Attention Deficit Hyperactivity Disorder (ADHD) Among Longer-term Prison Inmates is a Prevalent, Persistent and Disabling Disorder

Ylva Ginsberg; Tatja Hirvikoski; Nils Lindefors

BMC Psychiatry. 2010;10(1)

Conclusions

This study suggested ADHD to be present among 40% of adult male longer-term prison inmates. Diagnostic evaluations for ADHD among 30 inmates showed them severely disabled from ADHD and coexisting disorders, such as SUD, ASD, personality disorders, mood- and anxiety disorders. Further, these ADHD prison inmates displayed poorer executive functions, also when controlling for estimated IQ, compared with ADHD psychiatric outpatients and healthy controls. We infer the reported findings of ADHD symptom severity, coexisting disorders and executive functioning among prison inmates, are clinical important and relevant. These findings imply the need for considering these severities when introducing ADHD treatment programmes for prison inmates.

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Acknowledgements
The Swedish Ministry of Health and Social Affairs, and Stockholm County Council, Sweden financially supported this study. The funding sources were not involved in the authors' work. We are grateful to all participants and collaborators from Stockholm County Council and the Swedish Prison and Probation Service who made this work possible. We especially thank Gunnar Johansson at Norrtälje Prison for invaluable help in administering the screening survey, Monica Hellberg for administrative assistance, and co-investigators Michaela Wallensteen, Ann-Charlotte Wiklund, Maria Kristensen, Agneta Ljungberg, Anna Eriksson, Julia Alfredsson, Else Waaler, Pernilla Bothén, and Annelie Holmström for providing data. We thank Martin Grann for valuable comments on the manuscript.

Authors' contributions
YG designed the study in collaboration with NL and TH, applied to the Ethical Board in collaboration with NL, prepared the Case Report Forms, conducted clinical assessments, collected data, planned and executed the analyses, interpreted the results in collaboration with TH and NL, and prepared all drafts of the manuscript in collaboration with TH. NL revised the manuscripts critically. TH was responsible for assessments and analyses of the psychiatric outpatients and controls. All authors read, commented on and approved the final manuscript.

Competing interests
YG has been on the speaker's bureau and consultant for Janssen-Cilag, Novartis and Lundbeck A/S. YG has been the principal investigator of two clinical trials sponsored by Janssen-Cilag. NL has been the investigator of a clinical trial sponsored by Janssen-Cilag. TH declares no conflicts of interest.

Cite this: Attention Deficit Hyperactivity Disorder (ADHD) Among Longer-term Prison Inmates is a Prevalent, Persistent and Disabling Disorder - Medscape - Dec 01, 2010.

Table 1. Demographic and Clinical Characteristics of Prison Survey Sample
Study sample (n = 315)	Responders (n = 194)	Non responders^a (n = 121)	p
Men, n (%)	194 (100)	121 (100)
Age, median^b (IQR), y	31.3 (14)	29.4 (12)	.028^d
Conviction time, median^b (IQR)^c, months	69 (66)	60 (54)	.030^d

^aNon-responders were defined as those approached but actively refused to take part, those who consented but not returned questionnaires, and those who returned unanswered questionnaires; ^bMedians were used as measures of central tendencies as age and conviction time were non-normally distributed; ^c IQR: Interquartile range; ^dMann-Whitney U-test was employed due to non-normal distributed data.

Table 2. Demographic and Clinical Characteristics of Assessed Groups; ADHD-prison group, ADHD-psychiatry group, Healthy controls. Not applicable = N/A.
	ADHD-prison, n = 30	ADHD-psychiatry, n = 20	Controls, n = 18	F or χ²	p
Age, mean, (SD), y	34.4 (10.67)	33.4 (8.65)	35.2 (9.85)	.14	.87^e
Educational level, nine-year compulsory school or less, n (%)	25 (83)	6 (30)	1 (6)	39.28	< .001^e
ADHD, combined, n (%)	28 (93)	18 (90)	N/A
ADHD, inattentive, n (%)	2 (7)	2 (10)	N/A
≥ 1 current co-morbid disorder, n (%)^a	15 (50)	12 (60)	N/A		.569
Autism spectrum disorder^b	7 (23)	N/A	N/A
Mood and anxiety disorder, lifetime^a	22 (73)	N/A	N/A
Personality disorders, (N = 23)^c
Antisocial, n (%)	22 (96)	N/A	N/A
Borderline, n (%)	17 (74)	N/A	N/A
Paranoid, n (%)	17 (74)	N/A	N/A
Narcissistic, n (%)	15 (65)	N/A	N/A
Obsessive-Compulsive, n (%)	12 (52)	N/A	N/A
Passive-Aggressive, n (%)	11 (48)	N/A	N/A
Avoidant, n (%)	11 (48)	N/A	N/A
Depressive, n (%)	8 (35)	N/A	N/A
Dependent, n (%)	7 (30)	N/A	N/A
Schizotypal, n (%)	5 (22)	N/A	N/A
Schizoid, n (%)	2 (9)	N/A	N/A
Histrionic, n (%)	0 (0)	N/A	N/A
Substance use disorder, n (%)^a	30 (100)	N/A	N/A
Amphetamine preferred, n (%)	19 (63)	N/A	N/A
Cocaine preferred, n (%)	4 (13)	N/A	N/A
Alcohol preferred, n (%)	4 (13)	N/A	N/A
Psychopathy, n (%)^d	3 (10)	N/A	N/A
Concomitant psychotropic's, n (%)	13 (43)	N/A	N/A
Onset of alcohol, mean (SD), y	11.9 (1.81)	N/A	N/A
Onset of illegal drugs, mean (SD), y	14.0 (2.41)	N/A	N/A
Onset of criminality, mean (SD), y	11.2 (3.40)	N/A	N/A
Educational assistance at school, n (%)	24 (80)	N/A	N/A
Child psychiatry/school health, n (%)	18 (60)	N/A	N/A
ADHD diagnosed in childhood, n (%)	2 (7)	N/A	N/A

^aAccording to DSM-IV by the SCID I interview, ^bAccording to DSM IV, Autism spectrum disorder includes both Asperger syndrome and PDD-NOS, ^cFrequencies of personality disorders were estimated by increasing the cut-off level for each personality disorder by one score, on the SCID II PQ to equal the cut-off score of the SCID II interview, ^dPsychopathy was defined as a total sum score of ≥30 by the PCL-R, ^eAnalyses of variance (ANOVA) for continuous variables and Fisher's exact test for categorical variables.

Table 3. Self-rated ADHD symptoms and behaviours during both childhood and adulthood; parental ratings of childhood ADHD-symptoms. All results divided by group.
	ADHD-psychiatry n = 20	ADHD-prison n = 30	t	p
*Self-rating questionnaires*	M (SD)	M (SD)
WURS-25	54.70 (14.31)	67.43 (13.48)	-3.19	.002
ASRS^a	45.11 (12.85)	55.30 (8.89)	-3.28	.002
*Parental rating/questionnaires completed by significant others*
Five to Fifteen - Executive Functions Subscale^b	1.23 (0.59)	1.20 (0.44)	0.19	.848
Conners' Hyperactivity Index^b	13.47 (10.34)	15.19 (8.07)	-0.52	.608

^a Data missing for one subject among the ADHD-psychiatry group; ^b The FTF Executive Functions Subscale includes ADHD criteria according to DSM-IV. For 15/20 (75%) among the ADHD-psychiatry group and 16/30 (53%) among the ADHD-prison group, a significant other completed the FTF and the Conners' Hyperactivity Index. For all questionnaires, higher scores indicate increased problems.

Table 4. ANOVA statistics included post hoc IQ adjustments for tests of executive functions. The statistics F, p, and ηp2 presented for ANOVAs without IQ adjustments. On working memory tests, higher scores reflect better results, whereas on Conners' CPT II, higher scores reflect poorer results.
Test and measured function	N	F	p	η _p ²	Post hoc test	Post hoc adjusted for IQ
*Measures of working memory*	Control:18 ADHD-psych: 20 ADHD-prison: 30
*Digit Span*		21.29	< .001	.396	C>Psych > Prison	C > Psych = Prison
*Span Board*		24.88	< .001	.434	C>Psych > Prison	C > Psych = Prison
*Conners' CPT II*	Control:18 ADHD-psych: 20 ADHD-prison: 27
CCPT reaction time
Hit RT		.48	.617	.015	C = Psych = Prison	C = Psych = Prison
*CCPT variability*
Variability		26.38	< .001	.460	C = Psych < Prison	C = Psych < Prison
Hit RT block change		.29	.749	.009	C = Psych = Prison	C = Psych = Prison
Hit SE block change		.165	.848	.005	C = Psych = Prison	C = Psych = Prison
Hit RT ISI change		1.22	.302	.038	C = Psych = Prison	C = Psych = Prison
Hit SE ISI change		.662	.519	.021	C = Psych = Prison	C = Psych = Prison
Perseverations		8.66	< .001	.218	C = Psych < Prison	C = Psych < Prison
*CCPT accuracy*
Omission errors		16.23	< .001	.344	C = Psych < Prison	C = Psych < Prison
Commission errors		12.61	< .001	.289	C = Psych < Prison	C = Psych < Prison
Detectability (d')		9.21	< .001	.229	C < Prison Psych = C Psych = Prison	C < Prison Psych = C Psych = Prison
Response style (beta)		4.27	.018	.121	Psych < Prison Psych = C Prison = C	Psych < Prison Psych = C Prison = C

Note: CCPT = Conners' Continuous Performance Test; RT = reaction time; SE = standard error; ISI = interstimulus interval; N/A = not applicable

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