The authors of this article declare no conflict of interest.
This study aimed to describe and compare the educational, social, and family profiles of adults with and without ADHD from two different settings: a prison and an outpatient psychiatric setting. A total of 542 participants, aged between 17 and 69 years, took part in the study. The participants consisted of four groups: a prison sample with ADHD (n = 69) and without ADHD (n = 183), and an outpatient psychiatric sample with ADHD (n = 218) and without ADHD (n = 72). The results showed that, firstly, there were some statistically significant differences between the groups in academic history, social and family situation, and the adoption of risk behaviors during adolescence and early adulthood. Secondly, some of these differences were related to diagnosis (ADHD versus non-ADHD) while others were related to the sample being examined (prison versus psychiatric). The findings from the study showed the presence of significant implications in social, family, educational, and employment achievements both for adults with ADHD (both prison and psychiatric samples) and for adults without ADHD.
Este estudio tiene como objetivo describir y comparar los perfiles educativos, sociales y familiares de un grupo de adultos con y sin TDAH de dos muestras diferentes: una de carcelarios y una población clínica. Formaron parte del estudio 542 participantes, con edades comprendidas entre los 17 y 69 años. La muestra se dividió en cuatro grupos, un grupo de carcelarios con TDAH (n = 69) y sin TDAH (n = 183) y un grupo clínico con TDAH (n = 218) y sin TDAH (n = 72). Los resultados apoyan la hipótesis inicial, que establece que, primero, hay diferencias estadísticamente significativas entre los grupos en cuanto a historial académico, situación social y familiar y la adopción de conductas de riesgo durante la adolescencia y la adultez temprana; en segundo lugar, algunas de las diferencias se relacionarán con el diagnóstico de TDAH, mientras que otras estarán más vinculadas a la población examinada. Los hallazgos del estudio mostraron la presencia de consecuencias significativas para los contextos sociales, familiares, educativos y laborales tanto en poblaciones adultas con TDAH (pacientes en carcelarios y clínicos) como aquellas sin TDAH.
Attention deficit hyperactivity disorder (ADHD) is a neuro-developmental disorder characterized by inattention, hyperactivity, and impulsivity (
Adult ADHD is prevalent (observed in approximately 4.4% of adult populations) (
Recent studies have continued to demonstrate significantly higher functional impairment in adults with ADHD compared to controls (
Previous research suggests that ADHD symptoms during childhood and adolescence may affect academic, social, and family functioning, and may also be related to the adoption of high-risk behaviors, such as drug consumption and legal problems. Unsurprisingly, high rates of neurodevelopmental disorders and difficulties, including ADHD, have previously been reported for incarcerated male, adult offenders (
In a recent study
However, social and academic difficulties are not exclusive to ADHD or the prison population. There is a good deal of evidence for the relationship between mental illness and impaired functioning in various everyday life contexts (
Very common mental disorders, such as anxiety, depression, and some personality disorders, are associated with significant disability and poorer quality of life, as well as impaired social and family functioning (
Several studies suggest that adolescents with mental health problems perform less well in school and attain lower qualifications than other young people without these conditions (
This study aimed to describe and compare the educational, social, and family profile of adults with and without ADHD from two different settings: a prison population and an outpatient psychiatric setting. In particular, this study sought to determine whether there are differences in the psychosocial profile between adults with ADHD from two different settings (psychiatric and prison), and with controls (non-ADHD groups) from the same two settings. The psychosocial variables of interest were: a) academic history (educational failing, repeating school years, academic level achieved), social situation (last work situation before prison, marital status), and family context (family history of substance abuse and mental health problems); and b) adoption of risky behavior during adolescence and adulthood, mainly drug consumption and (for participants from the outpatient psychiatric setting only) having a criminal record.
The sample of 542 participants were aged between 18 and 69 years old (M = 34.04, SD = 10.35 years). Of the total sample, 433 (80%) were men and 109 (20%) were women. Participants were divided into four groups based on two criteria: ADHD diagnosis (ADHD/non-ADHD) and type of setting (prison/psychiatric outpatient). In order to verify the diagnosis of ADHD and to assign the participants to each group, the ADHD-IV scale (
The differences in mean ages between the four groups were statistically significant (
There were also statistically significant differences in gender distribution, with a higher number of men in all of the groups. Differences in the proportion of men and women were statistically significant for the ADHD prison group (c2 = 61.232, p < .001), the non-ADHD prison group (c2 = 152.399, p < .001), and the ADHD psychiatric group (c2 = 24.495, p < .001); while these differences were not significant in the non-ADHD psychiatric group (p = .059).
Participants in the groups with ADHD had higher total scores on the ADHD-Rating Scale IV (
Given the difference in mean ages between the groups, this analysis was repeated with age as a covariate. Age did not have a statistically significant effect (p = .763) on ADHD symptoms. The group from the psychiatric outpatients setting (both with and without ADHD) scored significantly higher on the ADHD scale than the group from the prison setting. This finding may be due to the comorbidity of some ADHD symptoms with symptoms of other mental disorders. This aspect could also explain the absence of differences between the ADHD prison group and the non-ADHD outpatient group.
- For participants in the prison setting information on their family, academic, and social history was obtained via the Penitentiary History Sheet (
- The ADHD Rating Scale-IV (
Approval to conduct this project was obtained from the Research Ethics Committee of the University of Oviedo. The prison setting was a penitentiary center in northern Spain. The prisoners were part of the ordinary program (second grade of the Spanish Prison System). Participants in the psychiatric outpatient setting came from the clinical specialized services of a psychiatric hospital unit in the west of Spain. The psychiatric sample was accessed and selected from patients who came to the hospital requesting psychiatric assessment and treatment. All participants were volunteers who provided informed consent to take part in the study. Confidentiality of participants’ information was guaranteed (
None of the participants in the prison group had a formal diagnosis of ADHD. The prison setting ADHD group was obtained by administering the ASRS scale (
Participants from the psychiatric outpatient setting with ADHD and other clinical disorders had previously been diagnosed by specialized services. However, in order to verify the diagnosis of ADHD and to assign participants to each group, the ADHD Rating Scale-IV (
The information about participants’ academic history, social, and family records was organized in different groups of variables. (1) Academic history and social records: academic failure (failed school years and course repetitions), academic level achieved (from “without studies” to “University”), current or last work performed before prison (“unemployed, employed, informal economy, own business, pensioner, or other”), and marital status (“single, married, divorced, widower, with couple”). (2) Family records: family substance abuse and history of mental health problems. Both questions had two response options (presence = yes, or absence = no) . The type of substance or mental illness was not included in the analyses. (3) Participants’ risk behaviors: substance abuse (frequency by type of substance; “marijuana, cocaine, to sedatives, heroin, ecstasy, inhalants, hallucinogens, and other”), and criminal record (having been tried on at least one occasion - presence = yes, or absence = no). This last variable was only reported in the case of the psychiatric sample.
In keeping with the main objectives of the study, data were analyzed as follows. For differences in academic, social, family, and criminal records between pairs of groups (first comparison: ADHD groups from clinical and prison populations; second comparison: non-ADHD groups from clinical and prison population), given the (qualitative) nature of the variables and the study objectives, frequencies and percentages were used. The χ2 test - or Fisher’s exact test - for categorical variables were used. The Z statistic was used to analyze the differences in percentages. The level of statistical significance was set at p < .05.
One result which stands out as statistically significant in participants’ academic profiles is the difference in percentages of subjects with ADHD who had failed school years. In the prison group the percentage was 87.5% compared to the clinical group’s 72.4% (SE = .064, Z = 2.333, p = .019). Results for the non-ADHD groups were different, with a 76.9% of prisoners having experienced academic failure in comparison to 83.3% in the clinical population. These differences were not statistically significant (p = .302).
The differences in history of repeating school year were not statistically significant. Within the ADHD group, 75% of prisoners had repeated a year, compared to 65.1% of the clinical population (p = .161). In the non-ADHD groups, 65.3% of the prison group had repeated at least one school year, in contrast to 61.6% of the clinical sample (p = .605).
Differences in the participants’ educational level achieved are sharper (
There were no statistically significant differences in the social context variables in relation to the last work performed or in the rates of unemployment (in the case of prisoners, this refers to their situation before imprisonment). However, there were differences in the source of income in the group who were employed, with a higher proportion of prisoners (with and without ADHD) earning money from the informal economy and from subsidies or other social assistance in comparison to the clinical sample with and without ADHD (
Lastly, some differences in marital status between the ADHD and non-ADHD groups were found. In the ADHD group, a statistically significantly higher percentage of prisoners were divorced (p < .01). The percentage of married people in this group was also significantly lower. No statistically significant differences between the prison and clinical population were found in the non-ADHD group (
In the ADHD group (n = 273), a total of 136 participants (49.8%) reported a family history of substance abuse, while in the non-ADHD group, with a total of 225 subjects, this percentage was 52.4%. The difference was not statistically significant (p = .559).
A higher percentage of participants whose families had a history of substance abuse was found in the prison population with ADHD. Of the total sample of 57 inmates with ADHD, 41 (71.9%) reported substance use by their family, in comparison to 95 participants (43.9%) – from a total of 216 – in the clinical sample. These differences were statistically significant (SE = .744, Z = 3.753, p ≤ .001). In the non-ADHD group, 27 participants from the prison sample reported family problems with drugs (47.3%, n = 57), in contrast to 67 from the clinical sample (30.7%, n = 218). These differences were statistically significant (SE = .072, Z = 3.835, p ≤ .001).
Significant differences were also found in the variable: history of family mental health problems. In the ADHD groups, a total of 94 participants (34.18%) answered yes to this question. In the prison group, comprising 158 people, a total of 96 (60.7%) answered yes to this question in comparison to 22 participants (32.8%) from a total of 57 in the clinical group (ES = .705, Z = 2.357, p ≤ .001). Furthermore, in the non-ADHD group, the proportion of family mental health problems was 41.9% (107 from 225 participants). The percentage of mental health problems in the family was higher in the clinical sample (44 participants from a sample of 67 reported these problems, 65.6%) compared to the prison sample, where 63 participants (39.8%) from a population of 158 also reported these problems (SE = .072, Z = -3.543, p ≤ .001).
Analysis of risk behavior habits revealed that there were statistically significant differences in substance abuse for all of the types of drugs analyzed, with higher percentages in prisoners in both ADHD and non-ADHD groups (
Finally, looking at criminal records in the psychiatric outpatients sample only, 20 participants in the ADHD group from a total 218 (9.2%) reported having a criminal record, while 21 participants from 72 in the non-ADHD group (29.2%) answered yes to this question. These differences were statistically significant (SE = .047, Z = -4.221, p ≤ .001).
ADHD is a chronic disorder with onset during childhood, the symptoms of which may persist over time. It is important to note that an individual’s personality is mostly created during that period, and it is considered to be a relatively stable cognitive, emotional, and behavioral pattern. The stability and chronic nature of ADHD suggest at least a theoretical association between this disorder and personality development and consolidation, both adaptive and maladaptive (
Our results support our initial hypothesis, which states that there will be some statistically significant differences between groups in terms of academic history, social, and family situation, and the adoption of risky behaviors during adolescence and early adulthood; some of the differences will be related to the diagnosis of ADHD whereas others will be linked to the population being examined.
The results indicated a general tendency to academic failure in all sub-samples (with and without ADHD, clinical vs. prison population). The high percentage of failures and repeated school years in all the groups is notable, over 70% and 60% respectively in the general sample. It is also worth noting that prisoners with ADHD had the highest proportion of failed school years, followed by those in the clinical sample without ADHD, with percentages of failure over 80% in both sub-samples. The results also showed that there is a higher proportion of uneducated people (or those with only the most basic qualifications) in the sample of prisoners than in the clinical samples. It is worth noting that none of the participants with ADHD in the prison group had university level education, in comparison to 6.5% of prisoners without ADHD who did. This is in line with previous studies which found a relationship between ADHD and other clinical disorders, and academic failure (
Results indicated that there were no differences related to the diagnosis of ADHD and family history of substance abuse, but rather that it was related to the condition of being in prison. A higher frequency of drug abuse in families (i.e., parents, siblings, and partners) was found in this group in comparison to those in the clinical sample. This was expected considering the implications of substance abuse in families for both adults and children (
Results from this study support the hypothesis that in the prison sample, both with and without ADHD, the condition of being in prison is associated with increased and aggravated the adoption of risk behaviors compared to the clinical group, mainly drug consumption in adolescence and adulthood, among others. Various studies show the existence of drug abuse in individuals with ADHD. Specifically,
There are structural and functional alterations in reward circuits in this population (
ADHD is a very common clinical condition in children, but also, importantly, in adults. However, current assessment tools and intervention programs seem to be more aimed at overcoming problems associated with the disorder as early as possible, which is tremendously important. Sometimes, however, we fall into the error of not paying attention to the part of the population that, although adult, may be suffering from the consequences of ADHD. Our study aimed to examine this specific population in two different contexts (prison, and the mental health system), in order to look more deeply into these consequences. Findings showed the presence of significant consequences in social, family, educational, and work contexts for both populations with ADHD in comparison to those without, although some sort of differential profiles were found between them. The group of prisoners with ADHD is especially vulnerable in this sense, exhibiting the highest levels of disorganization and impairment in their daily lives. This suggests the need to consider these particular issues when designing treatment programs for prison inmates with ADHD, as well as more fluid communication and collaboration between prison and mental health services. The clinical sample cannot be overlooked, however. The incidence of family mental illness in this population is huge, which suggests the importance of resilience at the same time as calling for specific family – and environmentally based – programs in order to break this tendency (
In general terms, based on the participants’ reports, some problems could be related to the ADHD symptoms while others are more likely linked to factors found in prison populations. Firstly, regarding academic failure, there is a statistically significant higher percentage of participants with no schooling in the prison population, and some differences related to ADHD symptoms increase the risk. The same pattern occurs in terms of job and unemployed before prison, or differences in substance abuse, or mental health problems in the family with some influence of ADHD symptoms or diagnosis. On the other hand, some social variables like earning money from the informal economy and from subsidies or a higher percentage of divorce are more prevalent in the prison population. Also, participants in the prison setting reported more family problems with drugs and higher percentages in substance abuse of the different types of drugs.
It is necessary to acknowledge some limitations in the present study. First, it is important to note that the sample was not evenly distributed between genders, with a higher proportion of male participants, especially in the prison group. Although some studies have been carried out with female prisoners (
We would like to thank Dr Stephen Loew and Nigel Marsh for their contribution in the areas of language and style corrections.
Cite this article as: García, T., Rodríguez, C., Rodríguez, J., Fernández-Suárez, A., Richarte, V., & Ramos-Quiroga, J., A. (2019). Psychosocial profiles of adults with ADHD: A comparative study of prison and outpatient psychiatric samples.
Funding: This work was supported by the Regional Government of Asturias under Grant [FC-15-GRUPIN14-053].