ADHD for the Legal Profession
Dr GD Kewley and Mrs PA Latham
Attention-Deficit / Hyperactivity Disorder (ADHD) is a neuropsychiatric disorder relevant to the legal profession. It is due to brain dysfunction and can cause a number of potentially serious handicaps and is a major Public health problem. Some subgroups of people with ADHD are at increased risk of criminality, substance abuse, accidents, motor vehicle accidents, suicide, educational, behavioural and other psychiatric difficulties. It has a very significant financial cost to society. As awareness of the facts and reality of the condition rapidly develops, legal practitioners are increasingly being confronted with its implications.
© adders.org 2004
The probable basis of ADHD is difficulty with rule governed behaviour and lack of behavioural inhibition. Those with associated early onset Conduct Disorder (CD), are at much greater risk of persistent criminal activity and substance abuse. Studies suggest that a significant number - possibly 30 per cent of those convicted of serious and recurrent offences - may have untreated ADHD and Conduct Disorder. Such people may therefore comprise a significant percentage of the total prison population, particularly in young offender institutions.
o Internationally recognized
o Variable in presentation
o Biological, and genetic
o More common than generally realized
o Predisposes those with the disorder to educational, psychiatric and social problems.
ADHD is a common but complex medical condition, affecting children and adults, characterized by excessive inattentiveness, impulsiveness, and/or hyperactivity' that significantly interferes with everyday life, and for which there is no other reason. The condition manifests itself in many ways - some children may he only inattentive, others may ~he persistently hyperactive, for some, hyperactivity may lessen with persistently hyperactive, The wide range of possible presentations can be confusing. There are also Many complications that may mask or overshadow the underlying core symptoms and worsen with time.
Research shows that ADHD is a genetic, inherited condition that can he effectively managed. Evidence of brain dysfunction has been found in cerebral imaging studies.! If untreated the disorder can significantly interfere with educational and social development and predispose to psychiatric and other difficulties.
Psychoanalytical approaches support a societal belief that poor parental discipline causes most children's behaviour problems. Such approaches generally ignore a biological basis to difficulties in self control, concentration, and hyperactivity that is present in some individuals. Widespread ignorance exists about attention deficit hyperactivity disorder and the need for, and aim of, medication as a component of treatment.-, Trite and simplistic explanations for the symptoms of the disorder are perpetuated which encourage the view that merely naughty children are being diagnosed to absolve parental responsibility.
British child-care professionals have traditionally used the more restrictive World Health Organization' International Classification of Diseases (ICD 10) term "hyperkinesis", which means severe, persistent hyperactivity. Many people wrongly believe that Attention Deficit Hyperactivity Disorder is the less severe form of hyperkinesis. In fact, hyperactivity is just one possible feature of the disorder and often the least of the child's problems'.
Core ADHD Symptoms
o and/or impulsiveness
o and/or hyperactivity
o Hyperactivity only
o Impulsive/diminished hyperactivity
o Predominantly inattentive ADHD
o ADHD core symptoms masked by comorbidity
ADHD is very variable in its presentation. It is important to understand that ADHD is often found together with a number of other conditions, the symptoms of which often overlap.11 If a child has ADHD he or she is more likely to have other co-existing or complicating conditions, such as excessive oppositionality and conduct disorder, anxiety and depression, learning difficulties, obsessions, co-ordination and speech and language difficulties. At least 60-70 per cent of those diagnosed with ADHD also have one or more co-existing conditions, and the later the diagnosis, the more likely these are to occur. Many children, who have been suspended or expelled, or are in schools for children with emotional and behavioural difficulties, have ADHD with many co-existing problems.
These conditions frequently mask or camouflage the underlying ADHD and can make recognition and accurate diagnosis more difficult. There has been increasing acknowledgement of the concept of co morbidity - or co-existence of conditions and its treatment - over the past 7-10 years.
Common Co-existing Conditions and Complications of Attention Deficit Hyperactivity Disorder
o Oppositional defiant disorder (ODD)
o Conduct Disorder o Depression
o Anxiety and obsessions
o Specific learning difficulties
o Speech and language disorder
o Bipolar disorder
o Co-ordination difficulties
o Substance abuse
o Asperger's syndrome
o Tics and/or Tourette's Syndrome
o Sleep difficulties
Common Additional Problems of ADHD
People with ADHD commonly exhibit a number of additional problems, which are largely secondary and may get worse if the ADHD is not treated.
o Poor self-esteem
o Poor social skills
o Variation in symptoms from day to day
o Excessive dogmatism
o Poor organization and management of time
o Relationship difficulties Lack of motivation
o Problems with rule-governed behaviour
o Vulnerability to stress
o Auditory short-term memory problems
o Physical symptoms relationships. Yet again, others have under-achieved academically, have low self-esteem and poor social skills, and may be anxious, depressed or obsessive.
An experienced, comprehensive specialist assessment is required as the symptoms can vary so much between individuals and because ADHD is so easily confused with many other conditions, which must be excluded.
Management of ADHD
Medication is the option considered to have most benefit in treating the core symptoms of ADHD, ie, inattentiveness, impulsivity and/or hyperactivity as part of the comprehensive management. It frequently has a flaw-on effect to many of the other problems. Individuals with significant ADHD should be seriously considered for medical treatment. Medication should be seen as providing a "window of opportunity" that normalizes brain function and stabilizes the situation and allows other strategies to be more effective, making the sufferer less vulnerable to the stresses of the environment. The two medications that are available in the UK to treat ADHD core symptoms are meth- ylphenidate (Ritalin) lO mg and dexamphetamine (Dexedrine) 5mg. Studies show that approximately 90 per cent of children with ADHD will show a very significant improvement on medication. However, there will still be on-going difficulties in about 40 per cent, usually because of the co-existing conditions. Once the core ADHD symptoms are managed, the other problems can often be dealt with more effectively.
The management of a teenager with ADHD is a particular challenge to the professional. Often more than one medication is necessary, to treat some of the difficult complications. It must be appreciated that there are likely to be setbacks and difficulties in management that require fine tuning, patience and understanding.
One of the myths of ADHD is that it is outgrown by puberty and/or is not present by late teens. In reality, by teenage years, as ADHD is progressive, it is often much worse and compounded and masked by the other difficulties. Hyperactivity has often diminished, but there are often other problems. It is often essential to treat teenagers and also adults.
Possible Masked Presentations of ADHD
o School underachievement and/or behavioural difficulty
o Special schooling, especially EBD (emotional and behavioural difficulties) or dyslexic school
o Gifted children with self-esteem problems
o Children involved with Portage who also have poor concentration
o Early onset Oppositional Defiant Disorder/Conduct Disorder
o Those with predominantly inattentive problems Teenage suicide/attempted suicide
o Those with Asperger's Syndrome
o Early onset substance abuse
o Infants with persistent crying/sleeping difficulties.
In 1996, despite the fact that up to one per cent of UK schoolchildren had severe hyperaaivity,8 only one in 30 of such children were on medication.' Medication usage must be seen in context of the incidence of the condition. There is therefore very significant under-treatment of this medical condition in the UK.
It is therefore vital that the legal profession has factual knowledge of ADHD. A great deal is already known about ADHD, research is increasing and the current under recognition in the UK means that large numbers of children with problems are overlooked. In children with severe complications, especially those with early onset Oppositional Defiant Disorder and Conduct Disorder, the underlying ADHD may he concealed and thus confuse or delay active treatment.
Those children tend to progress into lifelong criminal activity and antisocial personality disorder, comprising a large proportion of the criminal psychopaths. Those with persistent problems are strongly linked with the 5-10 per cent of offenders who commit 70 per cent of all homicides, rapes and serious assaults. The antisocial activity can range from premeditated acts of aggression through to impulsive actions. The theory that ADHD is a disorder of behavioural inhibition and impulse control with the associated difficulties in self-regulation, in rule-governed behaviour and development of a code of moral conduct is very relevant. Often, short-term memory difficulties mean that the offenders cannot remember what they have done in moments of extreme impulsivity. Being male is by far the strongest factor predisposing to crime. Many criminals are more vulnerable because they have brains that are dysfunctional, especially with regard to problems with impulse control.
The criminal justice, legal, police system and society in general, at the moment, appear to have a low awareness that there may be a genetic or biological basis to some criminal activity. h may well be worth screening prisoners for ADHD, especially those in young offenders' institutions, and as part of their sentence including the institution of effective treatment. It would seem more advantageous to these children and their relatives to identify them at an earlier age, when they are still at school, possibly in the care system, when treatment is more likely to be effective. ADHD may at times justify the consideration of mitigating circumstances; it is a biological explanation for some behaviour or actions, rather than an excuse.
There is a large and well-documented world literature on biological predisposition to crime, and the role of awareness of this in crime prevention. It is important that those involved in crime prevention fully understand the implications of this. Without such understanding, the basic notion that only environmental and social factors cause crime is perpetuated. The causes of crime are multi-factorial, but societal, environmental, economic and cultural factors alone do not yet give the total explanation for crime. Failure to take a wider view enables the high rate of chronic offending to continue and is cost-ineffective. The cast to Britain of juvenile crime is said to be £7 billion per year.
A long-term study from New Zealand has shown that the strongest risk factor for family and adult partner violence was childhood conduct problems and this has been virtually ignored in research and scarcely mentioned in the literature. Adult partners violent towards each other are also at increased risk of abusing their children. Studies suggest that the risk of child abuse is between three to nine times greater in homes where adult partners hit each other. Conduct Disorder also predicts many other undesirable outcomes, including teenage pregnancy (30 per cent of girls with Conduct Disorder) and the fact that 50 per cent of sufferers become involved in a violent intimate relationship.
Understanding the factual reality, and the suffering caused by ADHD and its importance as a public health issue for children and adults is vital, so that rational decisions can he made on the most appropriate provision of help.
Case History - Sam "Sam is now 18. From an early age he was hyperactive, impulsive, noisy and had poor concentration. His life was punctuated by numerous accidents as he had no awareness of danger or of cause and effect and never seemed to learn from his experiences - he broke nearly every bone in his hands during his skate-boarding obsession. Intelligent and quick-witted, Sam is a kind and caring lad with a well developed - if not somewhat excessive - sense of fun. He is an able sportsman and a creative and competent musician. Sam gained a reputation as the class clown and a loveable rogue but his IQ enabled him to achieve well in the more structured environment of junior school.
His work deteriorated in the larger classes in secondary school. His increasing disorganization led to failed homework and assignment deadlines. His self esteem decreased, he became depressed and was rude to teachers, being suspended on two occasions. Repeated detentions meant that his parents were regularly contacted because of his misdemeanours and underachievement. No amount of effort had been spared to give Sam and his older brother a caring and positive upbringing with good moral values. However, being easily led, Sam gravitated towards bad company and had repeated brushes with the law for physical impulsiveness. He began truanting. Friends persuaded him to make a bomb hoax call to his school which was captured on video. Fortunately, his head teacher saw beyond the moment, recognized his potential and prevented the matter being taken further by the authorities.
Unbeknown to his family, Sam had been introduced to drugs at the age of 13 and began to smoke cannabis regularly and steal from his mother to fund this and smoking cigarettes. Needing constant stimulation, entertainment and little sleep, as well as being fidgety and restless meant Sam was always out with friends, sometimes vandalising - often until well into the early hours.
Sam's intelligence, with little effort, gained good GCSE results. He went onto sixth form college. However, the lack of structure and intervals between lectures compounded his growing difficulties. During a free period, Sam was arrested in the local park for possession of a quantity of cannabis with suspected intent to deal - at the age of only 17. He was ' cautioned. This crisis resulted in referral for help which his mother had been abortively seeking for several years - her single parent-status having been blamed for his problems. He was belatedly diagnosed as having severe ADHD with oppositionality and associated substance abuse - a frequent complication of late-diagnosed ADHD - depression and low self-esteem.
Sadly, because of late diagnosis and the very nature of untreated ADHD, Sam could not co-operate with recommended medical and other management of his problems. Police cautioned him but he continued to gravitate downwards personally and socially. Although expected to achieve well in `A' levels, his poor attendance, concentration and other problems, resulted in expulsion just before the exams. Nine months later, Sam's continuing and untreated difficulties led to another arrest. In court his ADHD, good upbringing/environment and academic potential was cited, resulting in a conditional discharge and fine with a warning to stay away from drugs and bad company or face a severe penalty. ' Sam's untreated ADHD prevents him from halting his behaviour or concentrating long enough to consider the gravity of his situation, despite having an obvious high intelligence - or to motivate himself to get a job to pay the fine or support himself. Untreated, he will undoubtedly reoffend and be seen by society as someone who deserves his fate rather than as a victim of a medical condition, needing understanding and support - not punishment. Had Sam's problems been recognized and treated earlier, many of his difficulties could have been prevented. Until such time as he is able to recognize the need for help, his progressive ADHD is increasingly likely to have serious consequences.