ADHD and the Pathway to Delinquency

A couple of years ago I got caught with cannabis on me, got a fine through that....I've smoked cannabis for about five years now. I started smoking it because my medications weren't right so I used to self-medicate. Now that my medication's right I'm still smoking it, but I'm cutting down.

The symptoms of ADHD and the difficulties that may be associated with the condition can sometimes lead to problems with antisocial and/or reckless behaviours including dangerous driving, alcohol and substance use and, in serious cases, crime. Not all young people with ADHD will present with these behaviours, but a sizeable subgroup has antisocial co-morbid difficulties [1]. Indeed, comorbid ADHD and conduct disorder together comprise a more severe condition than either disorder alone [2] and this co-occurrence may contribute to violent and antisocial behaviour.

Retz and Rösler [3] have developed a theoretical framework to explain the relationship between ADHD (combined and hyperactive/impulsive subtypes), early-onset conduct disorder, and both conditions with the subsequent development of Antisocial Personality Disorder. It is proposed that this developmental subtype of Antisocial Personality Disorder is more frequently associated with impulsive aggression as a reaction to a situation, rather than with premeditated, proactive aggression, whereas ADHD without comorbid conduct disorder is more associated with social problems and rule breaking behaviour (e.g. traffic infractions). In the model, substance use disorders also impact on ADHD-related antisocial behaviour (see Figure 1).

Risky and Dangerous Behaviour

Participation in reckless behaviours that involve pushing social boundaries and rule-breaking is more common in ADHD adolescents than adults. These behaviours can place young people at risk of harm; ADHD has been associated with a greater number of accidental injuries and presentations to hospital Accident and Emergency, and a greater number of injuries [4-6]. This may be explained by individuals seeking highly stimulating activities, combined with poor consequential thinking skills and/or an underestimation of the likelihood of injury.

Risky sexual behaviour is also more common in adolescents with ADHD (see Module 6 in this series), who report more casual, unprotected sex than controls and, as a result, they are more likely to contract sexually transmitted infections [7]. In part these behaviours may be due to a difficulty in forming meaningful relationships with peers, leading young people to seek peer acceptance through sexual promiscuity and/or antisocial behaviours.

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Driving and Traffic Violations

Symptoms of inattention and impulsiveness may lead young people with ADHD to be prone to driving errors [8]. Research looking at the driving ability of young adults with ADHD has found that they are more likely to have 'scrapes' and accidents than controls, who have better concentration and are less likely to be distracted or lose attention whilst driving.

I do get road rage. Sometimes when you're in the car its that power, the adrenaline buzz. You need something to keep you going when you're sitting there for two hours, like when I do 120 on my motorbike it just keeps me buzzing.

Research suggests that people with ADHD are significantly more likely to have a history of driving without a license as adolescents [8]. Once they gain a driving license, they are more likely to be caught speeding or committing other traffic violations leading to 'points' and license suspensions. Other more serious, illegal driving behaviours, such as drink-driving, are also found to be more common in people with ADHD [9,10].

Thus it is important that young people with ADHD are aware of the risks that their symptoms pose when driving and they put strategies in place to reduce risk when driving. Simple adjustments to the driving environment, such as asking passengers to be quiet and not distract the driver, and avoiding multi-tasking when driving (e.g. speaking on the mobile phone or changing music) can be helpful to maximise responsible driving and road safety. The DVLA list a number of conditions that they require a driver to inform them of if they are diagnosed; this does include ADHD and it is important that people with ADHD should disclose this to the DVLA.

Offending

Around 45% of youth offenders and 30% of adult male offenders have ADHD [11-13]. They are more likely to have contact with the police, younger age of first conviction, higher rates of recidivism and, if incarcerated, to be involved in a greater number of critical incidents within the institution [11,12,14]. Mood instability, a low tolerance of frustration, a need for stimulation and poor response inhibition may all be associated with offending behaviours, and the combination of these characteristics can lead to unplanned or opportunistic criminal acts of a violent or acquisitive nature.

A community study in the United States [15] found a direct relationship between ADHD symptoms for all categories of offending (see Figure 2). Those with a history of childhood ADHD had significantly greater rates of offending than community controls, but less than those with persisting symptoms. Another study however has reported that offending may be associated with both childhood and persisting ADHD symptoms [14]. Nevertheless, risk may be mediated by conduct disorder, and while ADHD presents a greater risk for aggressive behaviour within prison establishments, it appears to be the association with conduct disorder, substance use and delinquent peers that leads them to offend [16].

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ADHD is a treatable condition with both pharmacological and psychological interventions [17, 18]. However, specific interventions may need to be applied for ADHD antisocial youths that address their underlying cognitive problems in addition to their antisocial behaviours and attitudes. One such programme is the R&R2 for ADHD Youths and Adults, which has shown a large treatment effect when delivered in the community [19] and in incarcerated adults [20]. It is important that mental health and criminal justice agencies work together to ensure early identification of ADHD antisocial youths because, as for many disorders, early intervention may interrupt the antisocial pathway.

Substance Use

Smoking has been reported to be more common and to have an earlier onset among adolescents with ADHD compared with those without ADHD. In particular, those with predominantly inattentive symptoms may be at risk for later development of nicotine dependence, especially in the absence of constructive coping mechanisms [21, 22]. Although the specific nature of this relationship requires further investigation, research has highlighted an increased vulnerability in those with ADHD to smoking, and it is speculated that this may be due the additive effect of ADHD symptoms and increased novelty seeking behaviour [23].

The association between ADHD and substance abuse is complex. Impulsive behaviour may lead to an increased risk of drug-taking and excessive alcohol consumption, as well as greater use of a number of other substances (including illicit sedatives) compared to those who are not symptomatic for ADHD [24] (see Figure 3). Low self-esteem and poor self-confidence may additionally play a part, together with peer pressure and a desire to 'fit in' with those around them. The tendency of people with ADHD to seek new experiences and minimise their perception of risk may also influence their decision to experiment with illicit substances.

In my everyday activity if I'm playing X-Box or something, I'm used to smoking a joint before so I concentrate. That's kind of how my mind thinks now - smoke a joint then play X-Box, otherwise I won't concentrate.

An epidemiological study of over eleven thousand young people in Iceland reported that, after controlling for gender and school grade, poly-substance use was incrementally related to ADHD symptoms with a large effect size. This study focused on early drug use rather than substance dependence, and the findings suggest there is a specific pathway into initial substance use for young persons with ADHD symptoms, possibly as a means of self-medication, aside from unconventional attitudes and poor socialization [24].

There have been concerns that pharmacological treatment of ADHD will lead to abuse of, and addiction to, medication or other substances later on. Evidence suggests that the opposite is the case and that stimulant medication reduces substance abuse in later life by treating the problems related to ADHD [25-27].

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Key points from Module 7nd substance misuse

Box 1: Key points from Module 7 - ADHD, antisocial behaviour and substance misuse
  • ADHD and comorbid conduct disorder may be more associated with impulsive, reactive aggression rather than premeditated behaviours.
  • ADHD without comorbid conduct disorder may be more associated with social problems and rulebreaking behaviours.
  • ADHD is associated with higher rates of accidental injury and presentations to hospital Accident and Emergency.
  • A greater incidence of traffic violations has been recorded by people with ADHD, including driving without a licence, minor scrapes, accidents and drink-driving.
  • Around 45% of male youth offenders and 30% of male adult offenders in prison have ADHD symptoms. ADHD is associated with greater police contact, younger age of first conviction, higher rates of recidivism and critical incidents within prison establishments.
  • The relationship between ADHD and substance misuse is complex and some young people may abuse substances as a form of self-medication.
  • Treatment with stimulant medication has been shown to reduce substance misuse and therefore may be protective.

References

[1] Kessler, R.C., Adler, L., Barkley, R., Biederman, J., Conners, C.K., Demler, O. et al. (2006). The prevalence and correlates of adult ADHD in the United States: Results from the national comorbidity survey replication. American Journal of Psychiatry, 163(4), 716–723.

[2] Thapar, A., Harrington, R., & McGuffin, P. (2001). Examining the comorbidity of ADHD-related behaviours and conduct problems using a twin study design. British Journal of Psychiatry, 179, 224–229.

[3] Retz, W., & Rösler, M. (2009). The relation of ADHD and violent aggression: What can we learn from epidemiological and genetic studies? International Journal of Law and Psychiatry, 32(4), 235–243.

[4] Barkley, R.A. (2006). Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment (3rd ed.) New York: Guilford Press.

[5] Hoare, P., & Beattie, T. (2003). Children with ADHD and attendance at hospital. European Journal of Emergency Medicine, 10(2), 98-100.

[6] Rowe, R., Maughan, B., & Goodman, R. (2004). Childhood psychiatric disorders and unintentional injury: Findings from a national cohort study. Journal of Paediatric Psychology, 29(2), 119-130.

[7] Flory, K., Molina, B.S.G., Pelham, W.E, Gnagy, E., & Smith, B. (2006). Childhood ADHD predicts risky sexual behaviour in young adulthood. Journal of Clinical Child and Adolescent Psychology, 35(4), 571-577.

[8] Barkley, R.A., Murphy, K.R., DuPaul, G.J., & Bush, T. (2002). Driving in young adults with attention deficit hyperactivity disorder: knowledge, performance, adverse outcomes, and the role of executive functioning. Journal of the International Neuropsychological Society, 8(5), 655-672.

[9] Barkley, R.A., & Cox, D. (2007). A review of driving risks and impairments associated with attention deficit/hyperactivity disorder and the effects of stimulant medication on driving performance. Journal of Safety Research, 38(1), 113-28.

[10] Jerome, L., Segal, A., & Habinski, L. (2006). What we know about ADHD and driving risk: A literature review, meta-analysis and critique. Canadian Academy of Child and Adolescent Psychiatry, 15(3), 105-125.

[11] Young, S., Gudjonsson, G., Misch, P., Collins, P., Carter, P., Redfern, J., & Goodwin, E. (2010). Prevalence of ADHD symptoms among youth in a secure facility: the consistency and accuracy of self- and informant-report ratings. Journal of Forensic Psychiatry & Psychology, 21(2), 238-246.

[12] Young, S., Gudjonsson, G.H., Wells, J., Asherson, P., Theobald, D., Oliver, B., Scott, C., & Mooney, A. (2009). Attention deficit hyperactivity disorder and critical incidents in a Scottish prison population. Personality and Individual Differences, 46(3), 265–269.

[13] Young, S.J., Adamou, M., Bolea, B., Gudjonsson, G., Müller, U., Pitts, M., et al. (2011). The identification and management of ADHD offenders within the criminal justice system: a consensus statement from the UK Adult ADHD Network and criminal justice agencies. BMC Psychiatry, 11:32, dx.doi.org/10.1186/1471-244X-11-32

[14] Young, S., Wells, J., & Gudjonsson, G. (2011). Predictors of offending among prisoners: the role of attention-deficit hyperactivity disorder and substance use. Journal of Psychopharmacology, 25(11), 1524-32.

[15] Barkley, R.A., Murphy, K.R., & Fischer, M. (2007). ADHD in adults: What the science says. New York: The Guilford Press.

[16] Gudjonsson, G.H., Sigurdsson, J.F., Sigfusdottir, I.D., & Young, S. (in press). A national epidemiological study of offending and its relationship with ADHD symptoms and associated risk factors. Journal of Attention Disorders, http://dx.doi.org/10.1177/1087054712437584

[17] National Institute for Clinical Excellence. (2009). Attention deficit hyperactivity disorder: Diagnosis and management of ADHD in children, young people and adults. NICE clinical guideline 72. London.

[18] Young, S., & Amarasinghe, J.M. (2010). Practitioner Review: Non-pharmacological treatments for ADHD: A lifespan approach. Journal of Child Psychology and Psychiatry, 51(2), 116–133.

[19] Emilsson, B., Gudjonsson, G., Sigurdsson, J.F., Baldursson, G., Einarsson, E., Olafsdottir, H., et al. (2011). Cognitive behaviour therapy in medication-treated adults with ADHD and persistent Symptoms: A randomized controlled trial. BMC Psychiatry, 11:116, dx.doi.org/10.1186/1471-244X-11-116

[20] Young, S., Hopkin, G., Perkins, D., Farr, C., Doidge, A., & Gudjonsson, G.H. (2013). A controlled trial of a cognitive skills program for personality disordered offenders. Journal of Attention Disorders, 17(7), 598-607, dx.doi.org/10.1177/1087054711430333

[21] Rodriguez, D., Tercyak, K. P., & Audrain-McGovern, J. (2008). Effects of inattention and hyperactivity/impulsivity symptoms on development of nicotine dependence from mid adolescence to young adulthood. Journal of Pediatric Psychology, 33(6), 563-575.

[22] Young, S. (2005). Coping Strategies used by ADHD adults. Personality and Individual Differences, 38(4), 809-816.

[23] Tercyak, K. P., & Audrain-McGovern, J. (2003). Personality differences associated with smoking experimentation among adolescents with and without comorbid symptoms of ADHD. Substance Use and Misuse, 38(14), 1953-1970.

[24] Gudjonsson, G.H., Sigurdsson, J.F., Sigfusdottir, I.D., & Young, S. (2012). An epidemiological study of ADHD symptoms among young persons and the relationship with cigarette smoking, alcohol consumption, and illicit drug use. Journal of Child Psychology and Psychiatry, 53(3), 304–312.

[25] Wilens, T.E. (2003). Does the medicating ADHD increase or decrease the risk for later substance abuse? Revista Brasileira de Psiquiatria, 25(3), 127-128.

[26] Wilens, T.E., Faraone, S.V., Biederman, J., & Gunawardene, S. (2003). Does stimulant therapy of attentiondeficit/hyperactivity disorder beget later substance abuse? A meta-analytic review of the literature. Pediatrics, 111(1), 179-185.

[27] Faraone, S.V., & Upadhyaya, H.P. (2007). The effect of stimulant treatment for ADHD on later substance abuse and the potential for medication misuse, abuse, and diversion. Journal of Clinical Psychiatry, 68, e28.

Further Reading and Useful Resources

Gudjonsson, G.H., & Young, S. (2011). Predictors of Offending and Critical Incidents among Prisoners. European Psychiatric Review, 4(1), 15-17.

Harpin, V., & Young, S. (2012). The Challenge of ADHD and Youth Offending. Focus Issue: The Management of ADHD in Children, Young People and Adults. Cutting Edge Psychiatry in Practice, 2, 138-143.

Young, S.J., & Ross, R.R. (2007). R&R2 for ADHD Youths and Adults: A Prosocial Competence Training Program. Ottawa: Cognitive Centre of Canada, www.cognitivecentre.ca/rr2adhd

Young, S., & Goodwin, E. (2010). Attention-deficit/hyperactivity disorder in persistent criminal offenders: the need for specialist treatment programs. Expert Review of Neurotherapeutics, 10(10), 1497-1500.

Young, S., & Thome, J. (2011). ADHD and offenders. SWBP World Journal of Biological Psychiatry 12(S1): 126–130

Young, S. (2013). The ‘RAPID’ cognitive behavioral therapy program for inattentive children: preliminary findings. Journal of Attention Disorders, 17(6), 519-526.

Young, S., Fitzgerald, M., & Postma, M.J. (2013). ADHD: making the invisible visible An Expert White Paper on attention-deficit hyperactivity disorder (ADHD): policy solutions to address the societal impact, costs and long term outcomes, in support of affected individuals, www.europeanbraincouncil.org/pdfs/ADHD%20White%20Paper_15Apr13.pdf

Behaviour Disorders and ADHD: www.helpforadd.com/co-occurring-disorders/

Youth Crime Action Plan: ADHD and its links to antisocial behaviour: www.addiss.co.uk/YouthCrime30.pdf

ADHD and Substance Misuse: www.adhdandsubstanceabuse.org/adhd-and-substance-abuse