder (ADHD) and subsyndromal ADHD versus non-ADHD concerning criminal features. ADHD + Subsyndromal ADHD in Childhood (n = 87)
Number of imprisonments (mean, SD) Age at first arrest (mean, SD) First arrest before 13 years old (number, %) *p < 0.05. † p < 0.10.
ADHD + Subsyndromal ADHD in Adulthood (n = 87)
Presence (n = 41)
Absence (n = 46)
p
Presence (n = 40)
Absence (n = 47)
p
3.3 (2.25) 15.5 (3.72) 10 (25%)
2.5 (2.03) 17.7 (4.7) 3 (7%)
NS 0.019* 0.02*
3.4 (3.3) 15.5 (3.6) 8 (21%)
2.4 (1.9) 17.6 (4.7) 5 (11%)
0.084† 0.023* NS
GA€IFFAS ET AL.
carefully because of the potential confounding effect created by numerous comorbid conditions and environmental risk factors. However, early identification and prevention concerning externalizing psychopathology of individuals at risk for continuous offending carries substantial relevance. References 1. Fayyad J, De Graaf R, Kessler R, Alonso J, Angermeyer M, Demytenaere K, et al. Cross-national prevalence and correlates of adult attentiondeficit hyperactivity disorder. Br J Psychiatry 2007;190:402–9. 2. Faraone S, Biederman J, Mick E. The age-dependent decline of attention-deficit/hyperactivity disorder: a meta-analysis of follow-up studies. Psychol Med 2006;36:159–65. 3. Biederman J, Mick E, Faraone SV. Age-dependent decline of symptoms of attention deficit hyperactivity disorder: impact of remission definition and symptoms type. Am J Psychiatry 2000;157:816–8. 4. Mannuzza S, Klein RG, Moulton JL 3rd. Lifetime criminality among boys with attention hyperactivity disorder: a prospective follow-up study into adulthood using official arrest records. Psychiatry Res 2008;160: 237–46. 5. Fazel S, Danesh J. Serious mental disorder in 23 000 prisoners: a systematic review of 62 surveys. Lancet 2002;359:545–50. 6. Brink J. Epidemiology of mental illness in a correctional system. Curr Opin Psychiatry 2005;18:536–41. 7. Hassan L, Birmingham L, Harty MA, Jarrett M, Jones P, King C, et al. Prospective cohort study of mental health during imprisonment. Br J Psychiatry 2011;198:37–42. 8. Coid J, Bebbington P, Jenkins R, Brugha T, Lewi G, Farrell M, et al. The National Survey of Psychiatric Morbidity among prisoners and the future of prison healthcare. Med Sci Law 2002;42:245–50. 9. Fazel S, Baillargeon J. The health of prisoners. Lancet 2011;377:956–65. 10. Curran S, Fitzgerald M. Attention deficit hyperactivity disorder in the prison population. Am J Psychiatry 1999;156:1664–5. 11. Ginsberg Y, Hirvikoski T, Linderfors N. Attention Deficit Hyperactivity Disorder (ADHD) among long-term prison inmates is a prevalent, persistent and disabling disorder. BMC Psychiatry 2010;10:112. 12. R€ osler M, Retz W, Rets-Junginger P, Hengesh G, Scheinder M, Supprian T, et al. Prevalence of attention deficit-/hyperactivity disorder (ADHD) and comorbid disorders in young male prison inmates. Eur Arch Psychiatry Clin Neurosci 2004;254:365–71. 13. Einarsson E, Sigurdsson JF, Gudjonsson GH, Newton AK, Bragason OO. Screening for attention-deficit hyperactivity disorder and co-morbid mental disorders among prison inmates. Nord J Psychiatry 2009;26:1–7. 14. Eyestone LL, Howell RJ. An epidemiological study of attention-deficit hyperactivity disorder and major depression in a male population prison. Bull Am Acad Psychitry Law 1994;22:181–93. 15. Matsumoto T, Yamaguchi A, Asami T, Kamijo A, Iseki E, Hirayasu Y, et al. Drug preferences in illicit drug abusers with a childhood tendency of attention deficit/hyperactivity disorder: a study using the Wender Utah Rating Scale in a Japanese prison. Psychiatry Clin Neurosci 2005;59:311–8. 16. Rasmussen K, Almvik R, Levander S. Attention deficit hyperactivity disorder, reading disability, and personality disorders in a prison population. J Am Acad Psychiatry Law 2001;29:186–93.
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17. Vegue-Gonzales M, Alvaro-Brun E, Santiago-Saez A, Kanaan-Kanaan A. Retrospective evaluation of attention deficit hyperactivity disorder with the Wender Utah Rating Scale in a sample of Spanish prison inmates. J Forensic Sci 2011;56(6):1556–61. 18. Westmoreland P, Gunter T, Loveless P, Allen J, Sieleni B, Black DW. Attention deficit hyperactivity disorder in men and women newly committed to prison: clinical characteristics, psychiatric comorbidity, and quality of life. Int J Offender Ther Comp Criminol 2010;54:361–77. 19. Ward MF, Wender PH, Reimherr FW. The Wender Utah Rating Scale: an aid in the retrospective diagnosis of childhood attention deficit hyperactivity disorder. Am J Psychiatry 1993;150:885–90. 20. Johansson P, Kerr M, Andershed H. Linking adult psychopathy with childhood hyperactivity-impulsivity-attention problems and conduct problems through retrospective self-reports. J Pers Disord 2005;19:94–101. 21. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (4th edn, text revised) (DSM-IV-TR). Washington, DC: APA, 2000. 22. Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, et al. The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 1998;59(Suppl 20): 22–30. 23. World Health Organization. ICD-10 international statistical classification of diseases and related health problems (10th revision.) Geneva, Switzerland: World Health Organization, 2010. 24. Epstein JN, Johnson D, Conners CK. Conners’ adult ADHD diagnostic interview for DSM-IV. North Tonawanda, NY: Multi-Health Systems Inc, 2000. 25. Epstein JN, Kollins SH. Psychometrics properties of an adult ADHD diagnostic interview. J Atten Disord 2006;9:504–14. 26. Fazel S, Doll H, L€angstr€om N. Mental disorders among adolescents in juvenile detention and correctional facilities: a systematic review and metaregression analysis of 25 surveys. J Am Acad Child Adolesc Psychiatry 2008;47:1010–9. 27. McCann BS, Scheele L, Ward N, Roy-Byrne P. Discriminant validity of the Wender Utah Rating Scale for attention-deficit/hyperactivity disorders in adult. J Neuropsychiatry Clin Neurosci 2000;12:240–5. 28. Falissard B, Loze JY, Gasquet I, Duburc A, de Beaurepaire C, Fagnani F, et al. Prevalence of mental disorders in French prisons for men. BMC Psychiatry 2006;6:33. 29. Galera C, Bouvard MP, Lagarde E, Michel G, Touchette E, Fombonne E, et al. Childhood attention problems and socioeconomic status in adulthood: 18-year follow-up. Br J Psychiatry 2012;201:20–5. 30. Cohn M, van Domburgh L, Vermeiren R, Geluck C, Doreleijers T. Externalizing psychopathology and persistence of offending in childhood first-time arrestees. Eur Child Adolesc Psychiatry 2012;21:243–51. Additional information and reprint requests: Anne Ga€ıffas, M.D., M.Sc. Department of child and adolescent psychiatry H^opital Charles Perrens 121 rue de la Bechade 33076 Bordeaux Cedex France E-mail: [email protected]
PAPER PSYCHIATRY & BEHAVIORAL SCIENCES
Anne Ga€ıffas,1,2 M.D., M.Sc.; Cedric Galera,1,3 M.D., Ph.D.; Virginie Mandon,1 M.D.; and Manuel P. Bouvard,1,2,4 M.D., Ph.D.
Attention-Deficit/Hyperactivity Disorder in Young French Male Prisoners
ABSTRACT: While forensic studies have reported higher than community rates of mental disorders in imprisoned populations, few studies
have focused on attention-deficit/hyperactivity disorder (ADHD) in these subjects. The aim of this study was to investigate ADHD prevalence among young French male prisoners. A specific diagnostic interview (Conners’ Adult ADHD Diagnostic Interview for DSM-IV, CAADID) was used. Correlations between ADHD, subsyndromal ADHD, and criminal features were investigated. 11% of young male prisoners among 93 male subjects aged 18–35 years met the criteria for actual ADHD, and 17% met those for childhood ADHD. Considering ADHD and subsyndromal ADHD, prevalence was about 43% in adulthood. ADHD and subsyndromal ADHD in adulthood were significantly associated with a higher number of imprisonments and a younger age at first arrest. It could be advisable to better identify subjects with ADHD symptoms among prison populations.
KEYWORDS: forensic science, forensic psychiatry, prevalence, attention-deficit/hyperactivity disorder, prison, Conners’ adult ADHD diagnostic interview for DSM-IV
Attention-deficit/hyperactivity disorder (ADHD) is an impairing clinical syndrome with childhood onset and persisting features in adulthood. Adult ADHD prevalence has been estimated at about 3.4% (1). Several studies of children with ADHD followed up into adulthood have shown the possibility of full or partial persistence, thereby defining a subsyndromal ADHD in adulthood (2,3). ADHD is highly comorbid with psychiatric disorders, including substance use disorder, conduct disorder, and antisocial personality. As antisocial behaviors associated with ADHD may contribute to criminality and subsequently increase involvement with the legal system (4), it is important to study ADHD in criminal populations. Numerous studies across a wide spectrum of forensic settings have reported higher than community rates of mental disorders in imprisoned populations (5–8), particularly juveniles (9). In the past 10 years, a few studies have focused on ADHD in prison populations (10–18). Forensic studies have shown ADHD to be common among prison inmates with a prevalence ranging from 21% (18) to 45% (12). Surveys to date have used heterogeneous procedures and measures. Most of the research on childhood ADHD diagnosis until now has most relied on the Wender Utah Rating Scale (WURS) (19). However, a limitation of this scale is that it spuriously identifies subjects with antisocial conducts as ADHD, 1
Department of child and adolescent psychiatry, Charles Perrens Hospital, 121 rue de la Bechade, 33076 Bordeaux, France. 2 University Bordeaux Segalen, 146 rue Leo Saignat, 33076 Bordeaux Cedex, France. 3 INSERM U 897, 146 rue Leo Saignat, 33076 Bordeaux Cedex, France. 4 CNRS UMR 5287, 146 rue Leo Saignat, 33076 Bordeaux Cedex, France. Received 14 Feb. 2013; and in revised form 23 May 2013; accepted 13 June 2013.
1016
leading to inflated ADHD prevalence rates due to false positives (20). In addition, there is no French study regarding ADHD prevalence in the prison population. The main objective of this study was to estimate the prevalence of ADHD among a population of young French male prisoners using a comprehensive and accurate diagnostic DSM-IV procedure (21). A secondary objective was to investigate the correlation between ADHD, subsyndromal ADHD, and criminal features. Method This cross-sectional study was conducted between November 2007 and July 2008 in the “Maison d’Arr^et” in Bordeaux-Gradignan in France. The “Maisons d’Arr^et” are intended for remand prisoners and/or for prisoners with short sentences who have been convicted for a wide range of offenses. The study was proposed to all male remand and convicted prisoners, aged 18–35 years who were imprisoned between November 2007 and February 2008. Interviews and questionnaires were administered at the prisoner medical and psychological department, which is a psycho-medical unit inside the prison (“Service Medico-Psychologique Regional,” SMPR). Subjects were received at the SMPR by a psychiatrist between 2 weeks and 3 months after beginning their imprisonment. All subjects received full information about the study. Informed consent was obtained before inclusion. Data collection lasted about 90 mins for each subject and concerned sociodemographic and criminal data and psychiatric history. Psychiatric diagnoses were recorded using the Mini-International Neuropsychiatric Interview (MINI) (22), a short structured diagnostic interview for DSM-IV (21) and ICD-10 (23) psychiatric disorders. Past and actual diagnoses were collected, including © 2014 American Academy of Forensic Sciences
GA€IFFAS ET AL.
mood disorders, anxiety disorders, psychotic disorders, eating disorders, conduct disorder, substance-related disorders, and antisocial personality disorder. Adult and childhood ADHD diagnoses were evaluated using the Conners’Adult ADHD Diagnostic Interview for DSM-IV (CAADID) (24,25). The CAADID is a semi-structured interview for diagnosing ADHD in adults. It was designed to assess DSMIV criteria for adult ADHD in order to establish an accurate and appropriate ADHD diagnosis. The CAADID questions assess DSM-IV ADHD symptoms (inattention symptoms, hyperactive/ impulsive symptoms) as follows: the presence or absence at onset, pervasiveness, and impairment caused by the symptoms during childhood and adulthood. The ADHD diagnosis is established when the subject presents at least six of the nine symptoms on at least one dimension (inattention and/or hyperactivity/ impulsivity). Subsyndromal ADHD is established when the subjects present at least four symptoms on any dimension (inattention or hyperactivity/impulsivity). Descriptive statistics were provided (percentages and means with standard deviations). Comparative statistics (using v², t test, and nonparametric statistics when applicable) were then conducted. The study was conducted in accordance with penitentiary administration rules and conformed to the French bioethics and clinical research and data protection legislation. All data were de-identified.
.
PSYCHIATRY AND BEHAVIORAL SCIENCES
1017
Prevalence of ADHD and Comorbidities Among the 93 subjects, 13% had a history of hospitalization for psychiatric reasons, and 35% were under psychotropic medication at the time of the study. No subject was receiving any prescription for stimulants, and only one subject had received stimulant in childhood. Table 2 presents the estimated prevalence of ADHD diagnosis and subsyndromal ADHD diagnosis according to the CAADID questionnaire. 11% of young male prisoners met the criteria for actual ADHD, and 17% met those for childhood ADHD. 43% presented ADHD or subsyndromal ADHD. ADHD diagnosis in childhood persisted in adulthood in 62.5%. Concerning subtypes of ADHD, hyperactive/impulsive type (50%) or combined type (44%) were more frequent in childhood. ADHD comorbidities (internalized and externalized disorders) are presented in Table 3. Subjects with psychotic disorder (n = 6) were excluded from this analysis because they all presented a positive symptomatology or severe cognitive impairment that ruled out an ADHD diagnosis. Assessment of “severe cognitive impairment” was based on judgment by the clinician. Conduct disorder and antisocial personality disorder were significantly associated with ADHD. ADHD and Criminal Features ADHD and subsyndromal ADHD in childhood were significantly associated with a young age at first arrest. ADHD and
Results Between November 2007 and July 2008, 126 inmates were received among the eligible inmates. A total of 16 inmates refused to participate in the study, 14 subjects were excluded, nine because they did not speak French fluently, and five because they presented mental retardation and could not understand and/or give their consent for the study. During the study, two subjects were lost to follow-up and one withdrew his consent. Ninety-three males on remand, that is, pretrial men (41%) or convicted (59%) subjects aged 18–35 years were included; mean age was 26 years. Sociodemographic and criminal characteristics of the study population are presented in Table 1. Their educational status was low. Most of the offenses committed involved violence to persons or property.
TABLE 2––Attention-deficit/hyperactivity disorder (ADHD) prevalence (n = 93). ADHD
n
%
ADHD diagnosis in childhood IN type HA/I type combined type ADHD diagnosis in adulthood IN type HA/I type combined type ADHD + subsyndromal ADHD In childhood In adulthood
16 1 8 7 10 3 6 1
17 1 9 7 11 3 6 2
41 40
44 43
TABLE 3––Attention-deficit/hyperactivity disorder (ADHD) comorbidities. TABLE 1––Sociodemographic and criminal features (n = 93). n Age Educational level secondary school or lower high school or lower higher education Job at imprisonment Criminal status Remand Convicted Reason for actual imprisonment attack on property attack on persons sexual offense illegal drugs road traffic offenses Prior sentences
%
38 50 5 68
41 54 5 73
38 55
41 59
38 26 3 14 11 82
41 28 3 15 12 88
Infancy and Adulthood ADHD
Average
SD
26
4.38
Internalized disorders Major depression (lifetime) Major depression (actual diagnosis) Suicide attempt Suicidal risk Anxiety disorder (lifetime) Anxiety disorder (actual diagnosis) Externalized disorders Conduct disorder Antisocial personality *p < 0.05. † p < 0.10.
ADHD (n = 10) (%)
No ADHD (n = 77) (%)
5 (50) 4 (40)
29 (38) 17 (22)
NS NS
2 (20) 3 (30) 5 (50)
16 (21) 32 (42) 22 (29)
NS NS NS
2 (20)
15 (20)
NS
8 (80) 7 (70)
39 (49) 28 (36)
0.067† 0.04*
p
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subsyndromal ADHD in adulthood were significantly associated with a higher number of imprisonments and younger age at first arrest (Table 4). Discussion In the present study, 11% of young male prisoners met the criteria for actual ADHD, and 17% met the childhood ADHD criteria. This is fewer than in previous inmates studies using less stringent evaluation tools. However, if we compare this result to the cross-national prevalence of adult ADHD published in 2007 by Fayyad et al. (1) (3,4%), the prevalence among young male prisoners is still three times greatest. Among the 17% of subjects meeting the criteria for childhood ADHD, 63% had symptoms both in childhood and adulthood. In the study by Faraone et al. (2), 15% of subjects with childhood ADHD still met ADHD criteria in adulthood, suggesting a higher adult persistence of ADHD among imprisoned populations. Einarsson et al. (13) found a similar result (60%) for the number of prisoners fully symptomatic or in partial remission of their ADHD symptoms. In the present study, ADHD was highly comorbid with conduct disorder (80%) and antisocial personality disorder (70%). ADHD and subsyndromal ADHD in adulthood were significantly associated with a higher number of imprisonments and younger age at first arrest. Previous studies in various Western countries have also revealed a higher-than-expected prevalence of actual ADHD among adult prisoners. Although ADHD is common among prison inmates, prevalence rates are inconsistent, probably because of the heterogeneity of the criteria used. Westmoreland et al. (18) found a prevalence of 21.3% for ADHD among 319 offenders using a version of the Mini-International Neuropsychiatric Interview, while Ginsberg et al. (11) estimated the prevalence of adult ADHD among long-term inmates to be 40%. Our results are consistent with those published by Fazel et al. (26) in a recent meta-analysis. They found a prevalence of 18.5% for ADHD among populations of imprisoned adolescents, although the subjects were aged 18 years or under in that study. In various studies conducted in prisons in the past 10 years, childhood ADHD prevalence has been estimated to be around 50% (12,13,16,17). These studies differed from ours in several aspects. First, most of them used the Wender Utah Rating Scale (WURS), but the cutoff was different. The WURS can lead to false-positive diagnoses of ADHD. It is sensitive in detecting ADHD, but it misclassifies approximately half of those who do not have ADHD (27). In fact, it can lead to misclassifying as ADHD other subjects with major depression or with conduct disorder symptoms, which are very common symptoms among imprisoned individuals. For this reason, we used the CAADID to be more specific.
Second, the French prison population might differ from those of other countries owing to legal differences. The main study conducted in French prisons, and evaluating the prevalence of mental disorders (28) did not assess ADHD. Our study was conducted in a “Maison d’Arr^et,” so our subjects had not yet been convicted (remand prisoners) or had been convicted only for short sentences. The other studies concerned longer-term prison inmates. The literature concerning long-term outcomes in individuals diagnosed with ADHD underlines the possible evolution to subsyndromal ADHD in adulthood, with a reduction in the number and intensity of symptoms and behaviors associated with ADHD. In the present study, prevalence of ADHD and subsyndromal ADHD was about 43% in adulthood, which is consistent with previous studies. The difficulty, however, is to determine the influence of each single disorder on social outcome and delinquency. Some follow-up studies of hyperactive children have explored the relationship between childhood ADHD and subsequent criminality by considering ADHD and its comorbidities separately. Manuzza et al.(4) found that even in the absence of comorbid substance disorder in childhood, ADHD increases the risk of developing antisocial personality and substance use disorders in adolescence, which, in turn increases the risk of criminal behavior in adolescence and adulthood. Galera et al. (29) showed an association between childhood attention problems and socioeconomic disadvantage in adulthood, which could constitute a confounding factor. ADHD and subsyndromal ADHD were associated in this study with younger age at first arrest (before 13 years old). At present, studies on predictors of persistence among childhood onset offenders have been scarce. In a recent study, Cohn et al. (30) compared three groups of offenders among a sample of 192 first-time arrestees aged under 12: persistent high, occasional, and persistent low offenders. After logistic regression analyses, only comorbid ADHD and ODD/CD significantly predicted persistent high offending as compared to occasional and low offending. The present study has several limitations. First, the results need to be extended to cover larger prison populations over a longer period. Second, childhood ADHD is often diagnosed using parent and teacher reports, neither of which was available here. Third, owing to self-report measures, our study ran the risk of an information bias, which should be considered when interpreting the results. This study is the first to screen ADHD in a French prison population using specific measures. Our results are consistent with those of previous studies underlining a higher-than-expected prevalence of ADHD among young adult prisoners and suggesting that ADHD is a diagnosis that should be borne in mind in adolescent and adult forensic evaluations. The relationship between childhood ADHD and delinquency should be examined
TABLE 4––Comparison between attention-deficit/hyperactivity disorder (ADHD) and subsyndromal ADHD versus non-ADHD concerning criminal features. ADHD + Subsyndromal ADHD in Childhood (n = 87)
Number of imprisonments (mean, SD) Age at first arrest (mean, SD) First arrest before 13 years old (number, %) *p < 0.05. † p < 0.10.
ADHD + Subsyndromal ADHD in Adulthood (n = 87)
Presence (n = 41)
Absence (n = 46)
p
Presence (n = 40)
Absence (n = 47)
p
3.3 (2.25) 15.5 (3.72) 10 (25%)
2.5 (2.03) 17.7 (4.7) 3 (7%)
NS 0.019* 0.02*
3.4 (3.3) 15.5 (3.6) 8 (21%)
2.4 (1.9) 17.6 (4.7) 5 (11%)
0.084† 0.023* NS
GA€IFFAS ET AL.
carefully because of the potential confounding effect created by numerous comorbid conditions and environmental risk factors. However, early identification and prevention concerning externalizing psychopathology of individuals at risk for continuous offending carries substantial relevance. References 1. Fayyad J, De Graaf R, Kessler R, Alonso J, Angermeyer M, Demytenaere K, et al. Cross-national prevalence and correlates of adult attentiondeficit hyperactivity disorder. Br J Psychiatry 2007;190:402–9. 2. Faraone S, Biederman J, Mick E. The age-dependent decline of attention-deficit/hyperactivity disorder: a meta-analysis of follow-up studies. Psychol Med 2006;36:159–65. 3. Biederman J, Mick E, Faraone SV. Age-dependent decline of symptoms of attention deficit hyperactivity disorder: impact of remission definition and symptoms type. Am J Psychiatry 2000;157:816–8. 4. Mannuzza S, Klein RG, Moulton JL 3rd. Lifetime criminality among boys with attention hyperactivity disorder: a prospective follow-up study into adulthood using official arrest records. Psychiatry Res 2008;160: 237–46. 5. Fazel S, Danesh J. Serious mental disorder in 23 000 prisoners: a systematic review of 62 surveys. Lancet 2002;359:545–50. 6. Brink J. Epidemiology of mental illness in a correctional system. Curr Opin Psychiatry 2005;18:536–41. 7. Hassan L, Birmingham L, Harty MA, Jarrett M, Jones P, King C, et al. Prospective cohort study of mental health during imprisonment. Br J Psychiatry 2011;198:37–42. 8. Coid J, Bebbington P, Jenkins R, Brugha T, Lewi G, Farrell M, et al. The National Survey of Psychiatric Morbidity among prisoners and the future of prison healthcare. Med Sci Law 2002;42:245–50. 9. Fazel S, Baillargeon J. The health of prisoners. Lancet 2011;377:956–65. 10. Curran S, Fitzgerald M. Attention deficit hyperactivity disorder in the prison population. Am J Psychiatry 1999;156:1664–5. 11. Ginsberg Y, Hirvikoski T, Linderfors N. Attention Deficit Hyperactivity Disorder (ADHD) among long-term prison inmates is a prevalent, persistent and disabling disorder. BMC Psychiatry 2010;10:112. 12. R€ osler M, Retz W, Rets-Junginger P, Hengesh G, Scheinder M, Supprian T, et al. Prevalence of attention deficit-/hyperactivity disorder (ADHD) and comorbid disorders in young male prison inmates. Eur Arch Psychiatry Clin Neurosci 2004;254:365–71. 13. Einarsson E, Sigurdsson JF, Gudjonsson GH, Newton AK, Bragason OO. Screening for attention-deficit hyperactivity disorder and co-morbid mental disorders among prison inmates. Nord J Psychiatry 2009;26:1–7. 14. Eyestone LL, Howell RJ. An epidemiological study of attention-deficit hyperactivity disorder and major depression in a male population prison. Bull Am Acad Psychitry Law 1994;22:181–93. 15. Matsumoto T, Yamaguchi A, Asami T, Kamijo A, Iseki E, Hirayasu Y, et al. Drug preferences in illicit drug abusers with a childhood tendency of attention deficit/hyperactivity disorder: a study using the Wender Utah Rating Scale in a Japanese prison. Psychiatry Clin Neurosci 2005;59:311–8. 16. Rasmussen K, Almvik R, Levander S. Attention deficit hyperactivity disorder, reading disability, and personality disorders in a prison population. J Am Acad Psychiatry Law 2001;29:186–93.
.
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17. Vegue-Gonzales M, Alvaro-Brun E, Santiago-Saez A, Kanaan-Kanaan A. Retrospective evaluation of attention deficit hyperactivity disorder with the Wender Utah Rating Scale in a sample of Spanish prison inmates. J Forensic Sci 2011;56(6):1556–61. 18. Westmoreland P, Gunter T, Loveless P, Allen J, Sieleni B, Black DW. Attention deficit hyperactivity disorder in men and women newly committed to prison: clinical characteristics, psychiatric comorbidity, and quality of life. Int J Offender Ther Comp Criminol 2010;54:361–77. 19. Ward MF, Wender PH, Reimherr FW. The Wender Utah Rating Scale: an aid in the retrospective diagnosis of childhood attention deficit hyperactivity disorder. Am J Psychiatry 1993;150:885–90. 20. Johansson P, Kerr M, Andershed H. Linking adult psychopathy with childhood hyperactivity-impulsivity-attention problems and conduct problems through retrospective self-reports. J Pers Disord 2005;19:94–101. 21. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (4th edn, text revised) (DSM-IV-TR). Washington, DC: APA, 2000. 22. Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, et al. The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 1998;59(Suppl 20): 22–30. 23. World Health Organization. ICD-10 international statistical classification of diseases and related health problems (10th revision.) Geneva, Switzerland: World Health Organization, 2010. 24. Epstein JN, Johnson D, Conners CK. Conners’ adult ADHD diagnostic interview for DSM-IV. North Tonawanda, NY: Multi-Health Systems Inc, 2000. 25. Epstein JN, Kollins SH. Psychometrics properties of an adult ADHD diagnostic interview. J Atten Disord 2006;9:504–14. 26. Fazel S, Doll H, L€angstr€om N. Mental disorders among adolescents in juvenile detention and correctional facilities: a systematic review and metaregression analysis of 25 surveys. J Am Acad Child Adolesc Psychiatry 2008;47:1010–9. 27. McCann BS, Scheele L, Ward N, Roy-Byrne P. Discriminant validity of the Wender Utah Rating Scale for attention-deficit/hyperactivity disorders in adult. J Neuropsychiatry Clin Neurosci 2000;12:240–5. 28. Falissard B, Loze JY, Gasquet I, Duburc A, de Beaurepaire C, Fagnani F, et al. Prevalence of mental disorders in French prisons for men. BMC Psychiatry 2006;6:33. 29. Galera C, Bouvard MP, Lagarde E, Michel G, Touchette E, Fombonne E, et al. Childhood attention problems and socioeconomic status in adulthood: 18-year follow-up. Br J Psychiatry 2012;201:20–5. 30. Cohn M, van Domburgh L, Vermeiren R, Geluck C, Doreleijers T. Externalizing psychopathology and persistence of offending in childhood first-time arrestees. Eur Child Adolesc Psychiatry 2012;21:243–51. Additional information and reprint requests: Anne Ga€ıffas, M.D., M.Sc. Department of child and adolescent psychiatry H^opital Charles Perrens 121 rue de la Bechade 33076 Bordeaux Cedex France E-mail: [email protected]
