ADHD, Psychopathy, and other MH conditions

What is the main diagnostic criteria for ADHD?

Persistent patterns of attention and/or hyperactivity-impulsivity that impairs functioning or development

3 subtypes of ADHD

Predominantly inattentive (20-30%)

Hyperactive-impulsive (15%)

Combined both (50-75%)

What is the prevalence of ADHD in the UK?

3-4% of adults, 3:1 male:female ratio

Underdiagnosis in women - atypical symptoms, healthcare bias (Matheiken et al, 2024)

Why was their rising recognition of ADHD post-pandemic? according to who?

Heightened awareness, stress revealing symptoms (Matheiken et al, 2024)

Key features of ADHD

Lifelong for about half diagnosed in childhood

Co-morbid with low self esteem, and academic and occupational difficulties

What perspective can we take with ADHD?

Strength-based perspective - focus on creativity, humour, and hyperfocus can enhance wellbeing when recognised and utilised

ADHD and CJS - Young and Thomas (2011)

What is the prevalence of ADHD in the CJS?

45% of youths, 24% of male adults in CJS screen positive for a childhood history of ADHD

14% of those have persisting symptoms in adulthood - associated with younger offending onset, rates of recidivism

Young adults with ADHD are significantly more likely to interact with the CJS

Is their a link with the age of onset of criminal activities?

• Individuals with childhood ADHD committed first crime before 15 (Satterfield et al, 2017), and first police contact usually 1 year earlier in young offenders (DeLisi et al, 2013)

  • Individuals with childhood ADHD significantly younger that controls at time of first arrest (DeSanctis et al, 2014)

  • Men but not women with ADHD had earlier onset of criminal activities vs controls (Silva et al, 2014)

• Childhood ADHD associated with onset delinquency and higher arrest - early onset important

Is there an dependent decline in offending?

Rosler et al (2009) - declining rates of ADHD with age in the offender population

Suggests criminal behaviour in people with ADHD might decline with increasing ag

What types of crime is ADHD associated with

Raaj et al (2024) - road traffic rule violations, traffic accidents

Mohr-Jensen and Steinhausen (2016) - meta-analysis and systematic review - assault, theft, drug-related crimes, possession of weapons

Kelsey et al (2023) - link between ADHD, TBIs, and offending

TBIs are linked to increased interpersonal violence, recidivism, suicide, failed rehabilitation

ADHD associated with interpersonal violence, prior TBIs

Estimated prevalence of TBIs and ADHD prevalence among male inmates in psychiatric intensive care units (PICUs)

Found:

• High rates of TBI and ADHD

• Association between TBI history, ADHD symptoms

Highlights need for tailored assessment, intervention strategies in secure psychiatric settings

But - clinical implications not fully explored - how services should adapt, intervention strategies for dual-diagnosis patients

Young et al.’s (2009) Scottish Prison Study

Examined the effect of ADHD on critical incidents of aggression using self-report measures of ADHD and APD, and critical incident reports from prison records

Found those with higher symptoms showed higher verbal and physical aggression, total critical incidents, and severity of aggression

Retz et al (2004)

Examined the difference between young male offenders 15-28 - 1) with childhood and adult ADHD 2) with childhood but no adult ADHD 3) with no ADHD or current diagnosis

Age at 1st conviction was lower and delinquency prior to age 14 was higher in those with ADHD and CARS

What are some possible reasons for these findings?

Lower education status, higher unemployment, higher rates of family delinquency

Emotional problems and social characteristics like anxiety, depression, and aggressive behaviour

High N, lower C and A - N and C distinguish offenders from controls

What are some meta-analyses which support the idea that ADHD can be an important risk factor for offending, reflecting the growing body of research finding this?

Baggio et al (2018)

Young et al (2015)

What could the role of comorbid disorders here be?

Prevalence of co-morbid disorders in those with ADHD is generally high, such as conduct disorder and antisocial personality disorder which may mediate the association between ADHD and delinquency (complex interaction only partially understood so far - Sebastian et al, 2019)

ADHD medication

Change et al (2016) - use of ADHD medications is associated with a reduced risk of offending

Bolan et al (2020) - meta-analysis and lit review - ADHD med use associated with decreased risk of outcomes like motor vehicle crashes and depression. Also, variable but largely positive findings - lower rates of mood disorders, substance use disorders, criminality, suicidality, TBIs, motor vehicle crashes, injuries, academic outcomes, and ADHD medication use

Conduct disorder - main diagnostic criteria

Disrupive, impulse control issues

Problems in self-control of emotions and behaviours

Repetitive and peristent behaviours that violate the rights of others and / or significantly conflict with age-appropriate societal norms and authority figures

Must be prevalent pre-18 years

What does CD often lead to in adulthood?

ASPD

Key features of conduct disorder

Aggression to people / animals

Destruction of property

Deceitfulness / theft

Serious violations of rules

Subtypes of conduct disorder

Childhood onset - more likely to persist into adulthoos

Adolescent onset

Unspecified onset

Prevalence of CD

2-2.5% (3-4% in boys, 1-2% in girls)

• Some studies suggest increase in prevalence over recent decades (E.g. Ayano et al, 2024), whereas others have suggested minimal changes in prevalence over this period (e.g. Erskine et al, 2013)

• Studies in US didn't report differences between ethnic groups, any apparent differences accounted for by SES disparities between groups (e.g. Merikangas et al, 2010)

• Despite cultural differences in what is considered acceptable childhood behaviour, there is little difference suggesting prevalence of CD differs between countries (Erskine et al, 2013)

What is the prevalence of CD in young offenders?

23-87% of those in youth / juveniles in the US (DoJ, 2006)

What is CD diagnosis linked with?

• Poor educational performance

• Social isolation

• Substance misuse and increased contact with CJS in adolescence

• Poor educational/occupational outcomes, involvement with CJS< high level of MH problems in adulthood

Cognitive factor explanations

• Intelligence and cognitive deficits

• IQ 1 SD below mean

• EF difficulties (shifting tasks, planning, organising, Moffitt and Lynam, 1994)

• Remain once SES/education controlled

• Interacts with environmental factors (Pennington and Benneto, 1993)

Structural and functional brain differences

• Lower response in OFC regions during stimulus-reinforcement and reward task - maybe poor decision making

• Lower grey matter vol in amygdala - linked to fear conditioning deficits (Raine, 2011)

• Difficulty processing social emotional stimuli (regardless of age of onset, Fairchild et al, 2011)

• Neurochemical differences (lower serotonin and cortisol levels)- stress?

Genetic explanations

• Sibling / parent increases likelihood of heritability (.53, Gelhorn et al, 2005)

• Stronger genetic link for individuals with childhood-onset vs adolescent-onset

• However, genetic contribution is not stable over time, suggesting partly different genes contribute to CD at different stages of lifespan (e.g. Wesseldijk et al, 2017)

Family and peer influence

• Single parent status, parental divorce, large family size, young age of mothers (Hinshaw and Lee, 2003)

• Poverty and low SES - lower parental involvement, inadequate supervision, unpredictable discipline practices reinforce defiant behaviours

• Peer rejection leads to continuity of disorders over time - selection / facilitation effect - Hinshaw and Lee (2003)

ADHD, CD Comorbidity - Foley et al (!996)

• Both associated with juvenile delinquency and risk for ASPD

• CD reported present in 50% of people diagnosed with ADHD (Spencer, 2006)

• Common co-occurring childhood crimes

Whos suggested ADHD with comorbid CD might be a more severe variant of ADHD, that they may not be two distinct disorders?

Dick et al (2005)

What counters this suggestion and who showed this?

Fergusson et al (1993)

Based on difference in long-term behaviour outcomes

CD at 6,8,10 years - continuous with offending behaviour at 13 BUT unrelated to academic achievment when accounting for comorbid ADHD effects

ADHD - correlated with academic difficulties BUT unrelated to offending behaviour when CD effects controlled

What did Foley et al (1996) say about CD and ADHD overlap?

This may be related to somehting about school behaviour as a risk factor

ADHD→poor school performance→dropout→CD risk

What kind of studies support this?

30 year follow-up studies

Satterfield et al (2006) - boys with hyperactive ADHD AND CD had a higher risk of criminality, no increase without CD
Mordre et al (2011) drew similar conclusions from a Norwegian study including boys and girls

What is the current state of research about the nature of the associations of ADHD with CD?

Not fully understood so far

What did Azeredo (2018) do?

Systematic review

Concluded the causes for onset and maintenance of ADHD and CD are more associated with genetic factors that environmental ones, and that children with ADHD have a predisposition to manifest behaviours that are common to CD

What has been found about environmental factors?

Identified as increasing the risk for the development of CD and later delinquency in persons with ADHD such as low SES and IQ

Diagnostic criteria for ASPD

Pervasive pattern of disregard for and violation of the rights of others post 15 years old

Individual is 18 years plus

Evidence of CD with onset before 15 years

Behaviour not exclusively during the course of SZ / bipolar disorder

Can include failure to conforms to social norms, lying, conning, impulsivity, irritability, aggressiveness, lack of remorse

Prevalence of ASPD

• Higher if family APD< substance abuse

• Nurture also plays part in familial relationships

• Higher in lower SES

Age of onset of symptoms

Symptoms apparent from childhood and adolescence, tend to diminish across lifespan

Progress of disorder over age

• The estimated prevalence of ASPD rises to almost 4% among individuals ages 25–34 years and falls to under 1% in the 65 and older age group (Holzer et al., 2020).

• Surveys in the United States and United Kingdom show that 2%-5% of the general adult population meet criteria for lifetime ASPD (Goldstein, 2022).

• The disorder may mellow or burns out like a lightbulb over time (e.g., Kenan et al., 2000) or that individuals age out of the ASPD symptoms (Mattar & Khan, 2017) .

ASPD and offending

Strong predictor of offending behaviour - Fridell et al (2008)

ASPD higher prevalence in incarcerated populations - Black et al (2010)

Higher recidivism risk in adult offenders - Harris et al (2017)

What theory is this consistent with?

Moffitt’s (1993) Dual Taxonomy Theory of Antisocial Behaviour - there are two main types of antisocial offenders in society adolescence-limited offenders, and the life-course-persistent offenders,

Aligned with the concept of life-course persistent offenders

Offending initiated at early ages

Chronic offending paths through life

What did Black et al (2010) do?

Random sample of newly incarcerated offenders, mostly men

35.3% ASPD, no gender difference

Younger, higher suicide risk, higher substance misuse, MH disorders including mood, anxiety, BPD, ADHD, poor quality of life, higher risk for recidivism

When combined with ADHD< higher suicide risk and rates of comorbid disorders, lower MH functioning

What did Blair et al suggest about psychopathy?

‘Psychopathy can be considered an extension and one form of refinement of DSM diagnoses of CD and ASPD. Specifically, psychopathy identifies one form of pathology associated with high levels of antisocial behaviour; individuals who present with a particular form of emotional impairment. In contrast, those with CD or ASPD may have a variety of different conditions’

Early signals of psychopathy

• Frick et al (1994; 2014)

  • Callous, unemotional traits - can predict violent / antisocial behaviour / psychopathy in later life

  • Lack of remorse, guilt

  • Shallow affect - no emotional connection

  • Lack of empathy

  • Manipulation of others

  • Grandiose sense of self worth

Review on characteristics of psychopaths

• Callous affect, lack of empathy, manipulativeness

• But - inclusion of criminal / antisocial behaviour as a key component of the psychopathy construct remains debatable

Prevalence of psychopathy

• 0.3-2% in general pop

• Slightly higher rates of self-identified males,, 1-2% vs females 0.3-0.7% of females - Patrick and Drislane (2015)

• Prevalence of psychopathy in prisons higher than general pop, estimates 15-25% (Lilienfeld & Arkowitz, 2007)

What are the tools for measuring psychopathy?

Psychopathy Checklist (Hare, 1980), and more recent version Psychopathy Checklist - Revised (Hare, 1991, 2003)

Criticism of the scale

may be that using the assessment has resulted in overestimation of the disorder in samples who offend

Psychopathy and Recidivism

Hart et al (1988) and Sering and Amos (1995) found much higher rates in recidivism after a 3year follow-up

Hare et al (2000) - higher rate of reconviction and violence after a follow up

Gang membership and peer influence

• One of the most well-established predictors of crime and delinquency is peer influence (e.g. McGloin & Thomas, 2019)

  • Company of peers makes deviance easier and more appealing for youth

  • Peers serve as watchmen during commission of crime, share info about easy and attractable targets

  • Peer relationships also increases symbolic rewards of deviance like reputation, in which deviance can be a performance for peer audiences, leading individuals to achieve and maintain a street reputation

• Membership in gangs involves active interaction with delinquent peers and exposure to peer influence

• Gang membership predicts increased criminal behaviour (Krohn and Thornberry, 2008)

Psychopathy and gang membership

• Limited research looking at psychopathic traits and gangs

  • Vs non-gang members, youth in gangs exhibited higher levels of psychopathic traits, scored 2x higher on lack of empathy (Valdez et al, 2000)

  • Adolescents with psychopathic traits 1.6x more likely to join gang than those who did not (Dupere et al, 2007)

Psychopathy and substance abuse

• The association between substance use & psychopathy has also long been recognized since Cleckley (1941):

  • Ray et al. (2016) showed that a small n. of adolescents with high psychopathic traits accounted for a disproportionate amount of delinquency and substance use.

  • Substance use also facilitates the display of psychopathic features, including risky decision making, aggression, & decreased sensitivity to cues of punishment (Lejuez et al., 2010)

• Substance use could potentially intensify criminogenic behaviours among psychopathic individuals?

Genetic basis of psychopathy

Blonigen et al (2003) - male twins showed moderate heritability

Social basis of psychopathy

 trauma - related to mood disturbance and anxiety (lower in psychopaths)

Neural basis of psychopathy from the grontal lobe

• Orbital and ventrolateral frontal cortex regulate the amygdala, hypothalamus, peri-aqueductal grey & regulate threat responses (Gregg & Siegel, 2001)

• Linked to reactive aggression.

• Psychopathy associated with instrumental AND reactive aggression

• Amygdala implicated - problem learning social behaviours

Passive avoidance learning

Finger et al (2011) - Individuals with conduct disorder with psychopathic traits

• Lower responsibility to early stimulus-reinforcement exposure in the orbitofrontal cortex

• Disruption in the neural systems necessary for appropriate decision making

• Less likely to learn from mistakes

• Selection of non-optimal choices - like harming others

• Learn from emotional feedback more slowly

Amygdala and reinforcement

• Blair et al (2006)

  • Amygdala involved in stimulus-reinforcement associations

  • Expressions of fear and sadness usually are negative social reinforcers, but less so in psychopaths

  • More difficult to socialise via standard parental reinforcement (Oxford et al, 2003)

  • Do not learn to avoid using antisocial behaviour to achieve goals - relative indifference to punishment of victim's distress

Social and environmental influences

• Little direct evidence

  • Some associates with increase in aggression - inconsistent parenting and antisocial background

  • But, inconsistent parenting is related to difficulties for healthy children but not those exhibiting early signs of psychopathy (Oxford et al, 2003) - less able to benefit from different parenting techniques

  • Psychopaths from disadvantaged backgrounds are more violent

Genetic influence - Frick and Viding (2009)

children with Conduct DIsorder do not always have callous-unemotional (CU) traits, but a sizable minority do

Without CU - reactive aggression, feel remorse, can have high / typical anxiety levels

With CU - proactive aggression, lack remorse, have lower anxiety

Early signs of CD / psycopathy

Frick et al (2014)

CD and CU traits include difficulty recognising and reacting to others’ emotions especially fear and sadness

they report less fear themselves and are less responsive to punishment

difficult to socialise - they don’t care about punishment, and don’t empathise with others

Twin study of CD, CU

Viding et al (2005)

Twin pairs (large sample) - those who have CD, at least one twin has high CU, those who have low CU traits

Shared and non-shared environmental factors don’t account for variance in high CU

Co-twins of MZ high CU probands 73% similar to probands

Co-twins of DZ high CU probands only 39% similar

About 2/3s of diference between high CU children in pop can be explained genetically - strong genetic underpinning

Johnson et al (2006) - breaking a cycle

593 families in community sample

longitudinal analysis - offspring 6, 13/16, 22, 33

Low parental affection / nurturin associated with elevated risk for offspring PDs including ASPD across ages 22-33

Environmental risk facros

Those with high CD but low CU - maltreatment and harsh inconsistent parenting predicts increasing high conduct problems (Byrd and Manuck, 2013), so parental warmth may help those with high CU (Pasalich et al, 2011)