ADHD, criminality, pharmacotherapy, and substance abuse typically meet one another in media stories decrying the overuse of drug therapy for ADHD. In a welcome contrast to that popular tale, an elegant research project by Lichtenstein and colleagues1 tells a new story using the same characters. But in this story, stimulant therapy prevents criminal behavior; keeps ADHD patients out of prison; and leads to better outcomes for the patients, their families, and society.
I call the research elegant because it uses a large Swedish population registry to track verified prescriptions of stimulant medications for ADHD along with verified evidence of criminal activity. Because the large sample deflects criticisms of low power, the population sample provides a representative sample and the use of registries deals with possible investigator biases in making diagnoses. And in Sweden, findings indicate that the prevalence of treated ADHD is only 0.7%2; thus, it is highly likely that the patients in the Swedish registry truly had ADHD. We cannot accuse the Swedes of overdiagnosing ADHD.
Elegance and simplicity often travel together. That they traveled to Sweden is seen in the simple statement of the main result: “Among patients with ADHD, rates of criminality were lower during periods when they were receiving ADHD medication.”1(p2006) Among 25,656 patients with ADHD, pharmacotherapy for the disorder reduced criminality by 32% for men and by 41% for women.
The reduction in criminality afforded by ADHD medications was equally high for stimulant and nonstimulant medications and for patients with and without a history of conduct disorder. The probability of committing a crime increased when ADHD patients moved from a treatment period to a nontreatment period and decreased when they moved from a nontreatment period to a treatment period. These simple results are easy to explain and difficult to refute.
Although the work by Lichtenstein and colleagues does not explain why ADHD pharmacotherapy reduces criminality, earlier work offers reasonable explanations. ADHD medications have well-documented, strong, short-term effects on reducing ADHD symptoms and both overt and covert aggression.3-5 Although long-term data are limited, Fredriksen and colleagues6 found persistent therapeutic effects of these medications. Data from naturalistic studies show that long-term pharmacotherapy for ADHD reduces substance abuse in adolescence.7 Thus, reductions in the impulsivity of ADHD, the severity of comorbid aggression, and the risk of substance abuse might mediate the link between ADHD medication use and criminality.
Studying the effects of pharmacotherapy for ADHD on crime makes sense. Decades of research show that ADHD is associated with conduct disorder in youths and antisocial personality disorder in adults.8,9 Consequently, the prevalence of ADHD in prisons is very high. Findings from a recent literature review indicate that 10% to 70% of prisoners have ADHD.10 This is not news. ADHD was reported in 25% of prisoners more than 2 decades ago.11 Consistent with the idea that failure to treat ADHD increases the risk of criminal behavior, Ginsberg and colleagues12 found that ADHD had been identified in childhood in only 2 of 30 inmates with the disorder. Sadly, the incarceration of ADHD sufferers begins early: prevalence of ADHD among adolescents in juvenile detention is 12% to 19%.13
We now know that some criminal activity can be eliminated by pharmacotherapy for ADHD. Should this information influence clinical practice? The short answer is an unequivocal “yes.” Despite media outcries about the overmedication of youths, ADHD is not routinely managed with pharmacotherapy. In a 2007-2008 survey by the CDC, only two-thirds of children with a parent-reported diagnosis of ADHD were taking a medication for the disorder.14 The undertreatment of ADHD is greater than this suggests because many cases of ADHD are not diagnosed.
Froehlich and colleagues15 reported that 8.7% of 3082 youths in an epidemiological sample met DSM-IV criteria for ADHD. Among these children, only 47.9% had a prior diagnosis of ADHD and only 32% had been treated consistently with ADHD medications. Poor children were the most likely to meet criteria for ADHD but were the least likely to receive consistent pharmacotherapy. Similarly, Kessler and colleagues16 report that the majority of adults with ADHD are not treated for the disorder. The results of the Swedish study suggest that increasing the appropriate treatment of ADHD should decrease ADHD-associated criminal behaviors, which would benefit patients and reduce correctional costs to society.1
The ability of ADHD medications to reduce criminality should remind clinicians that the goal of ADHD pharmacotherapy is not simply a reduction of ADHD’s core symptoms of inattention, hyperactivity, and impulsivity. As Rostain and colleagues17 discuss, the treatment goals for ADHD should go beyond symptomatic improvement and short-term treatment response. These authors counsel clinicians to set the bar high when defining treatment success by using ADHD treatments to improve the functional status of patients, including non-core symptoms such as aggression, which are known to respond to medication. Although the initial improvements in ADHD symptoms can be dramatic, these should not obscure the need to address outcomes in other areas that may require an increased intensity of pharmacotherapy or the use of ajunct psychosocial treatments.
The ability of ADHD medications to reduce criminality clearly has implications for the treatment of ADHD in prisoners. Some work suggests that the clinical features of ADHD are more severe for prisoners with ADHD than for others with ADHD.12 Among imprisoned youths, higher levels of hyperactive/impulsive symptoms, but not inattentive symptoms, predicted violent and nonviolent breaches of prison discipline.18 The effective treatment of ADHD in prisoners would likely facilitate rehabilitation and decrease recidivism. Given the high rates of recidivism, any method of dealing with this issue should be welcomed by the prison system.
The prison system is, however, over-burdened, and pharmacotherapy for prisoners with ADHD is controversial. Burns19 raises several concerns about treating prisoners with stimulants, which are typically the first-line treatment for ADHD because of their high degree of efficacy. Many prisoners have had substance use disorders, and they would likely abuse stimulants in the prison environment. Prisoners with ADHD could divert stimulants for use as currency in the prison’s black market, making them available to other inmates.
Although no studies have examined the diversion of stimulants among prisoners, in their review of 21 studies of students, Wilens and colleagues20 reported that the lifetime rates of diversion ranged from 16% to 29% of students. Notably, extended-release preparations were less likely to be diverted than immediate-release preparations, which is probably because of the greater difficulty in transforming extended-release products into a compound with abuse potential.
Burns19 also raises other concerns. Prisoners who seek to misuse or abuse stimulants would likely intimidate or assault prisoners with ADHD who are under treatment. And practical issues must be considered. Prison psychiatric services could be overwhelmed by drug-seeking inmates simulating ADHD, because prison formularies would need to adopt costly storage, inventory, and handling procedures.
Because of these concerns, nonstimulant treatment has been suggested as the first approach to ADHD pharmacotherapy in prisons.21 Three FDA-approved nonstimulants are available (atomoxetine, extended-release guanfacine(Drug information on guanfacine), and extended-release clonidine(Drug information on clonidine)). In Appelbaum’s21 prison treatment protocol, stimulants are only used after failed trials of one or more nonstimulants. Patients are required to cooperate with nonpharmacological treatment recommendations. Among the latter, cognitive therapy for ADHD has been demonstrated to improve outcomes for stimulant-treated patients.22 Bupropion, which is used off-label for treating ADHD, is not recommended for prisoners because it has been diverted and abused in prison populations.19
Nothing in this commentary, or in the report by Lichtenstein and colleagues,1 should be taken to mean that ADHD medications will prevent crime in people without ADHD or that the appropriate treatment of ADHD will lead to dramatic reductions in the overall crime rate. The causes of criminal behavior are complex and multifactorial. Although ADHD may play only a small role in the full range of criminal activity, it is a treatable risk factor for criminal behavior. For physicians who treat patients with ADHD on a regular basis, it is reassuring to know that their careful work has had this unforeseen benefit. For physicians who are reluctant to treat patients with ADHD, especially those with a criminal history, the Swedish data call for a reassessment of clinical priorities.