Attention deficit disorders

The diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) in correctional settings is in itself problematic and quite contentious; treating the disorder more so. Community prevalence studies estimate that 2.5% to 4% of adults in the United States and worldwide meet diagnostic criteria for ADHD. Some research findings suggest that ADHD occurs at far greater prevalence rates among criminal justice populations than in the population at large. The nature of the condition, its assessment, and its management combine to create a perfect storm of potentially vexing challenges for the prison psychiatrist. This chapter reviews those diagnostic and treatment challenges, including the risk of diversion and misuse of controlled substances among inmates. An assessment and treatment model is presented that takes into account and minimizes risk while helping ensure access to care in appropriately selected cases. Some inmates have a compelling need for treatment, potentially including stimulant medications. Neither unbridled use nor complete elimination of stimulants makes good clinical or administrative sense for correctional systems. An approach that relies on current impairment in significant functional areas, meaningful involvement in treatment, and absence of active misuse of substances will allow access to medication for those with verifiable need while lessening the risks associated with prescription of controlled substances in jails and prisons. The issues of differential diagnosis in a population with epidemic substance abuse, the challenges of appropriate management, and an evidence-based treatment model are discussed in this chapter.