Attention-deficit/hyperactivity disorder (ADHD) is the most commonly diagnosed behavioral disorder among children and adolescents. It affects between 3% and 5% of school-age children, and the prevalence rate is four times higher among boys than girls (Agency for Health Care Policy and Research, 1999). Children and adolescents with ADHD experience difficulty controlling their behavior in school and social settings, which puts them at increased risk for involvement in the juvenile justice system. In this article, we explore the relationship between juvenile offending behavior and ADHD. Through a review of the literature and an individual example, interventions to be considered by advanced practice nurses will be discussed.
It is estimated that 45% to 75% of the young people in the juvenile justice system have one or more disabilities (National Center on Education, Disability and Juvenile Justice, 2001; Shelton, 2001), including emotional and behavioral disorders, learning disabilities, and developmental disabilities. The most common diagnoses are ADHD, learning disabilities, depression, developmental disabilities, conduct disorder, anxiety disorders, and posttraumatic stress disorder (PTSD). In many cases, young people are dually diagnosed and experience co-occurring emotional and substance abuse problems; more than half also have a diagnosis of chemical dependence (Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, 2003). Among juvenile offenders, it is estimated that more than 30% may have ADHD (Shelton, in press,), and 40% of boys with untreated ADHD will be arrested for a felony by the time they reach their 16th birthdays (Wasserman, Miller, & Cothern, 2000).
Attention-deficit/hyperactivity disorder is one of a group of disorders, including conduct disorder and oppositional defiant disorder, collectively known as disruptive behavior disorders (McGowan, 2002). Some of the symptoms of conduct disorder, such as theft, are illegal activities, while others, such as lying, are not. Many of the symptoms involve physically aggressive or violent behaviors. Attention-deficit/hyperactivity disorder and/or oppositional defiant disorder usually develop before a conduct disorder; therefore, it is likely that some children with ADHD will also develop conduct disorder and possibly become involved with the juvenile justice system (Wasserman et al., 2000).
The presence of ADHD alone does not predetermine that children or adolescents will engage in the high-risk behaviors that lead to a delinquent status and involvement with the juvenile justice system (Children and Adults with Attention-Deficit/Hyperactivity Disorder [CHADD], 2000). However, the symptoms of the disorder do put children at higher risk for academic failure (including dropping out of school), involvement with drugs and alcohol, and engagement in impulsive, socially unacceptable behavior that may lead to school exclusion or juvenile court prosecution.
Children and adolescents with ADHD are at risk for many other mental disorders. Approximately half of young people with ADHD also have oppositional or conduct disorder, one fourth also experience an anxiety disorder, one third have depression, and approximately one fifth have a learning disability (Kaplan & Cornell, 2004). These children are also at risk for developing personality and substance abuse disorders in adolescence or adulthood.
Relationship Between ADHD and Violent Behavior
Evidence from a meta-analysis of 66 independent studies to identify predictors of youth violence consistently suggests a correlation between symptoms of ADHD (e.g., hyperactivity, concentration problems, restlessness, risk-taking) and later violent behavior, particularly when combined with parental criminality and sibling delinquency (Hawkins et al., 2000). Data also suggest the influence of genetic predisposition and environmental learning in ADHD and criminality. Farrington (1989) observed that boys who had a parent arrested before the boys' 10th birthday were 2.2 times more likely to commit violent crimes than those whose parents were not arrested. Farrington (1989) also found that for boys, concentration problems and restlessness predicted academic difficulties and later violence. In another study, conducted by Klinteberg, Andersson, Magnusson, and Stattin (1993), boys who experienced restlessness and concentration difficulties were five times more likely to be arrested for violence than boys without these characteristics.
The presence of ADHD is not an excuse for illegal behavior. Rather, suspicion about a disability requires that more efforts be made to identify young people who may be depressed, angry, isolated, or experiencing harassment or learning difficulties in school. There is concern that children with ADHD are at disproportionate risk for involvement with the juvenile courts (CHADD, 2000). In many states, once young people are placed under the authority of the juvenile justice system, evaluation for ADHD is minimal and is not taken into account during the dispositional process. Frequently, effective diversion programs, psychiatric treatment services, and community transition services to promote successful reintegration are lacking.
Increasingly, nurses' role in working with adolescents in the juvenile justice system is being recognized as critical to meeting the health and psychosocial needs of this population. To address the complexity of issues facing these young people and to optimize their care provision, multidisciplinary and multisectoral approaches that bring together members of justice, law, social services, educational, and health care systems are necessary (Shelton, 2002, 2003; Wasserman et al., 2003).
Advanced practice nurses are ideally situated to collaborate and work with individual clients, their families, and the other care providers frequently involved with this population. However, regardless of practice level, all nurses have a role in working with young people who are in the juvenile justice system or at risk for such involvement.
The following example, which is a composite of cases encountered by the authors and not an existing adolescent or his family, demonstrates the influence of ADHD on a young person's functioning and treatment options, as well as the role to the nurse in meeting individual clients' needs.
Juan is a 14-year-old, bilingual (Spanish and English), Hispanic, male adolescent who was referred to the HomeCare Program (see the Sidebar on page 40 for a description of the program) by his probation officer. Juan had been in the juvenile justice system for 15 months; his arrest for larceny was the most recent in a series of nonviolent, delinquent behaviors that resulted in a 14-day stay in a juvenile detention center, followed by electronic bracelet monitoring and weekly toxicology screens for illicit substance or alcohol use.
The Homecare Program
The HomeCare Program is a short-term psychotropic medication management program developed in Connecticut as a response to the Emily J. Consent Decree. Settlement of this lawsuit resulted in increased assessment services in juvenile justice settings, increased community services, and improved psychiatric services for juvenile offenders. It is funded jointly by the Connecticut Department of Children and Families and Court Support Services Division and is administered by University of Connecticut Health Center.
The program, which operates in various federally qualified health care centers throughout Connecticut, uses an advanced practice nurse/child psychiatrist model of assessment and medication management of children and adolescents involved in the juvenile justice system. All referrals are initiated by probation officers.
Once accepted, the young person and his or her family receive intensive case management services, psychoeducation, and short-term medication management. Collaborative relationships among probation and child welfare personnel, primary health care providers, multisystemic therapists, school staff, and other individuals involved with the clients are the hallmark of the program. To date, more than 120 children and families have received services through the HomeCare Program.
For more information about the program, contact Geraldine Pearson, PhD, APRN, at
Juan's probation officer, who had worked previously with him, was concerned about Juan's escalating behaviors (e.g., smoking marijuana three to four times per week, breach of peace, chronic truancy) and lack of ongoing psychiatric treatment for a past diagnosis of ADHD. As part of the referral process, the probation officer included Juan's previous detention records, which outlined his behavior while incarcerated, a previous psychiatric evaluation, and consent from Juan's mother to proceed with the referral. Juan was accepted into the HomeCare Program health clinic for assessment, brief medication management services, liaison care with a multisystemic therapist (see the Sidebar on this page for a description of multisystemic therapy), and case management services, with the goal of discharge planning to a longer-term model of care.
Psychosocial Family History
Juan is the oldest of three children born to parents who, as children, immigrated from Puerto Rico to the United States. Juan's mother reports that her husband had a long history of drug use, was verbally abusive to her and their children, had many altercations with the law, and was frequently absent from the home. The parents separated when Juan was 10 years old. At the time of the referral, Juan's father was incarcerated for drug trafficking. Juan's younger sisters, ages 11 and 12, were both attending school and were reportedly doing well socially and academically.
The family lived in a three-bedroom apartment in an urban area, along with his mother's younger sister and a college student who helped care for the children. Juan's mother worked a split shift (i.e., from 3:00 to 7:00 a.m. and from 9:00 a.m. to 2:00 p.m.) for a cleaning company to be home with her children at the beginning and end of each school day.
When discussing Juan, his mother noted that although she was only 17 when she gave birth, she had followed prenatal care and had an uneventful pregnancy. However, her pregnancy was stressful due to her husband's drug use and frequent absences. She also noted that Juan had always struggled academically. By the time he was in second grade, Juan was in a special education class due to attention problems and undefined learning disabilities. He had a brief trial of Ritalin (methylphenidate) (short acting, by the mother's report) at that time. Although his mother thought the medication resulted in improved school performance and ability to do homework for Juan, she indicated her reticence to continue the medication, stating that her extended family did not support this. The family was concerned about addiction, given Juan's father's difficulties with drug abuse and drug trafficking. In addition, consistent with her Puerto Rican cultural and family influences, Juan's mother stated that, at that time, she had preferred to cope with Juan's problems herself, rather than rely on others for assistance. She quickly added that Juan needed “something” right now, and she was not opposed to medication management at this time in his life.
When describing Juan's incarceration in the detention facility, his mother became tearful and worried that Juan would end up just like his father. She wanted Juan to do well, finish school, and stop getting into trouble. She was concerned about Juan's choice of friends, many of whom had been involved with substance abuse, been frequently arrested, and dropped out of high school. She was clearly worried about Juan's future, eager to learn what the HomeCare Program had to offer, and interested in the multisystemic therapy services in an attempt to help Juan.
Juan, a handsome, well-groomed young man, came into the intake appointment in a defensive, negative manner. He immediately launched into a discussion of his mother's rules and the judge's lack of understanding of his situation. He showed the nurse his electronic bracelet and complained about its being uncomfortable. He admitted he did not want to come to the clinic and seemed surprised when the nurse listened to his reluctance.
The nurse explained the HomeCare Program in detail and told him that any decisions regarding medication use would be made together by a team that would include Juan, his mother, and the nurse. Juan seemed visibly relieved at this, although he had great difficulty sitting still throughout the interview. He jiggled his foot, gazed out the window while talking, and stood up at several points and paced. His speech was articulate and clear, and when questioned, he admitted he had great difficulty sitting still and focusing in school. He said this had been a problem “all through school” and that he remembered always having difficulty trying to pay attention. Juan did not remember the brief time in second grade when he had taken Ritalin.
Juan denied experiencing auditory or visual hallucinations or having suicidal or homicidal thoughts or feelings, either currently or in the past. He described having difficulty falling asleep at night and waking in the morning. Despite his sleep difficulties, he generally attended school regularly when not led astray by his friends. He denied feeling depressed and showed a range of affect during the evaluation. His thinking was logical, and there was no evidence of thought disorder. Juan displayed remorse regarding his past behaviors and implied a willingness to change. He admitted he hated hurting his mother. He also indicated that he thought he could work with the multisystemic therapist, who would see him three times per week.
Juan seemed embarrassed by perceived school failure and his early placement in special education, which targeted him as different from his peers. His mother produced school documents that indicated Juan had a mild receptive language disorder and a reading disorder. A Conners rating scale (Conners et al., 1997) completed by the classroom teacher in the detention center indicated Juan experienced motoric hyperactivity and difficulty paying attention. A psychological assessment, also completed while Juan was in detention, revealed no evidence of psychosis or depression, but did indicate a long history of ADHD and a recommendation for stimulant medication. In addition, IQ testing showed a full scale IQ of 83, with a verbal/performance split of 14 points, which is not surprising considering Juan's history of identified learning disorders. Juan's responses on projective testing showed conflicts around men, feelings of abandonment by parental figures, and problems with authority.
The evaluation also capitalized on Juan's strengths, including loving relationships with his mother and sisters, a good relationship with this aunt and extended family, a modest yet comfortable home environment, engagement with the local Roman Catholic church, and a wish to do well. He hoped to eventually become an automobile mechanic.
The nurse's recommendation for a trial of stimulant medication was given to Juan and his mother. This trial would be contingent on Juan's involvement with multisystemic therapy services and frequent collaborative contact with the HomeCare Program. Both Juan and his mother seemed to benefit from the psychoeducational model of care that focused on explaining ADHD, including behavioral interventions and the risks and benefits of medication management. Medication side effects were thoroughly discussed, including carefully observing Juan's weight and eating habits. The risks involved in using substances while taking stimulants was also discussed, along with the potential abuse issues. Juan reminded the nurse that he had many weeks of negative urine screens and was working hard to avoid substance use.
Cultural biases against medication were addressed directly with Juan and his mother, and both seemed to believe Juan should try the medication, despite the opposition of the extended family. Juan, a nonsmoker, had recently been seen by his primary health care provider, had no identified physical health problems, and had no past history of physical illness or accidents. Juan's height was 5 feet, 6 inches, his weight was 140 pounds, and he appeared physically healthy. Prior to beginning the medication, a baseline electrocardiogram was obtained in the clinic, with normal results. Juan's blood pressure and pulse were assessed and found to be within recommended limits.
Both Juan and his mother were committed to working with the HomeCare Program and promised to return to the clinic, remain in telephone contact with the nurse, and call if there were any problems. Juan's diagnoses and treatment plan can be found in the Sidebar on page 42.
Juan's Diagnoses and Treatment Plan
Axis I: Attention-deficit/hyperactivity disorder, combined type
Axis II: Deferred
Axis III: None
Axis IV: Legal problems, problems with educational system
Axis V: Global Assessment of Functioning: highest past year = 50; current = 50
Begin Adderall XR® 20 mg, one oral dosage in the morning. If well tolerated, either add a noon dosage of Adderall XR 20 mg or increase the single morning dosage to Adderall XR 40 mg.
Coordinate care with the multisystemic therapist.
Return to the clinic in 1 week with a plan to assess Juan's response to the medication with his classroom teacher and the multisystemic therapist.
Obtain release of information for the school setting, so the nurse can communicate with this individual.
Obtain release of information for the primary health care provider, who may assume prescriptive responsibility in the future.
Juan and his family were pleased to learn that the multisystemic therapist assigned to them was also Puerto Rican and could relate to Juan, his family, and their community. Juan had an excellent response to Adderall XR® 20 mg, and a noon dosage was added after a 2-week trial of a morning dose (Karch, 2005). Both Juan and his school guidance counselor noted that his ADHD symptoms returned after lunch. Juan experienced some appetite suppression at lunchtime but indicated that his evening appetite, even with a dosage of medication at noon, was good. His weight did not change after 6 months of treatment with stimulant medication.
HomeCare Program staff collaborated with the multisystemic therapist and Juan's primary health care provider, a local pediatrician. After 6 months, medication management was transferred to the pediatrician, and although the multisystemic therapy services ended, Juan continued with the mentor services established while in treatment. He had 6 more months of probation involving biweekly contact with his probation officer. Juan and his mother declined a referral to the local outpatient psychiatric clinic but assured the nurse that they would seek additional psychiatric services if they were recommended by the pediatrician, or if Juan experienced any more legal difficulties and was arrested. At the time of discharge, Juan was attending school regularly, making use of a school counselor, and had avoided further involvement in the juvenile justice system. Juan's response to treatment was very positive; he and his mother made use of the services provided by the HomeCare Program and the local school and community.
Discussion of the Example
Juan represents a typical adolescent who could be in the juvenile justice system; he had a long history of ADHD and engaged in nonviolent criminal activity that resulted in arrest. His impulsivity, school failure, and diagnosed learning disorder were all influenced by his ADHD, all of which likely contributed to his legal difficulties. Treatment with stimulant medication helped him gain better control of his impulsive behaviors, experience more school success, and may have helped him avoid arrest.
Young people being treated with psychotropic medication, including stimulants, need to understand the risks of abusing substances while taking prescribed medications. Efficacy of prescribed medications may be influenced by the ingestion of illicit substances, and more serious side effects involving cardiac functioning can also occur. The psychoeducational model of teaching should include information sensitive to the educational level of the young people and their families. The information should also be available in multiple languages, either in written form or through a translator. This is especially important for a juvenile justice population at risk for substance experimentation and abuse. For Juan, conditions of probation required negative urine screens. Efforts to change his peer group helped him avoid the continued use of marijuana.
Treatment Issues for Juvenile Offenders with ADHD
The American Academy of Child and Adolescent Psychiatry (AACAP) recommends specific, research-based, practice parameters for the diagnosis and treatment of ADHD in children and adolescents, including careful assessment of symptoms and recommendations for treatment. Support from and education of parents or guardians, appropriate school placement, and pharmacological management of the disorder are the cornerstones of treatment (AACAP, 1997). While, young people in the juvenile justice system require the same treatment recommended by the AACAP, there are additional considerations for providing care to this population (some of which also apply to all children and adolescents).
Assessment of Past History and Treatment
This involves a careful review of past records and systematic documentation of each client's treatment history. The type of provider, time frame of treatment, and treatment outcome and conclusion need to be assessed. Often, there is an urgency for treatment at the time of arrest or incarceration; nurses are urged to take the time to complete a thorough history and evaluation, obtain past treatment records, and contact previous providers before making treatment recommendations.
Identification of Comorbid Disorders
Teplin, Abram, McClelland, Dulcan, and Mericle (2002) found that nearly two thirds of young men and nearly three quarters of young women detained in a large urban detention center met diagnostic criteria for one or more psychiatric disorders. Rarely does ADHD occur alone in adolescents, which increases the complexity of the treatment plan and is arguably one of the best reasons to conduct a thorough evaluation of all young people in the juvenile justice system who require management of ADHD. Co-occurring disorders need to be assessed and treated, as they will confound the individuals' response to ADHD treatment.
Risk of Substance Abuse and Trafficking
It is not uncommon for adolescents experiencing psychiatric symptoms to self-medicate with illicit substances. Many will not admit this to a nurse until a therapeutic alliance has been established. Many young people in the juvenile justice system have mandated, as part of their parole, regular urine toxicology tests, which indicate the substances they may be using. Nurses need to access these tests and use them as they plan treatment strategies, including medication management.
Adolescents should not be given stimulant prescriptions if there is any chance they might sell their medication to others. McCabe, Teter, and Boyd (2004) described the use and misuse of prescription stimulants among middle and high school students. For those students taking stimulants to treat their ADHD, 23.3% reported being approached to sell, give, or trade their prescriptions. Stimulant medication has a high street value, and nurses must assess the potential of each client's selling the medication, rather than taking it. Thus, careful monitoring is an important nursing role.
Complexities of Care
Juvenile offenders with ADHD require several levels of treatment for interventions to be effective. The first level of treatment recommended by the AACAP involves psychosocial interventions, including training parents and teachers in behavior-management techniques. The efficacy of behavioral training with teachers is well established, while the evidence of its efficacy with parents is less robust (Pelham, Wheeler & Chronis, 1998). A number of studies have compared parent training (Firestone, Crowe, Goodman, & McGrath, 1986; Gittelman, 1980; Horn et al., 1991) or school-based behavioral modification (Gittelman et al., 1980; Pelham et al., 1998) with the use of stimulant medications. For example, some authors have studied outpatient behavioral therapy programs in which parents meet in groups and are taught behavior management techniques, such as time out, point systems, and contingent attention, and some have investigated the effects of teachers being taught similar classroom strategies. Although these programs may be helpful, the improvements in ADHD symptoms achieved with psychosocial treatments are not as significant as those achieved with stimulant medications (Pelham et al., 1998). Whenever possible, the best results are achieved through a combined approach to treatment that includes both psychosocial interventions and stimulant medication.
With a juvenile justice population in the middle of adolescence, interventions such as time outs and point systems are likely to be ineffective. Many young people diagnosed with ADHD, who are in the juvenile justice system, have been exposed to the interventions used with younger children. Caught between the dependence of childhood and the independence of adulthood, and most likely experiencing other comorbid psychiatric disorders and substance use issues, a multimodal treatment approach is essential.
Such an approach involves psychosocial interventions coordinated within the boundaries of the juvenile justice system. For example, a probation reporting system that combines brief counseling and regular parent meetings could be combined with medication management. A multimodal approach also makes use of the community system of care. Developing a comprehensive, realistic treatment plan involves the young people, their parents or guardians, school staff, and probation/juvenile justice personnel.
Use of Stimulant Medications
As with all psychotropic medications prescribed to children and adolescents, it is important for nurses to assess the meaning of medication to each client and his or her family, as well as their willingness to adhere to treatment regimens. The following questions are particularly useful in identifying areas for further assessment and intervention by the nurse and treatment team:
- Are the client and family aware of the risks and benefits of treating ADHD with medication?
- Is the client at risk for substance use and abuse or for trafficking the prescribed medication?
- What is the long-term plan for medication use?
- How will the client's response be assessed by others who are involved, including health care providers, school staff, and parents?
Such discussions also provide opportunities for young people and their parents to ask additional questions related to treatment and long-term management of ADHD. If clients or their families are unwilling to take the medication as prescribed, and return to the health care provider for follow-up care, they should not be given any medication prescriptions, and other intervention strategies may be attempted.
Young people in the juvenile justice system who have ADHD are particularly challenging to nurses who provide psychiatric treatment. Attention-deficit/hyperactivity disorder is often one of many disorders affecting the young people's functioning; comorbid anxiety, mood, psychotic, and conduct disorders may be operative. The keys to effective treatment of juvenile offenders with ADHD (or any other psychiatric disorder) include engaging them in the treatment process, educating them about their disorder, and offering alternative outlets for their impulsivity and feelings that do not involve breaking the law. Learning to manage their ADHD symptoms, either through psychosocial or pharmacological interventions, is essential to keeping these young people out of jail. Nurses can help them accomplish this by establishing and maintaining a therapeutic relationship, built on a foundation of respect, regardless of the clients' criminal histories.
Effective treatment begins with a thorough assessment of clients' developmental and psychiatric histories, past use of psychotropic medications, responses to treatment, current family and community issues, and other factors that may be influencing them. It is essential for nurses to engage the young people in a relationship in which various treatment options can be explored and mutually agreed on by the treatment team—the client, his or her parent or guardian, and the nurse. A psychoeducational model of ADHD and its presentation into adolescence and adulthood may be an effective way of engaging young people and their families in cooperative treatment.
Essentially, the best treatment involves a coordinated effort among clients and their families, health care providers, juvenile justice personnel (e.g., probation/parole officers, attorneys), school staff, and community members. Coordinating the efforts of a diverse group of practitioners, representing a variety of disciplines and sectors, each with their own mandates, policies, and procedures, can be particularly challenging for nurses. However, advocating for the individual needs of clients and their families is critical; often, this includes advocating for care that is not only evidence based, but also culturally competent. Too often, the treatment team's inability to consider the subtle nuances of cultural variance in symptom presentation, response to treatment, and treatment adherence can lead to inadequate health care for this at-risk group (Hufft & Kite, 2003).