Neurodevelopmental disorders in young violent offenders: Overlap and background characteristics

Treatments for ADHD in adults in jails, prisons and correctional settings: a scoping review of the literature

BACKGROUND

Attention-Deficit / Hyperactivity Disorder (ADHD) is prevalent at a higher rate in correctional settings than in the general population. Treatment of ADHD in this environment is challenging as stimulants, the most common treatment for ADHD, require cautious prescribing in the context of frequent substance use disorders (SUD) and diversion in the institutional setting. In addition, both pharmacological and non-pharmacological treatment approaches require significant staff resources. The aim of this scoping review is to map and summarize all literature addressing treatment of ADHD specifically in correctional settings, synthesize the evidence supporting various approaches, and highlight areas for future research. Due to the limited number of primary research studies addressing this question directly, we chose a scoping review methodology that would allow us to explore what kinds of studies and literature exist and include all types of articles directly related to our question.

RESULTS

Five-hundred sixty-five relevant articles were screened. Thirty-two articles were included in the final review. Eleven of the articles reported primary research. Five of these articles were based on three randomized controlled trials. Among randomized controlled trials on the effect of stimulants, inclusion criteria, outcome measures and effectiveness varied widely. Non-male and non-white populations were under-represented. Among review articles and recommendations opinion was inconsistent, with some recommending stimulants as first-line treatment and others recommending they be avoided altogether. The effect of non-stimulant medications was examined in 2 small studies. The only non-pharmacological treatment examined was dialectical behavior therapy, and only feasibility was reported. Four articles provided practice recommendations from consensus or expert opinion. Two of these recommended stimulants as first-line treatment, and two recommended stimulants as treatment of last resort.

CONCLUSIONS

We found a diverse but shallow literature addressing our research question. Primary research in the corrections setting is limited and varies in inclusion criteria, outcomes studied, and effectiveness. Recommendations on treatment are inconsistent. Future research should address methods of diagnosis, the role of non-stimulants, non-pharmacological interventions, non-male and non-white people who are incarcerated (PWAI), and effects of treatment method on patients, staff and other PWAI. Better research and guidance on treating ADHD has potential to improve health of PWAI, the institutional environment, and resource utilization.

ADHD as a Predictor of Quicker Time to Violent Recidivism and a Moderator of the Exposure to Violence-Violent Recidivism Relationship

Research on the role that attention-deficit hyperactivity disorder (ADHD) plays as a moderator of the relationship between exposure to violence and violent recidivism is limited. The Pathways to Desistance data were analyzed to examine these relationships. Survival analysis was used to examine ADHD as a risk factor predicting time to violent recidivism. Cox-proportional hazard modeling was used to assess the impact of ADHD on violent recidivism risk and examine ADHD as a moderator of the relationship between exposure to violence and violent recidivism. Results indicated that ADHD predicted quicker time to recidivism. The effect of witnessed violence was significantly weaker for participants with ADHD at baseline than those without ADHD at baseline. The direct effect of ADHD diagnosis at baseline on violent recidivism risk was only significant when the hypothesized interaction terms were included in the model. These findings suggest that individuals with ADHD may be less vulnerable to the impact of witnessing violence on their own risk for perpetrating violence. Effective targeting of treatment should be understood within this context.

Healthcare utilization and psychiatric morbidity in violent offenders: findings from a prospective cohort study

PURPOSE

Although persistent offenders with histories of imprisonment and violence have disproportionate high rates of psychiatric disorders, little is known of their psychiatric healthcare utilization (HCU) and HCU-associated factors. This study aimed to explore psychiatric HCU, psychiatric morbidity, and psychotropic prescription drugs in violent offenders with a history of incarceration.

METHODS

Male offenders aged 18-25 (n = 266) imprisoned for violent and/or physical sexual offenses were clinically assessed in 2010-2012 and prospectively followed in Swedish national registries through 2017. Register-based information regarding HCU, psychiatric morbidity, and psychotropic drugs was tracked and compared with a general population group (n = 10,000) and across offending trajectory groups. Baseline risk factors were used to explain prospective psychiatric HCU in violent offenders.

RESULTS

Violent offenders used less general healthcare and psychiatric outpatient care, but more psychiatric inpatient care and were more often given psychiatric diagnoses and psychotropic drugs than the general population. Participants previously assigned to persisting offending trajectory groups had higher rates of psychiatric HCU than those assigned to a desisting trajectory. In multivariable regression models, psychiatric HCU was associated with anxiety disorders, prior psychiatric contact, placement in a foster home, psychopathic traits, low intellectual functioning, and persistent offending.

CONCLUSIONS

Violent offenders are burdened by extensive and serious psychiatric morbidity and typically interact with psychiatric healthcare as inpatients rather than outpatients. Knowledge about their backgrounds, criminal behaviors, and psychiatric statuses can aid the planning of psychiatric services for this troublesome group.

Lifelong mental health service use among 15-22 years old offenders: a document-based, mixed-methods descriptive study

OBJECTIVES

Among young offenders, psychiatric morbidity and comorbidity are common, but our knowledge about their use of mental health services during childhood and adolescence is scarce. We aimed to describe the lifelong use of mental health services of young offenders who have committed serious crimes.

DESIGN AND STUDY SETTING

Using data on forensic psychiatric examinations of 42 Finnish offenders aged 15-22 years, we analysed the timing and typical patterns of their prior mental health service use with qualitative and quantitative content analysis and typification.

RESULTS

Young offenders appeared in this study as children with plenty of perinatal and developmental risks, and risks related to their family situation and peer relations. Most subjects were described as having had emotional or behavioural symptoms, or both, since childhood. Involvement in mental health services was rare before the age of 7 years but increased markedly after that, staying on the same level during adolescence. Five categories of mental health service users were identified: (1) continuing service use around a decade (14.3%), (2) one brief fixed treatment (11.9%), (3) involuntary use of services (31.0%), (4) evasive use of services (21.4%) and (5) no mental health service use (21.4%).

CONCLUSIONS

Young offenders had symptoms from early ages, but during childhood and adolescence, involvement in mental health services appeared for most as relatively short, repetitive or lacking. To help children at risk of criminal development, a multiprofessional approach, an early evidence-based intervention for behavioural symptoms and screening for learning problems, traumatic experiences and substance use are necessary. Results can help identify children and adolescents with a risk of criminal development, to develop mental health services and to plan further research.

Offending Trajectories in Violent Offenders: Criminal History and Early Life Risk Factors

The understanding of offending, and thus its possible prevention, is expanded through longitudinal studies on criminal trajectories depicting early life risk factors. This longitudinal study aimed to explore criminal trajectories, criminal histories, and early life risk factors in a cohort of violent offenders. A Swedish nationally representative cohort of male violent offenders (n = 266), clinically assessed while imprisoned aged 18 to 25, was followed through national registers from age 15 to 25-34. Substantial differences in criminal histories between violent offenders and a matched comparison group (n = 10,000) were demonstrated. Five trajectory groups were identified: four persisting and one desisting. Although differences were observed between persisting trajectory groups, a higher prevalence of early life risk factors was generally displayed compared to the desisting, especially in conduct problems and experiences of out-of-home placements. Neurocognitive ability and prevalence of ADHD and autism were similar across trajectories. Severe early life risks highlight the population's need for early interventions.

A Systematic Review of Autistic People and the Criminal Justice System: An Update of King and Murphy (2014)

The purpose of this paper was to determine whether recommendations made by King & Murphy (Journal of Autism and Developmental Disorders 44:2717-2733, 2014) in their review of the evidence on autistic people in contact with the criminal justice system (CJS) have been addressed. Research published since 2013 was systematically examined and synthesised. The quality of 47 papers was assessed using the Mixed Methods Appraisal Tool. Findings suggest a limited amount of good quality research has been conducted that has focused on improving our understanding of autistic people in contact with the CJS since 2013. Methodological limitations make direct comparisons between autistic and non-autistic offenders difficult. Autistic people commit a range of crimes and appear to have unique characteristics that warrant further exploration (i.e., vulnerabilities, motivations for offending).

Policy gaps and opportunities: A systematic review of autism spectrum disorder and criminal justice intersections

Autism spectrum disorder prevalence is rising, and as this population enters adulthood, preliminary research has identified high rates of contact with the criminal justice system. Policy and programmatic reform are crucial given reported negative and violent outcomes for autistic individuals when encountering the criminal justice system. Given the size and scope of the entire criminal justice system, identifying priorities and opportunities for change is critical, and must be rooted in evidence-based findings to maximize impact and scalability. This article provides a systematic review of the literature on autism spectrum disorder and criminal justice system intersections, analyzed through a convergent qualitative synthesis. As the extant literature is diverse and employs a variety of study methods, this review allows for an analysis across study types. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis structure was utilized and captured 89 total articles from six databases. Studies are grouped by the Sequential Intercept Model, which offers a framework for analyzing criminal justice system dimensions, and informs where research at the intersection of autism spectrum disorder and the criminal justice system is most prevalent. Themes were identified at each intercept and described through key study findings to articulate implications and guidance for policy, practice, and future research to promote equitable justice for autistic individuals.

Lay abstract

The number of people with autism spectrum disorder has increased, and as this population ages, research is showing high rates of contact with the criminal justice system among this group. Social and communication differences that autistic individuals experience can act as a risk factor during these interactions, as shown by public reports of negative and violent encounters between autistic individuals and the law enforcement. There is a clear need for evidence-based strategies to reduce high rates of contact and to improve outcomes when an interaction occurs. This article provides a systematic review of research on autism spectrum disorder and criminal justice system to compile this evidence base. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis structure was used to identify 89 articles after searching six databases. The Sequential Intercept Model describes the criminal justice system as different stages, or intercepts, that are connected, and the Sequential Intercept Model serves as an overall framework to organize the included articles. Articles were analyzed to identify research themes at each intercept, which offer guidance for policy and program changes that support equitable justice for autistic individuals.

Case-control study on clinical characteristics of child and adolescent psychiatric outpatients with child-to-parent violence

OBJECTIVES

To the best of our knowledge, no case-control study on child and adolescent psychiatric outpatients has investigated the clinical characteristics of patients with child-to-parent violence (CPV). The current study aimed to evaluate the clinical characteristics of child and adolescent psychiatric patients with CPV.

SETTING AND PARTICIPANTS

This research included child and adolescent psychiatric patients who were aged 10-15 years during their initial consultation. The participants were allocated to one of two groups: children with CPV (CPV group, n=109) and without CPV (non-CPV group, n=713).

OUTCOME MEASURES

This study analysed data including age, sex, diagnostic classification of the primary diagnosis, antisocial behaviour, suicidal attempt or self-harm and refusal to attend school. Moreover, a history of abuse by parents was investigated. Psychological rating scales such as the Spence Children's Anxiety Scale, Depression Self-Rating Scale for Children, Tokyo Autistic Behavior Scale, Attention-deficit/Hyperactivity Disorder-Rating Scale and Oppositional Defiant Behavior Inventory were used.

RESULTS

Of 822 patients who sought consultation in our department, 109 (13.26%) were included in the CPV group during the first consultation. Compared with the non-CPV group, the CPV group had significantly higher proportions of patients who experienced physical abuse, psychological abuse and who witnessed violence between parents. Meanwhile, the proportion of patients with neurodevelopmental disorders was significantly higher in the CPV group than in the non-CPV group. Regarding developmental characteristics, impulsivity might be correlated with CPV. Moreover, violence and behavioural problems outside of home were associated with CPV.

CONCLUSIONS

In patients with CPV who sought consultation, the findings of the current study should be considered to understand invisible side and to facilitate the use of appropriate treatment approaches. However, a prospective study should be performed to investigate the causality between CPV and clinical characteristics.

Self-report versus clinician-ratings in the assessment of aggression in violent offenders

BACKGROUND

The construct of aggression is central to work with violent offenders, but it is a broad construct that can be assessed by many different methods and instruments. Its measurement may, however, have profound implications for treatment planning. We need more knowledge about how different methods for assessing aggression relate to each other.

AIMS

Our aims were to investigate, first, the convergence and concordance of two methods of assessing aggression: self-report and clinical assessment and, second, to determine the degree to which aggression can be discriminated from neighbouring constructs, such as hostility, anger and criminal behaviour.

METHODS

A nationally representative Swedish cohort of 269 18-25-year-old incarcerated violent offenders was recruited. Data were collected through structured self-reports of aggression, anger and hostility traits (Aggression Questionnaire-Revised Swedish Version) and clinical assessments of lifetime prevalence of aggressive and antisocial behaviours (Life History of Aggression). Criminal records were retrieved from the Swedish National Crime Register.

RESULTS

Self-ratings and clinician-ratings of aggression were highly convergent and concordant, especially regarding physical aggression. Violent offence records were weakly, if at all, correlated, while self-reported hostility was weakly, or not at all, correlated with self-reported or with clinician-rated aggression. There was an inverse relationship between aggression and criminal records of sexual offences.

CONCLUSIONS AND IMPLICATIONS

Even though a combination of self-reports and clinician-ratings may provide a better overview of an individual's aggressive behaviours, our results indicate that they yield such similar information that either alone would be sensitive enough. Our results do not, however, support using one of these methods as a proxy for the other since choice of measure and accepted concordance between them depend on the context within which the assessment is conducted. We reconfirmed that official records of violent offending are unlikely to be adequate measures of outcome after interventions to reduce aggressive behaviours.

Underlying Thinking Pattern Profiles Predict Parent-Reported Distress Responses in Autism Spectrum Disorder

Appreciating autistic neurodiversity is important when supporting autistic people who experience distress. Specifically, use of a profiling model can reveal less visible autistic differences, including strengths and abilities. Binary logistic regressions showed that the likelihood of extreme distress responses could be interpreted based on parent-reported autistic thinking pattern profiles for 140 young people. Perspective-taking (specifically empathy), extreme demand avoidance, and over-sensory sensitivity each contributed to the combined regression models. From the clinical perspective of autism as a multi-dimensional and inter-connected construct, there may be implications for planning support and building positive self-understanding. Individually tailored adjustments and support strategies may be identified more easily after delineating variables found across four core aspects: sensory coherence, flexible thinking, perspective-taking, and regulation.

A Bad Start: The Combined Effects of Early Onset Substance Use and ADHD and CD on Criminality Patterns, Substance Abuse and Psychiatric Comorbidity among Young Violent Offenders

Substance abuse, conduct disorder (CD) and attention deficit/hyperactivity disorder (ADHD) are all known risk factors for developing aggressive behaviors, criminality, other psychiatric comorbidity and substance use disorders (SUD). Since early age of onset is important for aggravating the impact of several of these risk factors, the aim of the present study was to investigate whether young adult violent offenders with different patterns of early onset externalizing problems (here: substance use < age 15, ADHD, CD) had resulted in different criminality profiles, substance use problem profiles and psychiatric comorbidity in young adult age. A mixed-method approach was used, combining a variable-oriented approach (with Kruskal Wallis tests) and a person-oriented approach (with Configural frequency analysis). Overall, this combined approach indicated that persons with combined ADHD+CD and persons with CD + early onset of substance use had a more varied history of violent crimes, a more comprehensive history of aggressive behaviors in general, and more psychiatric comorbidity, as well as more varied SUD and destructive substance abuse in adult age, than persons without ADHD, CD or early SU. Results are in line with previous variable-oriented research, but also indicate that individuals in this group with heavy problem aggregation early in life have a wider spectrum of problems in young adult age. Importantly, among these young violent offenders, problem aggregation was the overwhelming norm, and not the exception, as in studies of the general population. This emphasizes the need for early coordinated interventions, but also that treatment within correctional facilities in adult age needs to be comprehensive and take individual patterns of comorbidity into account.

ADHD and offending

OBJECTIVES

International studies have reported disproportionately higher rates of Attention Deficit Hyperactivity Disorder (ADHD) among youth and adult offenders across police custody, prison, probation and forensic mental health settings, estimated to fall at around 25%. This review aimed to investigate the presentation and vulnerabilities of this subpopulation of people with ADHD compared to those with ADHD in the general population and consider how this may impact on the approach to assessment and treatment in this population.

METHODOLOGY

A selective review of the extant literature was conducted to investigate how offenders with ADHD may present differently from their non-ADHD peers in their clinical presentation, criminogenic behaviour and psychological vulnerabilities.

RESULTS

Nearly all (around 96%) offenders with ADHD have additional comorbid problems, including mood, anxiety, conduct, substance use and personality disorders. Compared with offenders without ADHD, they become involved in the criminal justice system (CJS) at a younger age, have higher rates of recidivism, are more likely to make a false confession, engage in behavioural disturbances in custody, have health risk behaviours and a lower quality of life. Assessing and treating ADHD in this subpopulation may be more complex due to their presentation.

CONCLUSIONS

Offenders with ADHD are disadvantaged within the system by their ADHD symptoms being unrecognised and/or misunderstood; their diagnosis of ADHD may be missed or misdiagnosed. This is at cost to the individual, from both a health and rehabilitative perspective, as well as more broadly to society.

Perceptions and Attitudes of Correctional Staff Toward ADHD-A Challenging Disorder in Everyday Prison Life

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder that is associated with risk-taking behaviors, poor self-control, and interpersonal difficulties. Affected individuals have an increased probability of involvement with the criminal justice system, contributing to a higher rate of arrest, and imprisonment compared with the general population; they are also inadequately treated once sentenced. Because prison staff play a central role in the identification of inmates with mental disorders, they could well be key to improving provision of care. There is however little knowledge of the conceptions, perceptions, and attitudes of prison staff toward ADHD. Such information could help to identify starting points for awareness training and further implementation of specific ADHD treatment. To bridge this gap, we undertook a study based on a qualitatively-driven mixed methods design, combining qualitative data collection in the form of narrative interviews with 19 prison staff from a Swiss correctional facility with quantitative data collection in the form of a survey that included the Attitudes toward Prisoners scale. The interviews were analyzed with QSR NVIVO 11 and a qualitative content analysis approach was used to evaluate findings. Prison staff were generally aware of ADHD and its symptomology, believing it to a be "real," but "fashionable" disorder and favoring hereditary-genetic or biological explanatory models for its development. They viewed inmates with ADHD rather negatively, as complicating correctional efforts, and perceived them as sticking out, as tying up more resources and as frequently being involved in confrontations. Our findings suggest that difficulties in pragmatic aspects of communication and language comprehension may be perceived "as not listening or following instructions," creating additional tensions. Consequently, inmates with ADHD are more often exposed to disciplinary sanctions, such as solitary confinement-an intervention deemed "necessary" by staff. Therefore, staff training on ADHD might need to cover evidence on adverse effects. Non-pharmacological interventions for treatment were preferred and considered to be highly efficacious. Skepticism toward pharmacological treatment prevailed, even when benefits from stimulant medication were described. Interestingly, this skepticism was not the result of negative experiences with the misuse and diversion of stimulants. Acceptance of multimodal treatment among prison staff may require customized strategies.

Patterns of Lifetime Criminality in Mentally Disordered Offenders - Findings From a Nationally Representative Cohort

Background: Treatment of mentally disordered offenders (MDOs) is challenging as their behavior and clinical conditions can be traced to a complex constellation of major mental disorders, substance use and antisocial lifestyle. Finding subgroups of these offenders, which could guide treatment and risk assessment, is desirable. There are few long-term, prospective studies of risk factors for persistent criminal behavior among MDOs. Aims: The aims are (1) to provide a map of lifetime criminality in MDOs, (2) to identify subgroups of offenders, and (3), if such clusters exist, to test whether they differ in lifetime criminality and patterns of negative events during in-patient treatment. Methods: Background data on all offenders from the Malmö University Hospital catchment area sentenced to forensic psychiatric in-patient treatment 1999-2005 (n = 125) was collected. Data on negative events during treatment (violence, threats, absconding and substance use) from date of admittance until discharge or until June 30, 2008 was gathered. Court decisions for 118 of the cohort-individuals were collected from the 1^st of January 1973 until December 31, 2013. We used hierarchical cluster analysis to identify subgroups and MANOVA-analysis to examine differences between these clusters on lifetime criminality variables and negative events. A MANCOVA was used to control for time in treatment. Results: The cohort was sentenced to a total of 3,380 crimes (944 violent) during the study period. Median age at first crime was 20 years (range 15-72), and at first violent crime 27 years (range 15-72). A subgroup (n = 26) was characterized by childhood adversities, neurodevelopmental disorders and later substance use disorders and was more often associated with substance-related crimes, financial crimes and lower age at first crime. During treatment, this cluster showed higher rates of substance use and threats. When controlling for treatment time, no differences in negative events were found. Conclusions: This study replicated findings from prison populations of the existence of a more criminally persistent phenotype characterized by early-onset neurodevelopmental and behavior disorders, childhood adversities and later substance use disorders. We did not find this cluster of variables to be related to negative events during inpatient treatment when controlling for length of stay.

Intellectual disability rates among male prison inmates

While only a small percentage of people with intellectual disabilities are responsible for criminal behaviors, the literature points to their overrepresentation in prisons, although not enough attention has been paid to intellectual disability data for inmates. We retrieved studies - in English, Spanish, Italian or French and indexed in Medline between 2000 and 2018 - that provided intellectual disability data for prisons collected by the administration of validated tests to male inmates. Identified were 13 studies involving more than 15,000 inmates referring to intellectual disability and borderline intellectual disability. The general findings of our review corroborate the overrepresentation of people with ID in prisons, although prevalence rates range widely, from as low as 1% to as high as 69.9% (p<0.000001), reflecting to differences in methodology, in local, social and cultural factors and in judicial procedures. Published studies clearly underline the overrepresentation of people with intellectual disabilities in prisons, differences between countries, the vulnerabilities of persons with intellectual disabilities and the need for proper assessment and management policies in prisons worldwide.

Socio-legal consequences of Tourette Syndrome and its comorbidities: A case study and review of the literature

Tourette Syndrome is a neurodevelopmental disorder that is associated with the presence of multiple motor and one or more verbal tics. In this case report, we present a 16 years old Tourette syndrome patient who was diagnosed with comorbid Attention Deficit Hyperactivity Disorder. The patient was evaluated for legal responsibility after she made untrue allegations saying that a bus driver had sexually harassed her. We summarize the case and review the current literature to assess the socio-legal aspects of Tourette syndrome.

Personality and Cognitive Functions in Violent Offenders - Implications of Character Maturity?

Previous research has suggested that personality and cognitive functions are essential in the emergence of persistent aggressive antisocial behaviors and that character maturity could be an important protective factor against these behaviors. The aims of this study were (1) to determine associations between personality traits, intellectual ability, and executive function in young male violent offenders, and (2) to investigate differences in intellectual ability and executive function between groups of violent offenders with low, medium, and high character maturity. A cohort of 148 male violent offenders (18–25 years of age) participated in this study. The Temperament and Character Inventory was used as a self-report measure of personality traits, and cognitive functions were measured with the Wechsler Adult Intelligence Scale – Third Edition and the Cambridge Neuropsychological Test Automated Battery. Intellectual ability was negatively correlated to the temperament dimension Harm Avoidance and the character dimension Self-Transcendence, and positively correlated to the character dimensions Self-Directedness and Cooperativeness and the temperament dimension Novelty Seeking. Visual sustained attention correlated positively to the temperament dimension Persistence and negatively to the temperament dimension Harm Avoidance. Spatial working memory correlated negatively to the character dimension Cooperativeness. Character maturity, however, did not affect intellectual and executive functions to a statistically significant degree. Our findings indicate that offender personality characteristics such as optimism, responsibility, empathy, curiosity, and industry that would seem more favorable to positive intervention outcomes are related to better cognitive functioning. Possible implications are that interventions in offender populations could be more effective if tailored to participants’ personality dimensions and cognitive proficiencies, rather than offered as “one size fits all.”

Borderline intellectual functioning

Borderline intellectual functioning (BIF), that is to say, tested IQ levels in the range of 70-84/85, is prevalent, affecting about 12%-14% of the population depending on the exact level for "diagnostic" cutoff. In the current Diagnostic and Statistical Manual of Mental Disorders, BIF does not have a separate diagnostic category but can be categorized with a V-code. Children and adolescents with BIF usually struggle both as regards school performance and in respect of social functioning. BIF is common in attention deficit hyperactivity disorder, but sometimes attention problems in schoolchildren with BIF may be a consequence of nonadapted academic demands. Autism and BIF may also coexist, and there are many cases of so-called high-functioning autism who are high functioning only in the sense that they do not meet criteria for intellectual disability, but function in the area of BIF. Currently, too little attention is given to the negative effects of BIF on child development and adaptation. Learning, academic, and behavioral problems and grade retention may be markers of BIF. Our diagnostic and classification manuals need to have specific categories that clarify the problems that BIF entails so that affected individuals can avail themselves of better educational support and understanding.

Exploring Traumatic Brain Injuries and Aggressive Antisocial Behaviors in Young Male Violent Offenders

Background: Traumatic brain injury (TBI) is a major cause of disabilities and mortality worldwide, with higher prevalence in offender populations than in the general population. Previous research has strongly advocated increased awareness of TBI in offender populations. The aim of this study was to explore the prevalence and characteristics of TBI, and to investigate associations and interactions between TBI, aggressive antisocial behaviors, general intellectual functioning, and substance use disorders (SUD) in a well-characterized group of young violent offenders. Methods: The study investigated a cohort (n = 269) of 18 to 25-year-old male violent offenders in Sweden. Data on TBI (files + self-report), aggressive antisocial behaviors (Life History of Aggression), SUD (clinical interviews), and general intellectual functioning (General Ability Index, Wechsler Adult Intelligence Scales Third Edition) were collected between 2010 and 2012. Parametric (Student's t-test) and non-parametric (Mann-Whitney U-test, Spearman's rho, χ², Kruskal Wallis test) inferential statistics were applied and effect sizes reported. Results: TBI, both with and without loss of consciousness, was common, with 77.5% of the offenders reporting having suffered at least one TBI during their lifetime. TBI was associated with an increased occurrence of aggressive antisocial behaviors and SUD, and offenders with both TBI and SUD evidenced the largest amount of aggressive antisocial behaviors. No clinically meaningful associations were found between TBI and general intelligence. Effect sizes were in the small to medium range. Conclusions: Our study confirms an increased prevalence of TBI among young violent offenders compared to the general population, as well as associations between TBI, aggressive antisocial behaviors, and SUD. However, it provides no information on the severity of the TBI, nor on the causality of the demonstrated associations. Nevertheless, TBI, and possible related deficits, need to be considered in the assessment and treatment of young violent offenders.

Gambling Disorder in Male Violent Offenders in the Prison System: Psychiatric and Substance-Related Comorbidity

Gambling disorder is an addiction that can cause major suffering, and some populations seem to be more vulnerable than others. Offender populations have a remarkably high prevalence of gambling problems and they are also over-represented in a number of diagnoses related to gambling disorder, like substance use disorders and antisocial personality disorder. Yet, there are few studies investigating gambling disorder prevalence and related psychiatric comorbidity in this group. This study aims to investigate the prevalence of, and association between, gambling disorder and other psychiatric diagnoses in a sample of young, male violent offenders. Two hundred and sixty-four male offenders, all serving sentences for violent crimes (recruited between 2010 and 2012) participated in this study and went through comprehensive psychiatric evaluation, including assessment for Diagnostic and Statistical Manual of Mental Disorders 4th Edition criteria. Sixteen percent of the participants met criteria for gambling disorder. Antisocial personality disorder, cannabis, cocaine and anabolic steroids abuse were significantly more common among participants with gambling disorder. The gambling disorder group also showed significantly lower educational attainment. Cocaine abuse and failure to graduate elementary and middle school in expected time were independently associated with gambling disorder in a regression analysis. This study confirms the previously described high prevalence of gambling disorder in offenders. The psychiatric comorbidity was high and the problems had started early, with lower educational attainment in the gambling disorder group. The findings stress the importance of increased awareness of gambling problems among convicted offenders and of gambling research on young people with delinquent behavior. There is a need of more research to investigate this further, in order to develop preventive strategies and treatment.

Facets of Psychopathy, Intelligence, and Aggressive Antisocial Behaviors in Young Violent Offenders

Psychopathy continues to be a challenge in forensic contexts, and evidence of its association with destructive behaviors, such as aggressive antisocial behaviors, is extensive. However, the potential role of intelligence as moderator of the well-established association between psychopathy and aggressive antisocial behaviors has largely been neglected, despite intelligence having been independently related to both concepts. Increased knowledge of whether intelligence is relevant to this association is needed because of its possible implications on the assessment and treatment of individuals with psychopathic traits and aggressive antisocial behaviors. This study aimed to investigate the association between psychopathic traits, aggressive antisocial behaviors, and intelligence in young violent offenders and to test whether intelligence moderates the relationship between psychopathic traits and aggressive antisocial behaviors. Participants were 269 male violent offenders aged 18–25 years, assessed on the Psychopathy Checklist-Revised (PCL-R), the Life History of Aggression (LHA), and the General Ability Index from the Wechsler Adult Intelligence Scale, 3rd edition. Associations were tested with Spearman’s rho, and moderation analysis was performed through ordinary least squares regressions. The PCL-R four-facet structure was used for the analyses. We found a positive association between psychopathic traits and aggressive antisocial behaviors, and a small negative association between the Affective PCL-R facet and intelligence. In the moderation analyses, a small yet statistically significant moderation effect of intelligence on the association between the Interpersonal facet and LHA total scores was demonstrated. However, the amount of variance in the LHA total score explained by the model was very small: 2.9%. We suggest that intelligence, however, important for rehabilitation strategies and everyday functioning, is not necessarily pertinent to understanding aggressive antisocial behaviors in young offenders with psychopathic traits.

Attention Deficit Hyperactivity Disorder (ADHD) in the Prison System

PURPOSE OF REVIEW

To examine recent advances in the understanding of attention deficit hyperactivity disorder (ADHD) among the prison population.

RECENT FINDINGS

Efforts have been made to develop useful tools for assessing ADHD among prisoners. Prisoners with ADHD demonstrate incremental vulnerability due to comorbid psychiatric disorders, neurodevelopmental disorders and traumatic brain injury. Compared with prisoners without ADHD, prisoners with ADHD become involved in the criminal justice system at a younger age and have higher rates of recidivism in adulthood. Recent studies demonstrate the effectiveness of extended release stimulant medication and psychological interventions. Early identification and treatment of prisoners with ADHD have the potential to demonstrate health economic benefits. Our understanding of ADHD among prisoners continues to develop. However, further research is needed, particularly among neglected groups such as females. Much more attention is needed by the prison service to engender better outcomes for this at-risk population.

Cognitive functioning and aggressive antisocial behaviors in young violent offenders

Studies have shown that offenders have impaired cognitive abilities yet it is unclear if cognitive dysfunction per se contributes to aggressive antisocial behaviors. Our aims were to (1) determine associations between cognitive functioning and different forms of aggressive antisocial behaviors, (2) describe prevalence of, and covariates to, uneven intellectual profiles, and (3) investigate associations between cognitive functioning and age at onset of aggressive antisocial behaviors. A cohort (n = 269) of 18-25 years old male violent offenders were assessed for general intellectual functioning with the Wechsler Adult Intelligence Scales-third edition, and for executive functions with the Cambridge Neuropsychological Test Automated Battery. Only one measure of cognitive functioning - slower reaction times in a response inhibition test - was significantly correlated with higher occurrence of aggressive, but not exclusively antisocial, behaviors. Furthermore, offenders with even intellectual profiles showed more aggressive antisocial behaviors than offenders with uneven intellectual profiles. Finally, increased errors in tests of cognitive flexibility and slower reaction times in a response inhibition test were associated with a younger age at onset of general, but not exclusively violent, criminality. Overall, effect sizes were small. The findings emphasize the need of research investigating how cognitive functioning in offenders affects susceptibility to treatment interventions.

Few Differences in the Externalizing and Criminal History of Young Violent Offenders With and Without Autism Spectrum Disorders

Autism spectrum disorders (ASDs) are known to be associated with an increased risk of aggression and challenging behavior. In this study, we have mapped the externalizing history of a nationally representative cohort of young violent offenders with ASD, compared with offenders without ASD. Two hundred and sixty-nine violent offenders were assessed for prevalence of ASD, and participated in a thorough assessment of previous externalizing problems and criminal history. Twenty-six offenders met consensus clinical DSM-IV criteria for ASD and they were compared to offenders without ASD from the same cohort. Overall, we found a very high prevalence of externalizing and antisocial behaviors in the history of these offenders and there were few differences between the groups. Placements in foster homes were overrepresented in the ASD group and the ASD-offenders had significantly more often been diagnosed with a neurodevelopmental disorder (i.e. ASD or ADHD) by a clinician before the study. At index conviction, ASD offenders were overrepresented in sex crimes with a child victim. Though offenders without ASD had more previous convictions, in particular drug crimes, we found no difference in terms of total number of prosecuted crimes. Substance use disorders were more common among offenders without ASD. The ASD offenders scored higher compared to the non-ASD offenders on the Affective facet of the Psychopathy Checklist-Revised (PCL-R) but there were no differences in terms of total PCL-R scores. Our results provide important knowledge of the developmental history of offenders with ASD. Though this is a small and atypical phenotype it poses significant challenges to the criminal justice system and we need to understand more of it to be able to prevent these individuals from committing crimes but also to provide a fair judicial treatment, to assess exculpatory factors and improve our forensic treatment models.

Clinical, Demographic, and Criminal Behavior Characteristics of Patients With Intellectual Disabilities in a Canadian Forensic Program

Background: People with intellectual disability (ID) and forensic issues constitute a challenging clinical group that has been understudied in forensic settings. Methods: We assessed the characteristics of patients with ID under the authority of the Ontario Review Board (ORB) in a large forensic program of a tertiary psychiatric hospital (excluding those with a cognitive disorder) and compared their characteristics with those of a non-ID control group. Results: Among 510 adult ORB patients, 47 had an ID diagnosis. ID patients were of younger age at index offense, with a lower level of education, and were less likely to have been married or employed, more likely to have committed a sexual offense, more likely to have a diagnosis of paraphilia, less likely to be "not criminally responsible," and more likely to be "unfit to stand trial." They were also more likely to have committed their index offenses against care professionals and be treated in a secure unit. Conclusion: Our findings have major implications for clinicians, clinical leaders, and policymakers about the specific needs of patients with ID presenting with forensic issues and differing needs in terms of treatment and risk management.

Examining Associations Between Psychopathic Traits and Executive Functions in Incarcerated Violent Offenders

Executive functions (EFs) are essential in almost all aspects of daily life and have been robustly related to antisocial behavior. However, the relationship between psychopathy and EFs has remained equivocal. Research investigating lower-level trait dimensions of psychopathy using standardized EF measures could be beneficial in addressing this issue. In this study, we examined associations between four EFs and four dimensions of psychopathic traits (interpersonal, affective, lifestyle, antisocial) using zero-order correlation and a combination of classical and Bayesian statistical methods. Two hundred and fourteen incarcerated male violent offenders were assessed with the Psychopathy Checklist-Revised and completed tests of cognitive flexibility, spatial working memory, response inhibition, and planning and problem-solving using the Cambridge Neuropsychological Test Automated Battery. Lifestyle psychopathic traits were significantly associated with reduced initial thinking time in a planning and problem-solving task, with a Bayes factor indicating substantial evidence for the observed correlation, and antisocial psychopathic traits showed a significant association with reduced initial thinking time in the same task, although the Bayes factor indicated only anecdotal evidence. Significant associations were also found between affective and antisocial psychopathic traits and less efficient strategic thinking in a spatial working memory task, and between affective, lifestyle and antisocial psychopathic traits and fewer problems solved in a planning and problem-solving task, although these findings were not corroborated by the Bayesian analysis. While the observed effects ranged between small and medium, our study suggests that reduced initial thinking times in planning and problem-solving is robustly associated with higher degrees of lifestyle and antisocial psychopathic traits.

Characteristics and Pathways of Long-Stay Patients in High and Medium Secure Settings in England; A Secondary Publication From a Large Mixed-Methods Study

Background: Many patients experience extended stays within forensic care, but the characteristics of long-stay patients are poorly understood. Aims: To describe the characteristics of long-stay patients in high and medium secure settings in England. Method: Detailed file reviews provided clinical, offending and risk data for a large representative sample of 401 forensic patients from 2 of the 3 high secure settings and from 23 of the 57 medium secure settings in England on 1 April 2013. The threshold for long-stay status was defined as 5 years in medium secure care or 10 years in high secure care, or 15 years in a combination of high and medium secure settings. Results: 22% of patients in high security and 18% in medium security met the definition for "long-stay," with 20% staying longer than 20 years. Of the long-stay sample, 58% were violent offenders (22% both sexual and violent), 27% had been convicted for violent or sexual offences whilst in an institutional setting, and 26% had committed a serious assault on staff in the last 5 years. The most prevalent diagnosis was schizophrenia (60%) followed by personality disorder (47%, predominantly antisocial and borderline types); 16% were categorised as having an intellectual disability. Overall, 7% of the long-stay sample had never been convicted of any offence, and 16.5% had no index offence prompting admission. Although some significant differences were found between the high and medium secure samples, there were more similarities than contrasts between these two levels of security. The treatment pathways of these long-stay patients involved multiple moves between settings. An unsuccessful referral to a setting of lower security was recorded over the last 5 years for 33% of the sample. Conclusions: Long-stay patients accounted for one fifth of the forensic inpatient population in England in this representative sample. A significant proportion of this group remain unsettled. High levels of personality pathology and the risk of assaults on staff and others within the care setting are likely to impact on treatment and management. Further research into the treatment pathways of longer stay patients is warranted to understand the complex trajectories of this group.

Neurodevelopmental disorders in prison inmates: comorbidity and combined associations with psychiatric symptoms and behavioural disturbance

The identification and management of inmates with neurodevelopmental disorders (ND) has been insufficiently addressed in the literature. We estimated the proportion of cases with Attention deficit/hyperactivity disorder (ADHD), Autism spectrum disorder (ASD) and Intellectual disability (ID) in prison, their comorbidity, and associations with disruptive behaviours and with psychiatric symptoms. Further, we examined the role of coexisting ND on psychiatric symptoms and attitudes toward violence. All 390 male inmates underwent an assessment that included the Diagnostic Interview for ADHD in Adults 2.0, the Autism Quotient, the Learning Disability Screening Questionnaire, the Brief Symptom Inventory (BSI), and measures of disruptive behaviours and attitudes towards violence. The percentage of cases with ADHD, ASD and ID were 25%, 9% and 9%. Inmates with ADHD and those with ID had significantly higher levels of disruptive behaviours. The combined ADHD/ASD group had significantly higher scores on global severity symptoms than either ADHD or ASD only. Meanwhile, the combined ADHD/ID group had significantly higher scores of behavioural disturbance than the ADHD-only group. Our findings show the extent of ND in prison, their inter-relations and associations with further mental health problems. Vulnerabilities conferred by ND within the criminal justice system should be addressed via interventions and preventative strategies.

Deliberate self-harm behavior among young violent offenders

Deliberate self-harm behavior (DSH) can have profound effects on a person's quality of life, and challenges the health care system. Even though DSH has been associated with aggressive interpersonal behaviors, the knowledge on DSH in persons exhibiting such behaviors is scarce. This study aims to (1) specify the prevalence and character of DSH, (2) identify clinical, neurocognitive, psychosocial, and criminological characteristics associated with DSH, and (3) determine predictors of DSH among young violent offenders. Data were collected from a nationally representative cohort of 270 male violent offenders, 18-25 years old, imprisoned in Sweden. Participants were interviewed and investigated neuropsychologically, and their files were reviewed for psychosocial background, criminal history, mental disorders, lifetime aggressive antisocial behaviors, and DSH. A total of 62 offenders (23%) had engaged in DSH at some point during their lifetime, many on repeated occasions, yet without suicidal intent. DSH was significantly associated with attention deficit hyperactivity disorder, mood disorders, anxiety disorders, various substance use disorders, being bullied at school, and repeated exposure to violence at home during childhood. Mood disorders, anxiety disorders, and being bullied at school remained significant predictors of DSH in a total regression model. Violent offenders direct aggressive behaviors not only toward other people, but also toward themselves. Thus, DSH must be assessed and prevented in correctional institutions as early as possible, and more knowledge is needed of the function of DSH among offenders.

The protective effect of character maturity in child aggressive antisocial behavior

BACKGROUND

Childhood aggressive antisocial behavior (CD) is one of the strongest predictors of mental health problems and criminal behavior in adulthood. The aims of this study were to describe personality profiles in children with CD, and to determine the strength of association between defined neurodevelopmental symptoms, dimensions of character maturity and CD.

METHODS

A sample of 1886 children with a close to equal distribution of age (9 or 12) and gender, enriched for neurodevelopmental and psychiatric problems were selected from the nationwide Child and Adolescent Twin Study in Sweden. Their parents rated them according to the Junior Temperament and Character Inventory following a telephone interview during which information about the children's development and mental health was assessed with the Autism-Tics, AD/HD and other Comorbidities inventory.

RESULT

Scores on the CD module significantly and positively correlated with scores on the Novelty Seeking temperament dimension and negatively with scores on character maturity (Self-Directedness and Cooperativeness). In the group of children with either neurodevelopmental or behavioral problems, the prevalence of low or very low character maturity was 50%, while when these two problems coexisted the prevalence of low or very low character maturity increased to 70%. Neurodevelopmental problems (such as: oppositional defiant disorder, symptoms of attention deficit/hyperactivity disorder and autism spectrum disorder) and low scores on character maturity emerged as independently significant predictors of CD; in a multivariable model, only oppositional defiant symptoms and impulsivity significantly increased the risk for coexisting CD while a mature self-agency in a child (Self-Directedness) remained a significant protective factor.

CONCLUSION

These results suggest that children's willpower, the capacity to achieve personally chosen goals may be an important protective factor - even in the presence of neurodevelopmental and psychiatric problems - against progressing into persistent negative outcomes, such as aggressive antisocial behaviors.

Mentally disordered offenders in Sweden: differentiating recidivists from non-recidivists in a 10-year follow-up study

BACKGROUND

Forensic psychiatric patients present a challenge as they manifest severe mental disorders together with criminal behaviour. There are well-known risk factors for criminal behaviour in the general population, yet knowledge of what predicts reconviction in the Swedish forensic population in the long-term perspective is still insufficient.

AIMS

The study aims to (1) describe background and clinical characteristics of forensic psychiatric patients in a 10-year follow-up, (2) analyse risk factors associated with recidivism, and (3) test the predictive validity of risk factors for general and violent criminality.

METHODS

Detailed information on all offenders from the Malmö University Hospital catchment area sentenced to forensic psychiatric in-patient treatment from 1999-2005 (n = 125) was collected. Court decisions were collected up until the end of 2008 (median follow-up time = 6.2 years, range = 0.6-9.7 years).

RESULTS

Relapse in general crime (n = 30) was predicted by low educational attainment, mental disorder in a first degree relative, and low age at first sentenced crime. Relapse in violent crime (n = 16) was predicted by low educational attainment and low GAF scores. Patients with a restriction order were less likely to relapse in both crime categories.

CONCLUSIONS

Signs of childhood adversities together with early debut in criminality appeared as important risk factors for general and violent recidivism. Forensic psychiatric treatment combined with a restriction order was demonstrated as a protective factor against recidivism, suggesting that the risk of recidivism is strongly related to the level of supervision. Although the low number of recidivism cases is highly desirable, it unfortunately reduces the power of the analyses in this paper.