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Originally published in: Susan Young , Gisli Gudjonsson , Sarah Ball & Jenny Lam (2003) Attention Deficit Hyperactivity Disorder (ADHD) in personality disordered offenders nd the association with disruptive behavioural problems, The Journal of Forensic Psychiatry & Psychology, 14:3, 491-505, DOI: 10.1080/14789940310001615461

Attention Deficit Hyperactivity Disorder (ADHD) in personality disordered offenders and the association with disruptive behavioural problems a

a

b

Susan Young , Gisli Gudjonsson , Sarah Ball & Jenny Lam

c

a

Department of Psychology , Institute of Psychiatry , De CrespignyPark, London, SE5 8AF, UK

b

Department of Psychology , St Andrew's Group of Hospitals , UK

c

Department of Clinical Psychology , University of Surrey , UK

Attention Deficit Hyperactivity Disorder (ADHD) in personality disordered offenders and the association with disruptive behavioural problems SUSAN YOUNG, GISLI GUDJONSSON, SARAH BALL, AND JENNY LAM,

ABSTRACT In this study the authors aim to establish the proportion of personality disordered patients that meet screening criteria for adult ADHD, and examine whether they are more disruptive and present with greater behavioural problems in hospital compared with a Non-ADHD Symptomatic personality disordered group. ADHD symptomology was assessed using two screening measures: (1) the Wender-Utah Rating Scale (WURS) measuring childhood symptoms, and (2) the DSM-IV Checklist of Symptoms measuring symptoms in adulthood. Behavioural problems were examined by a specially designed questionnaire administered to the participants’ primary nurse and critical incidents recorded in participants’ medical records. The participants were 69 males who were legally detained in hospital with a primary diagnosis of personality disorder. Fifty-four (78%) participants obtained scores consistent with a diagnosis of ADHD in childhood, but only three (6%) of them were likely to meet DSM-IV criteria for adult ADHD. Twenty (29%) of adults were classified in partial remission. The ADHD and the partial

remission groups were compared with the non-ADHD and in remission groups. The symptomatic group had a significantly greater number of critical incidents of aggression than the non-symptomatic group recorded in their medical files, but there was no significant difference of staff perception of disruptive behaviour and social problems. The clinical implications of the findings are discussed in terms of how treatment for their ADHD symptoms may have a positive impact on the behavioural problems presented by this population and their long-term outcome. Keywords: ADHD, personality disorder, violent incidents, behavioural pro-blems

INTRODUCTION The importance of the proper identification of Attention Deficit Hyper-activity Disorder (ADHD) is now recognized in mental health settings, but in forensic psychiatry there is a failure to diagnose and treat people with ADHD (Collins and White, 2002). In view of the well-documented relationship between ADHD symptomology and antisocial behaviour (Mannuzza, Klein, Konig and Giampino, 1989), it is remarkable that there has been such a dearth of studies in forensic settings. In this paper the authors screen for the frequency of ADHD symptoms in an adult forensic population, comprised of patients with a primary diagnosis of personality disorder, and examine the relationship between their ADHD symptoms and behavioural problems in their environment. Antisocial behaviour has been consistently reported in studies of adults and children with ADHD, ranging between 25% and 60% (Barkley, Fischer, Edelbrock and Smallish, 1990; Hechtman, 1985; Weiss, Minde, Werry, Douglas and Nemeth, 1971; Young, 2000; Young et al., 2003). Court records suggest that ADHD youths are four to five times more likely to be arrested and to have multiple arrests and convictions (Hechtman and Weiss, 1986; Lambert, 1988; Mannuzza, Klein, Konig and Giampino, 1989; Satterfield, Hoppe and Schell, 1982; Satterfield, Swanson, Schell and Lee, 1994). The association between adult ADHD, antisocial and criminal behaviour may well be explained by poor response inhibition in ADHD individuals (Rubia et al., 1999; 2000) and the offending behaviour of individuals with ADHD may be typified by impetuous, novelty seeking behaviour which leads to opportunistic crimes for which they are apprehended. Antisocial personality disorder has been reported to be up to ten times more likely to be present in ADHD adults (Biederman et al., 1993; Loney, Whaley-Klahn, Kosier & Conboy, 1983; Mannuzza, Klein, Bessler, Malloy and LaPadula, 1993; Young et al., 2003) and a strong correlation is reported between hyperactivity ratings and personality disorder in an offending population (Dalteg, Lindgren and Levander, 1999). Comorbid Personality

Disorder has been reported to range between 13% and 45% (Cantwell, 1972; Downey, Stelson, Pomerleau and Giordani, 1997; Guze, 1976; Satterfield, 1978; Weiss and Hechtman 1986; Wender, 1971; Wender and Klein, 1981; Young et al., 2003). Rey, Morris,-Yates, Singh, Andrews and Stewart (1995) interviewed 145 young men with Personality Disorder (mean 20 years) who had received DSM-III diagnoses for emotional and disruptive disorders in adolescence. They found 36% of the personality disordered sample had been diagnosed with ADHD and 50% had been diagnosed with ADHD and comorbid conduct disorder in adolescence.

Prison studies from the USA, Sweden, Canada and Norway suggest that between 22 – 67% of inmates had childhood ADHD and up to 30% of them continue to be symptomatic in adulthood (Eyestone and Howell, 1994; Dalteg et al, 1999; Rasmussen, Almic and Levander, 2001; Vitelli, 1995). These studies have all applied the Wender-Utah Rating Scale to classify participants, and only one study additionally applied a measure of adult symptoms (Rasmussen et al., 2001). Unfortunately although psychometrically sound, the measures used do not specifically correspond with the Diagnostic Statistical Manual IV [DSM-IV] (APA, 1994) classification of symptoms. It is unknown how many legally detained offenders with a primary diagnosis of personality disorder may have comorbid ADHD. The behaviour of such individuals is likely to be disruptive, provocative and challenging and there may be significant management problems for staff. They may have difficulty engaging in therapeutic programmes and/or lack motivation to do so. Indeed, ADHD patients in these settings may disrupt others who want to utilise those services and possibly incite restlessness and dissatisfaction in other patients (Young and Harty, 2001). Their ADHD may be unrecognised due to comorbid problems of personality, mood, anxiety and/or substance misuse and they may be considered to be ‘untreatable’. Stimulant medication has been shown to be efficacious in the treatment of ADHD adults (Mattes, Boswell and Oliver, 1984; Overmeyer and Taylor, 1999; Spencer, Wilens, Biederman, Faraone, Ablon and Lapey, 1995; Wender, Reimherr, Wood,and Word, 1985; Wender, Reimherr and Wood, 1981; Wood, Reimherr, Wender and Johnson, 1976; Young and Harty, 2001) and an improvement in underlying symptoms may result in individuals being better disposed to engage in psychological treatment and address their problems psycholo-gically. The study aimed to determine the proportion of personality disordered offenders detained in secure services meeting screening criteria for ADHD and continue to be symptomatic. It was hypothesised that symptomatic ADHD personality disordered offenders would be more disruptive and represent a greater management problem in this setting compared with non-

symptomatic ADHD personality disordered offenders. Specific hypotheses were as follows:(a) (b)

(c)

(d)

based on previous estimates, up to 25% of Personality Disordered offenders would meet criteria for ADHD in adulthood; the ADHD symptomatic group would obtain significantly higher ratings on a measure of disruptive behaviour completed by the participant’s primary nurse; there would be no significant differences between groups on a measure of social and psychological problems, completed by the participants’ primary nurse; the ADHD group would have a significantly greater number of aggressive critical incidents recorded in their medical records.

METHOD Participants The sample consisted of 69 offenders aged between 18 and 60 years (mean = 34 years, SD = 9.91). All participants were legally detained under the Mental Health Act in medium and maximum secure services with a primary diagnosis of personality disorder. Exclusion criteria included individuals who were mentally too unwell to participate; a history of learning disability, comorbid schizophrenia or bipolar disorder. Measures Wender-Utah Rating Scale (WURS): A 25-item retrospective self-report questionnaire consisting of statements relating to childhood symptoms of ADHD. Each item is scored on a five point rating scale of frequency of symptoms (ranging from 0 = ‘not at all’ to 4 = ‘very much’). The maximum total score on the WURS is 100. A score of 46 correctly classified 86% of participants with ADHD and 99% of ‘normal’ participants (Ward, Wender and Reimherr, 1993).

DSM-IV Checklist of Symptoms (DCS): An 18-item self-report questionnaire which consists of statements relating to symptoms of ADHD and directly corresponding with DSM-IV criteria (A.P.A., 1994). Nine items relate to problems with inattention and nine items relate to problems with hyperactivity/impulsiveness. Each item is

scored on a 3-point rating scale of frequency of symptoms in the last 6 months (0 = never, 1 = sometimes, 2 = often). For the study ADHD criteria was classified as follows:ADHD/Combined Type indicated by a score >= 46 on the WURS and a score of six or more inattentive items (rated as ‘often’) and six or more hyperactive/impulsive items (rated as ‘often’) on the DCS. ADHD/Predominantly Inattentive Type indicated by a score >= 46 on the WURS and a score of six or more inattentive items (rated as ‘often’) on the DCS. ADHD/Predominantly Impulsive/Hyperactive Type indicated by a score >= 46 on the WURS and a score of six or more hyperactivity/ impulsiveness items (rated as ‘often’) on the DCS. ADHD/In Partial Remission indicated by a score >= 46 on the WURS and a total score of 17 or more on the DCS [derived from the aggregation of numerical values 0, 1 and 2]. A score of 17 represents one standard deviation above the mean score obtained by a normal population (Young, 1999). ADHD/In Remission indicated by a score of >= 46 on the WURS and a total score of 16 or less on the DCS.

Disruptive Behaviour and Social Problem Scale (DBSP) Evidence of disruptive behaviour and social problems over the previous 3 months was determined using the DBSP Scale completed by the participants’ primary nurse (see Table 1 for the nature of the items). The questionnaire was specially designed for the present study and consists of 14 statements relating to the patient’s behaviour and social interactions. The responses for each item are scored on a 7-point rating scale of agreement (ranging from 1 = ‘Not at All’ to 7 = ‘Very Much So’). Scoring is reversed for items 9 to 14 and a higher score is indicative of a greater degree of problems on all three scales. Factor analysis of the DBSP revealed three factors with eigenvalues greater than 1, but two factors were rotated according to a Scree-test (Klein, 1994) using Varimax procedure. This appeared to give a meaningful and conceptually interpretable model. The loadings on these two factors, which accounted for 63% of the variance, and their means and standard deviations are shown in Table 1. Two factors were created as follows:(a)

Disruptive Behaviour Scale: eight items loaded on this factor relating to disruptive behavioural problems (mean 25.61, SD 11.78). Internal consistency of this scale estimated by Cronbach’s alpha was 0.92.

Table 1 Factor loadings (Varimax rotation) on the DBSP on the two Factors* Factor 1 Disruptive Behaviour

No

Questions

1 2

Is the patient difficult to manage on the ward? Does the patient often seek attention from staff? Is the patient’s behaviour often disruptive on the ward? Does the patient often demand attention from other patients? Is the patient often verbally aggressive? Is the patient often physically aggressive? Is the patient often provocative? Does the patient often act impulsively? Does the patient show good insight into his/ her behaviour? Do you find it easy to establish good rapport with this patient? Does the patient show feelings of guilt after wrongdoings? Is it easy for him/her to establish good rapport with other patients? Does the patient get on well with staff? Does the patient get on well with other patients?

3 4 5 6 7 8 9 10 11 12 13 14

(b)

Factor 2 Social Interaction

0.82 0.83

0.23 -0.04

0.88

0.09

0.87

0.08

0.84 0.48 0.79 0.79 0.31

0.14 0.28 0.15 0.01 0.55

0.02

0.70

0.14

0.71

-0.12

0.83

0.26 0.07

0.85 0.80

Social Problem Scale: six items loaded on this factor relating to social interaction (mean 23.43, SD 6.96). Internal consistency of this scale estimated by Cronbach’s alpha was 0.84. Critical Incidents

Behavioural problems were measured by the number of critical incidents recorded during the previous 3 months in the participant’s medical notes. Incidents of physical aggression, verbal aggression, damage to property, selfinjurious behaviour and arson were recorded and allocated a score (regardless of type of incident) of 1 point per incident, the sum total representing the Critical Incident Total Score. As an additional measure, severity of physically aggressive behaviour was rated by applying the following point system:-

0 No threat or physical violence 1 A threat of physical violence without violence being inflicted 2 Violence is inflicted but no injury is detectable on examination by a doctor and there is no significant pain 3 Significant pain, bruising or laceration 4 Any assault producing an injury that requires further hospital investiga-tion (e.g. X-ray, staff being sent off duty). Procedure Responsible medical officers at six locations of medium and maximum were asked to refer patients with a primary diagnosis of personality disorder who did not meet exclusion criteria. These individuals were provided with an information sheet and discussed their participation with a member of staff. It was emphasized that their treatment would not be affected in any way if they chose not to participate in the study and that information would not be made available to staff on a named basis. The participants were then visited by a researcher who administered the questionnaires. Participants were required to provide written consent for their primary nurse to complete a questionnaire relating to their behaviour on the unit (i.e. the DBSP scale). Following this, participants completed the WURS and DCS. Poor readers were given assistance but this did not include interpretation of test items or advice on how to answer questions.

RESULTS Seventy-eight per cent of participants (n = 54) obtained a score of 46 or over on the WURS consistent with a diagnosis of childhood ADHD. Of this group, three participants (6%) met ADHD criteria in adulthood (2 ADHD/ Combined Type; 1 ADHD/ Predominantly Inattentive); 20 participants satisfied criteria for ADHD in Partial Remission in adulthood (29%); 31 participants were classified as ‘ADHD in Remission’ (45%). Fifteen participants were classified as a ‘NonADHD’ group as they did not meet ADHD criteria (22%). The 20 patients meeting criteria for Partial Remission and the three who met the ADHD criteria for adult ADHD were combined into an ADHD Group and compared with the 46 patients who were non-ADHD Symptomatic. The difference in the mean age (33.9 and 33.1, respectively) for the two groups was not significant (t = 0.12). Table 2 gives the mean scores on the DBSP and Critical Incidents between the Non-ADHD Symptomatic and ADHD Groups. Independent

Table 2 Comparison between the ADHD group and non-ADHD symptomatic group on outcome measures

DBSP DBSP (total score) DBSP (disruptive behaviour sub-scale) DBSP (social and psychological sub-scale) Critical Incidents Mean overall incident score Verbal aggression Physical aggression Damage to property Arson Self-injury Severity of aggressive behaviour

Non-ADHD symptomatic group n = 46 mean (SD)

ADHD group n = 23 mean (SD)

t

48.17 (14.59) 24.37 (10.58)

50.70 (16.44) 28.22 (13.77)

0.65 1.18

23.79 (7.01)

22.48 (7.08)

0.73

2.74 (4.58) 2.11(3.69) 0.24 (0.60) 0.09 (0.28) 0.02 (0.15) 0.26 (0.85) 0.43 (1.07)

5.26 (5.55) 3.87 (4.05) 0.43 (0.84) 0.52 (1.12) – 0.30 (0.93) 0.65 (1.33)

2.00* 1.81* 0.99 1.83* 0.70 0.19 0.73

* p

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