1. ADHD and Youth Justice Professor Gisli Gudjonsson King’s College London, and Broadmoor Hospital.

2. Aims: Discuss the role of ADHD within the criminal justice system. Highlight the costs involved. Suggest ways of reducing costs of people with ADHD within the criminal justice system.

3. Where the cost incurs: 1.Offending (e.g. cost to victims and suffering). 2.Police investigation. 3.Prosecution/Court/Law Costs. 4.Secure Units. 5.Prison. 6.Probation/offender management team.

4. National Audit Office Review (June 2011): The cost of a cohort of young offenders (10-17) to the criminal justice system. 83,000 young offenders who committed their first (proven) offence in 2000 in England and Wales. Offending history analysed for period 2000-2009. 84% perceived as white and were 74% male. Main offences theft (37%), summary offences (29%), and violence (9%). The majority received a community penalty (43%) or conditional discharge (32%). 4% received a custodial sentence. 64% reoffended.

5. Unit cost for proven offending (Under 18): 1.Police per recorded crime = £ 494 2.Court (range £400 to £6,837) = £ 2,318 3.OM team (per year) = £ 1,469 4.Custody (per month) = £ 4,898

6. Total cost (Under 18): On average each young offender costs £ 8,000 per year.

7. Cost: Annual cost of each prisoner (>£40,000). Annual cost of secure unit placement (about £500 per day - £182,000 per year). Low secure (£152,00; medium £175,00; high secure £ 278,000).

8. Cost of treatment non-completion (Sampson et. al. 2013 -CBMH): Investigated the differential cost between those who completed treatment programmes and those who did not. Data collected from medium secure unit for personality disorders. In the first 10 years following admission, those who did not complete treatment incurred £52.000 more costs to the NHS and Criminal Justice System than those who completed treatment.

9. ADHD and Offending Court records: Youths 4–5 times more likely to get arrested Multiple arrests and convictions Meta-analysis of international prison studies 30% youths – 5-fold increase 26% adults – 10-fold increase 26% males: 18% females Little treatment reported Young et al. BMC Psychiatry. 2011;11:174.

10. ADHD symptoms Lewisham Police Station (N = 200): Childhood = 32.1% Current = 23.5% Interview rate = 18.5% Appropriate adult = 4.2% Probation Service (N = 108): Childhood rate = 45.5% Current = 20.5% Young et al. 2013, BMC Medicine, AIMS Public Health, in press.

11. Pre-Court Offence Police can re-bail in between Charged to attend court Court Dealt with differently depending on type of offence:  Indictable: Dealt with in crown court only  Either way: Can be dealt with in crown or magistrates court  Summary only: only dealt with in magistrates court  If non-imprisonable cannot be given community sentence Dealt with differently depending on type of offence:  Indictable: Dealt with in crown court only  Either way: Can be dealt with in crown or magistrates court  Summary only: only dealt with in magistrates court  If non-imprisonable cannot be given community sentence Attends court – may be adjourned for a variety of reasons Plea Guilty – move to sentence Not guilty – move to trial. If found guilty – move to sentence Arrest Post-Court – Sentencing Fine / Conditional discharge / Absolute discharge PLUS Ancillary orders (costs, driving disqualifications, compensation) Fine / Conditional discharge / Absolute discharge PLUS Ancillary orders (costs, driving disqualifications, compensation) Community orders (with requirements, e.g. supervision, unpaid work, mental health treatment – choice of 12 requirements) Note – A custodial sentence can be suspended with any of the same community requirements as are available for a community order. This will be supervised by the Probation Service No intervention from statutory agencies Probation intervention Imprisonment The Offender Pathway They all start here Young et al. BMC Psychiatry. 2011;11:174.

12. Vulnerability Cognitive deficits: they get caught! Opportunistic crime; high rates of recidivism. Coping with the process of the Criminal Justice System (police interview, court attendance) When incarcerated, undiagnosed and untreated individuals may be a management problem due to behaviour problems. See ADHD chapter in Young, Kopelman & Gudjonsson (2009), Forensic Neuropsychology in Practice, Oxford University Press

13. Interrogative Suggestibility Significantly impaired immediate and delayed verbal memory No difference in suggestibility scores Strategy of ‘don’t know’ – even for recognition items 1 Current symptoms of ADHD associated with compliance and false confession s 2 1 Gudjonsson et al. (2007). PAID. 2 Gudjonsson et al. (2008). Psych. Med.

14. Vulnerability in Court Need to pay attention, listen and understand evidence Anxiety exacerbates cognitive deficits Medication Special provisions for individuals who are unmedicated or have active symptoms

15. False Confessions Prison study 1 : among 90 prisoners, 22 (24%) reported a false confession. Among the ADHD symptomatic group 41% reported a false confession in contrast to 18% of the non-symptomatic group. Community study 2 (n = 11,388) – 20% reported having been interrogated and of those 12.4% reported a false confession. After controlling for gender, age and emotional lability both ADHD symptoms and history of negative life events predicted false confession above and beyond conduct disorder. 1 Gudjonsson et al. (2008). Psych. Med. 2 Gudjonsson et al. (2012). PAID.

16. “R v AR [2010] EWCA Crim 2664 successful murder appeal involving expert evidence on the reliability of voluntary confessions and the impact of childhood ADHD” – James Wood QC. On 5th November 2008 Mr R was convicted of murder. The case remained unsolved until Mr R wrote letters to his mother in law and wife in 2006 whilst on remand for allegations of child abuse against his own children. These were voluntary confessions that were produced during an acrimonious relationship Mr R was having at the time with his wife and mother in law. In evidence [at trial in 2008] the appellant denied that the confessions were true. He gave evidence consistently with that he had said throughout the investigations.

17. Letter from R to his partner: “……I did not realise what a violent monster I was…. Because of the serious charges to which I’m guilty of them all. Please use this admission to help your case against me and hand this letter to the police as no doubt you will…. Also I have to confess to killing Daryl Coles it was in one of my violent rages and he was just in the wrong place at wrong time and shouldn’t of been cheeky to me when he pissed on my garden…”

18. The case of AR: Mr R was extensively tested pre-trial but the expert psychological report was not used, because it involved a ‘risk assessment’ that was not favourable to the defence and a failure to properly translate the psychometric and clinical evaluation. Mr R was further assessed after his conviction by Dr Susan Young and Professor Gisli Gudjonsson, which laid the grounds for an appeal and resulted in Mr R’s conviction being quashed. Dr Young concluded that Mr R probably had childhood ADHD and was in partial remission of symptoms at the time of writing the incriminating letters in 2006. His ADHD symptoms had not been properly assessed during the pre-trial assessment.

19. The case of AR: Relying on parts of the original pre-trial findings assessment (e.g. emotionally unstable/borderline personality disorder), Dr Young’s ADHD assessment, and his own clinical evaluation, Professor Gudjonsson produced in Court a model of how Mr R’ psychopathology had impacted on his capacity to cope with pressures in prison and led to voluntary confessions which were unreliable. The Crown argued that the findings of Young and Gudjonsson were not new evidence and should not be admitted into evidence. Gudjonsson argued successfully that the new evidence was a proper translation of the pre-trial psychological evaluation and the incremental value of Dr Young’s ADHD assessment and the residual functional impairments (i.e. interpersonal difficulties, inadequate coping with stress).

20. The expert evidence (from the judgment): “Dr Young gave evidence to the effect that the appellant suffered from ADHD in his youth and that there was evidence of continuing symptoms. Professor Gudjonsson gave evidence to the effect that persons with ADHD are prone to make unreliable confessions and that these confessions were, for these reasons, unreliable. Mr Burrows accepted that this evidence was fresh evidence capable of belief”.

21. Outcome of pending trial (8 th March 2011): Expert for the Crown could not find any basis for declaring that Young and Gudjonsson were wrong in their opinions as presented at the appeal in November 2010. New pathology evidence made a hammer a very unlikely weapon. A reconstruction at the house showed that Mr R was very likely to have been able to see a body at the bottom of the garden from his window. As a consequence of the above, the Crown offered no evidence, and a verdict of not guilty was entered.

22. The importance of comorbidity (Beauchaine et al. 2010): Developmental pathway: (a) Hyperactivity/impulsivity early toddlerhood, (b) oppositional defiant disorder in preschool; (c) early onset conduct disorder (CD) in primary school; (d) Substance misuse (SUDs) in adolescence; and (d) antisocial personality disorder in adulthood. Impulsivity is predisposing vulnerability to both ADHD and CD. Environmental factors play an important role in how impulsivity is expressed and whether young children with ADHD develop conduct disorder and substance misuse. Protective environment: Calm but firm limit setting, avoid power struggle, de-escalation of arousal, clear consequences for aggression. Early diagnosis and behavioural intervention (e.g. parent, child and teacher training; RAPID) is extremely desirable.

23. Medication for ADHD and criminality: Observational Swedish database analysis Swedish national register of 25,656 patients with ADHD Examined medication and criminal convictions over period 2006 ‒ 2009 37% of males and 15% of females had been convicted of at least one crime When on medication, 32% reduction in crime rate for men and 41% for women No significant difference for treatment with antidepressants or SSRIs Lichtenstein P et al. N Engl J Med. 2012;367:2006 ‒ 14.

24. Swedish RCT of treatment with stimulant medication in prisoners Double-blind placebo-controlled 5-week trial of methylphenidate extended release (OROS-MPH) in 30 prisoners with ADHD and comorbid disorders (incl. lifetime history of substance use disorders [SUD]) Followed by a 47-week open label extension (OLE) Evaluated by blind assessor Large treatment effect (d = 2.17) during RCT with reduced symptom severity and improved global functioning. Therapeutic effect continued to improve during OLE Placebo response, cardiovascular measures and adverse events were non-significant No drug abuse detected during the course of the study Ginsberg & Lindefors. Br J Psychiatry. 2012;200:68 ‒ 73.

25. ADHD is a chronic condition Manualised group programme 13+ years ADHD + antisocial behaviour Manualised group programme 8-12 years ADHD + problem behaviour Individual/group programme Adolescents/adults ADHD + comorbid problems

26. Recommendations: The focus should be on prevention by early identification of ADHD and appropriate intervention, focusing on: (a) Preschool children (b) School children (c) Adolescents

27. Gains: 1.Reduction in Service costs. 2.Improved emotional, social, educational and occupational functioning. 3.Improved health and quality of life. 4.Fewer wrongful convictions.