Attention-deficit/hyperactivity disorder (ADHD) is associated with neurobehavioral reward system dysfunctions that pose debilitating impairments in adaptive decision-making. A candidate mechanism for such anomalies in ADHD may be a compromise in the control of motivated behaviors. Thus, demonstrating and restoring potential motivational control irregularities may serve significant clinical benefit. The motivational control of action guides goal-directed behaviors that are driven by outcome value, and habits that are inflexibly cue-triggered. We examined whether ADHD symptomology within the general population is linked to habitual control, and whether a motivation-based manipulation can break well-learned habits. We obtained symptom severity scores from 106 participants and administered a Go/NoGo task that capitalizes on familiar, well-learned associations (green-Go and red-NoGo) to demonstrate outcome-insensitivity when compared to newly learned Go/NoGo associations. We tested for outcome-insensitive habits by changing the Go and NoGo contingencies, such that Go signals became NoGo signals and vice versa. We found that generally, participants responded less accurately when green and red stimuli were mapped to color-response contingencies that were incongruent with daily experiences, whereas novel Go/NoGo stimuli evoked similar accuracy regardless of color-response mappings. Thus, our Go/NoGo task successfully elicited outcome-insensitive habits ; however, this effect was independent of ADHD symptomology. Nevertheless, we found an association between hyperactivity and congruent Go response latency, suggesting heightened pre-potency to perform habitual Go actions as hyperactivity increases. To examine habit disruption, participants returned to the lab and underwent the familiar version of the Go/NoGo task, but were given mid-experiment performance tracking information and a monetary incentive prior to contingency change. We found that this motivational boost via dual feedback prevented the incongruency-related accuracy impairment, effectively breaking the habit, albeit independent of ADHD symptomology. Our findings present only a modest link between ADHD symptomology and motivational control, which may be due to compensatory mechanisms in ADHD driving goal-directed control, or our task’s potential insensitivity to individual differences in ADHD symptomology. Further investigations may be crucial for determining whether ADHD is related to motivational impairments. Individuals with attention deficit-hyperactivity disorder (ADHD) are known to exhibit cognitive impairments that span domains of attention and impulsivity . These hThe motivational account of behavioral control posits that our actions can be either goal-directed, as in, performed deliberately in pursuit of a desirable outcome, or habitual, as in, triggered in response to a salient cue regardless of outcome value . These cIf ADHD is indeed associated with enhanced habitual control that favors outcome-insensitive behaviors, the next logical and translationally valuable step would be to identify strategies that can overcome this behavioral deficit. For instance, performance-contingent feedback is a frequently employed tool that has been shown to improve behavioral output . The posTackling the expression of habits and the restoration of goal-directed behaviors in potentially compromised populations may involve overcoming the methodological limitations of the traditional habit paradigm. A meaningful assessment of habit expression and disruption may require access to rigid habits with a strong association between the triggering stimulus and the behavioral response. Therefore, instead of relying on labile, newly learned habits that have been the subject of inquiry in most investigations of motivational control , it may 1, we used ADHD-related measures to detect whether symptoms of the disorder tracked well-learned habit expression and disruption.To this end, we developed a Go/NoGo task that capitalizes on familiar green and red traffic light stimuli that activate existing stimulus–response associations . If greea priori power analysis on data from an existing study that examined inhibitory control capacity and ADHD-related symptoms  from the Rutgers University-Newark campus participated for course credit. Informed consent was provided by all subjects per Declaration of Helsinki human subject protection guidelines. The Rutgers University Institutional Review Board approved study protocols. Individuals were excluded from participation for self-reported color-blindness. Two participants’ data were excluded from analyses due to attrition (n = 1) and data corruption (n = 1). Thus, the statistical analyses were performed on the remaining 104 participants .To determine the sample size for our study, we performed an symptoms . In thisParticipants performed Go/NoGo tasks adapted from Day two was completed within 3 days of day one and examined the potential habit-disrupting effect of a motivational enhancement. We separated these sessions by at least 1 day to minimize potential training effects. On day two, all participants underwent the Familiar condition of the Go/NoGo task, completing the “congruent” color-mapping first. Next, we induced motivational enhancement via the delivery of cumulative performance feedback and a monetary incentive. Specifically, participants’ cumulative task performance was displayed as a percentage score on the screen. Additionally, the experimenter briefly left the room, returning shortly after with a $5 cash bonus. The participants were informed that the $5 bonus was due to their performance on the task. The participants were then instructed to perform the “incongruent” color-mapping of the Familiar condition, and were informed that they may receive another performance-contingent cash bonus afterward. Unbeknownst to the participants, the mid-session cash bonus was not actually contingent on performance. We did not counterbalance color-mapping of Go/NoGo contingencies on day two to render the congruent color-mapping performance as baseline. Thus, we were able to test whether the presence of a mid-experiment motivational manipulation affected subsequent incongruent color-mapping performance . Lastly, participants completed the Creature of Habit Survey (COHS) , quantifIn each phase, there was a 5:1 Go/NoGo ratio, with 100 Go and 20 NoGo trials. Each Go/NoGo stimulus remained on the screen for 400 ms. Participants were required to respond to Go signals before the offset of the stimulus for a correct response. After offset, each response produced a brief “correct” or “incorrect” text slide. To ensure engagement with the task, inter-trial intervals varied randomly between 1200 and 2400 ms. Participants completed a practice session prior to each Stim_Familiarity condition, which consisted of six correct Go or NoGo responses using that condition’s stimuli. The experimenter remained present to ensure the instructions were understood during the practice sessions.We pre-registered our task procedures and analyses prior to data collection via the Open Science Framework project registration portal (document URL: see text footnote 1). Analyses that were not outlined in our pre-registration document are marked as exploratory below. Data analysis was performed using the nlme package in R (version 3.5.1).We used NoGo accuracy as our primary measure of outcome-sensitivity,as the moderate Go to NoGo ratio was hypothesized to produce prepotent Go responses . NoGo acParticipants with standardized residuals less than −3.3 and greater than 3.3 were identified as outliers . Analysepost hoc t-tests of NoGo accuracy between phases in each Stim_Familiarity condition to ascertain differential mapping-related impairment across Familiar and Novel conditions. Lastly, because of our specific focus on the influence of ADHD symptomology on habitual control, we also entered all individual difference measures’ interactions with Stim_Familiarity as regressors  into step four of the model. Thus, we were able to distinguish the effects of each variable on outcome-sensitivity across Familiar and Novel conditions.We performed an omnibus hierarchical multiple regression test to discern the contributions of symptom severity on outcome-sensitivity within Familiar and Novel condition data collected on day 1. This hierarchical structure permitted us to extract information about the amount of variance explained by groups of regressors , while also obtaining the predictive strengths of each individual regressor. Importantly, each additional step in the hierarchy updates the parameter estimates of the regressors in the previous steps, such that we are also able to detect how controlled variables may influence other regressors of interest. We used ΔNoGo_Accuracy  as our dependent variable (DV) to measure the within-subject mapping-related change in accuracy. A greater mapping-related impairment represents greater outcome-insensitivity . In a hierarchical structure, we first input the regressors Age, Gender, Stim_Familiarity_Order (order in which participants underwent Familiar and Novel conditions), Phase_Order (order in which participants underwent color-response mappings within each Stim_Familiarity condition), and Driving , with Subject as a random factor into a linear mixed model. This model extracted the predictive strength of each of these controlled variables on outcome-sensitivity. In the next hierarchical step, we added the regressors ASRS_Inattentive (part A of the ASRS measure capturing symptoms of inattention), ASRS_Hyperactive (part B of the ASRS measure capturing symptoms of hyperactivity), and ASRS_Total (parts A and B aggregated to derive a composite score of ADHD symptom severity). Because our sample included six participants who had received ADHD diagnoses, we also input a Diagnosis regressor to determine whether clinical manifestation of ADHD – albeit in a small proportion of participants – affects outcome-sensitivity. We used COHS scores as a regressor to find potential correlations with tendency to behave habitually in daily life and outcome-sensitivity in our task. These regressors served to explain the main effects of each individual difference measure on outcome-sensitivity. In the third step of the hierarchical model, we input Stim_Familiarity (Familiar/Novel) as a regressor to specifically detect whether participants exhibited differential outcome-sensitivity across Familiar and Novel conditions. A significant contribution of this variable would confirm that the familiar red and green stimuli indeed elicit outcome-insensitive, habitual control, while the novel stimuli are labile, and thus controlled by goal-directed processes. We performed In brief, we expected the controlled demographic and counterbalancing variables  to be trivial in predicting outcome-sensitivity. We did not expect the Driving regressor to play a significant role in altering outcome-sensitivity, as we expect our well-learned habit task to capture well-established associations that extend beyond experience with these color-response mappings in a traffic context. We input both main effect and interaction regressors related to individual differences in ADHD symptomology and daily habitual tendencies to reveal potential associations with outcome-sensitivity. This way, we were able to inquire whether these individual difference regressors yielded strong associations with global outcome-sensitivity , and further interrogate whether such an association existed with well-learned habit expression in particular . We also expected Stim_Familiarity to serve as a significant predictor in driving outcome-sensitivity, as the Familiar condition stimuli should selectively elicit outcome-insensitive habits, while the Novel condition stimuli should have no such effect on behavior.We have previously shown the habit-disrupting effect of cumulative performance and monetary feedback . Here, wSimilar to our previous omnibus regression, we expected trivial contribution from our controlled variables, but a significant contribution from the Feedback regressor, as the delivery of dual feedback should disrupt the well-learned habit. We expected that symptom severity may affect outcome-sensitivity globally , but also differentially across Feedback sessions . Additionally, we identified an alternative hypothesis – the possibility of habit disruption across the board . We expected no directionality in subtypes governing outcome-sensitivity , but we do note that if either subtype plays a major role in driving motivational control in the previous omnibus regression detecting the role of symptom severity on habitual control, that same subtype should predict habit disruption. We expected the frequency of habitual tendencies in daily life, as assayed by COHS, to yield a negative correlation with habit disruption .We used Go accuracy as a supplemental measure of outcome-sensitivity. Thus, we repeated all mixed models that examined ΔNoGo_Accuracy using ΔGo_Accuracy as DV.r values were corrected for multiple comparisons using the Holm–Bonferroni method. Specifically, we expected a negative correlation between RT and our individual difference measures. Most notably, we expected such an association between RT and ASRS_Hyperactivity, which would suggest quicker familiar Go actions to be associated with pronounced hyperactivity.We extended our analyses beyond the pre-registered plans and explored the potential correlations between Go reaction time (RT) and our individual difference measures of symptom severity (ASRS_Inattentiveness and ASRS_Hyperactivity) and daily habitual tendencies (COHS). These variables were entered into a correlation matrix, and Pearson’s We performed a linear mixed model using ΔNoGo_Accuracy as the DV and Subject as a random factor to determine whether ADHD symptom severity significantly predicts outcome-sensitivity in our well-learned habit task. Our proposed model violated the assumptions of non-multicollinearity, in that three pairs of fixed factors were highly correlated with each other , model R2 = 0.03. In the second step of the model, we added the individual difference measures of ADHD symptom severity, clinical ADHD diagnosis, and frequency of habitual tendencies in daily life (COHS). We found no main effects of individual difference measures on outcome-sensitivity . The log likelihood estimate derived by comparing first and second steps of our model yielded no significant global  contribution attributable to the ASRS_Inattentive, ASRS_Hyperactive, Diagnosis, and COHS regressors, χ2(4) = 0.70, p = 0.952, R2 = 0.03, ΔR2 < 0.01. In the third step, we entered the Stim_Familiarity regressor, which significantly improved the predictive strength of the model, χ2(1) = 21.53, p < 0.001, R2 = 0.13, ΔR2 = 0.10, βStim_Familiarity = 0.31, t(103) = 4.66, p < 0.001, meaning outcome-sensitivity was differentially affected by whether participants managed the Familiar or Novel versions of the task. Post hoc t-tests confirmed that mapping-related NoGo accuracy impairments were evident only when managing Go/NoGo contingencies in the Familiar condition, t(103) = 5.33, p < 0.001, while performance in the Novel condition was comparable regardless of color-mapping associations, t(103) = −1.09, p = 0.279  = 6.19, p = 0.186, R2 = 0.15, ΔR2 = 0.03). These results suggest that our sample exhibited outcome-insensitive well-learned habits across the board, but the degree of habitual control as assessed by change in NoGo accuracy was not significantly related to ADHD symptom severity.Standard within-group residuals were within −3.3 and 3.3; thus, no participants were identified as outliers . In the .279 see . In the ps > 0.142), model R2 = 0.01. In step two, we added ASRS_Inattentive, ASRS_Hyperactive, Diagnosis, and COHS into the model, and found that none of these regressors yielded main effects on outcome-sensitivity , and they did not significantly improve the predictive strength of the model, χ2(4) = 3.19, p = 0.526, R2 = 0.03, ΔR2 = 0.01. We input Feedback as a regressor in step three, which contributed significantly to predicting outcome-sensitivity, βFeedback = −0.28, t(103) = −4.13, p < 0.001, and rendered the model a significant predictor of ΔNoGo_Accuracy, χ2(1) = 17.10, p < 0.001, R2 = 0.11, ΔR2 = 0.08. We performed post hoc paired-samples t-tests to confirm the beneficial effect of dual feedback. We found that a significant NoGo accuracy impairment was evident in absence of dual feedback, t(103) = 5.33, p < 0.001, whereas the delivery of feedback yielded no significant accuracy impairments, t(103) = −0.50, p = 0.616  = 1.56, p = 0.815, R2 = 0.11, ΔR2 = 0.01). These results suggest that the delivery of dual feedback indeed had a protective effect on outcome-sensitivity when managing familiar stimuli, albeit independent of ADHD symptom severity.Similarly, we altered our pre-registered model to prevent multicollinearity, and performed a linear mixed model to examine the link between ADHD symptomology and habit disruption see . The pre.616 see . No indips > 0.323), model R2 = 0.01. In step two, the Diagnosis regressor, which codes for the presence of a clinical ADHD diagnosis, made a significant contribution, βDiagnosis = 0.17, t(94) = 2.11, p = 0.038  = 1.80, p = 0.076). Specifically, the presence of a diagnosis predicted more flexible Go actions. No other step two regressor significantly predicted ΔGo_Accuracy  The step two model was not significantly improved from step one, χ2(4) = 5.56, p = 0.235, R2 = 0.04, ΔR2 = 0.03. The Stim_Familiarity regressor in step three served as a significant predictor, βStim_Familiarity = 0.14, t(101) = 2.07, p = 0.010, improving the predictive strength of the model, χ2(1) = 4.44, p = 0.035, R2 = 0.06, ΔR2 = 0.02. Paired-samples t-tests revealed a significant Go accuracy impairment in the Familiar condition, t(101) = 3.80, p < 0.001, but not the Novel condition, t(101) = −0.77, p = 0.445  = 2.71, p = 0.008, no individual difference measures significantly predicted ΔGo_Accuracy across the Familiar and Novel conditions  = 10.43, p = 0.034, R2 = 0.10, ΔR2 = 0.05). Because we only had six individuals with an ADHD diagnosis, we refrain from further interpretations of the contribution of the Diagnosis regressor. These results suggest that Go accuracy is differentially affected by whether familiar or novel stimuli serve as Go/NoGo signals, and a significant impairment is evident when familiar contingencies are incongruent with daily experiences. However, the habitual Go actions elicited by our familiar stimuli are independent of ADHD symptom severity.We performed identical analyses using ΔGo_Accuracy as DV and Subject as a random factor to capture the potential association between ADHD symptomology and a supplemental assay of outcome-sensitivity see . Two par.445 see . Lastly ps > 0.093), model R2 = 0.02. In step two, COHS was a near significant variable, βCOHS = −0.14, t(94) = −1.95, p = 0.054  = −1.05, p = 0.296), suggesting that a higher frequency of daily habits may predict more outcome-insensitive Go actions. Otherwise, no individual difference regressor served as a significant predictor of ΔGo_Accuracy , although the inclusion of step two regressors resulted in the Phase_Order variable to yield a near-significant p-value, p = 0.066. Step two regressors in aggregate yielded only a near-significant contribution on the DV, χ2(4) = 8.56, p < 0.073, R2 = 0.06, ΔR2 = 0.04. In step three, the Feedback regressor significantly predicted outcome-sensitivity as indexed by ΔGo_Accuracy, βFeedback = −0.26, t(101) = −4.07, p < 0.001, improving the predictive strength of the model, χ2(1) = 16.01, p < 0.001, R2 = 0.13, ΔR2 = 0.07. This finding suggests that outcome-sensitivity as assessed by ΔGo_Accuracy is differentially impacted depending on the availability of dual feedback. Indeed, a post hoc paired-samples t-test confirms a significant impairment in Go accuracy when no feedback is delivered, t(103) = 3.85, p < 0.001, whereas with feedback, no such impairment is evident, t(103) = −0.56, p = 0.573  = −2.46, p = 0.016 (without outlier-correction: p = 0.120), suggesting that an increased daily habit frequency predicts a reduction in the beneficial effects of dual feedback in restoring goal-directed control. No other individual difference × Feedback regressor predicted habit disruption  = 9.70, p = 0.046, R2 = 0.16, ΔR2 = 0.04). Similar to our primary measure of outcome-sensitivity using NoGo accuracy, the protective effect of dual feedback on Go accuracy was independent from ADHD symptomology. However, we do observe a significant association between habitual tendencies in daily life and a difficulty in suppressing a well-learned habit.We investigated habit disruption via mapping-related changes in Go accuracy using a similar mixed model see . Our mul.573 see . In stepr = −0.25, p = 0.030, Holm–Bonferroni corrected , or when the Novel condition stimuli served as the Go signal . The association between familiar Go RT and ASRS_Hyperactivity may suggest that individuals high in hyperactive symptoms may be exhibiting abnormally pronounced prepotency to stimuli that evoke habitual control.We explored the potential association between prepotency to respond to the familiar Go stimulus and our individual difference measures of ADHD symptom severity (ASRS_Inattentiveness and ASRS_Hyperactivity) and daily habit frequency (COHS). We reasoned that hyperactive individuals may exhibit a more pronounced prepotency to respond to Go stimuli, thus we were especially interested in the hyperactivity scale’s association with RT. As hypothesized, we found a significant negative correlation between Go RT to the familiar green-Go color-response mapping and ASRS_Hyperactivity, orrected , suggestThe neurobehavioral evidence of atypical reward-related processes in ADHD, and the scarcity of strategies to restore potential behavioral rigidities, motivated us to examine the expression and disruption of well-learned habits as a function of ADHD symptom severity. To this end, we collected ADHD symptom severity metrics from a wide sample of participants in the general population and administered our Go/NoGo task that capitalizes on familiar green-Go/red-NoGo associations. Importantly, our incorporation of a motivational enhancement manipulation  permitted the study of habit expression and disruption. Our results replicate our recent documentation of familiar Go/NoGo stimuli evoking rigid habitual control, which is also rendered more flexible  with motivational enhancement . HoweverA cardinal indicator of habitual control is the performance of an action regardless of the outcome value . AccordiWe assert that our familiar stimuli elicit outcome-insensitive habits due to their well-established nature. The newly formed associations  are more labile, allowing the agent to exert goal-directed control regardless of changes to the color-response mappings. By this logic, these novel associations should eventually elicit habitual control with sufficient exposure – similar to overtraining of S–R associations in rodents . The magIn both scientific reports and diagnostic criteria, ADHD is characterized by pronounced deficits in inhibitory control . When tan = 1156) obtained from the general population pinpointed Go/NoGo impairments due to high ADHD-like symptoms, though these effects were sensitive to variations in task structure   . Taken tAn alternative explanation for the absence of a strong link between motivational control and ADHD symptomology is the notion that individuals with ADHD-like symptoms may also have compensatory mechanisms that promote adaptive behavioral output. For instance, despite the strong evidence of response inhibition deficits in ADHD, attention compensation supported by parietal brain activity has been documented, resulting in comparable Go/NoGo task performance . AnotherWe reasoned that because hyperactive ADHD presentation is associated with the number of impulsivity-related items endorsed on the ASRS , particiIn addition to the analyses reported here, an alternative method of exploring Go and NoGo performance is via signal detection. In a typical signal detection analysis, hits, misses, false alarms, and correct rejection values are used to derive d’ – an estimate of response bias . ImportaWe acknowledge several limitations in the present study that should be considered in future investigations.Although we were able to generalize our findings to a wider audience by recruiting without diagnostic cutoffs, we did not survey participants for history of psychiatric illnesses or psychoactive medication use. Several psychiatric conditions have been documented to affect motivational control . FurtherOur study’s primary hypotheses regarding habitual control and ADHD symptomology were motivated by reports of reward circuitry dysfunction in ADHD . HoweverWe adopted a within-subject design to tackle the expression and disruption of habits over the course of two sessions. This design permitted us to compare habit expression and disruption at an individual basis while improving statistical power. However, it can be argued that administering a task twice to the same set of participants may introduce training effects. Our second session data suggest that participants did not significantly improve their performance in the face of congruent associations by merely undergoing the task in the previous session. However, the definitive method to circumvent potential training effects would be to apply a between-subjects design, in which separate sets of participants undergo the feedback and no-feedback sessions. We report in another study that adopts a between-subject design a similar pattern of results – motivational enhancement indeed disrupts the expression of well-learned habits .Attention deficit-hyperactivity disorder is a heterogenous psychiatric condition with debilitating consequences to behavior, neural processing, and well-being. In this study, we aimed to reveal the potential irregularities in managing well-learned habits by sampling symptom severity information from the general population. Although we did not find a strong association between motivational control deficits and ADHD-related symptoms, our data replicate a previous report of well-learned habit expression and disruption, and allude to a link between hyperactivity and pre-potency to respond to well-learned Go stimuli. Taken together with previous reports of compensatory mechanisms aiding in Go/NoGo task performance in ADHD, delay in cortical maturation in ADHD yielding differential inhibitory processes across children and adults, and our sample largely comprising subclinical ADHD presentations, a full understanding of the potential link between ADHD and motivational control may require a neurobehavioral and developmental approach.The datasets and scripts associated with this study can be found in the This study was carried out in accordance with the recommendations of the Rutgers University Institutional Review Board with written informed consent from all subjects. All subjects gave written informed consent in accordance with the Declaration of Helsinki. The protocol was approved by the Rutgers University Institutional Review Board.AC and ET designed the experiments. AC and GE coded the experimental paradigm and collected the data. All authors contributed to the data analysis and manuscript preparation.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


In youth, ADHD is more commonly diagnosed in males than females, but higher male-to-female ratios are found in clinical versus population-based samples, suggesting a sex bias in the process of receiving a clinical diagnosis of ADHD. This study investigated sex differences in the severity and presentation of ADHD symptoms, conduct problems, and learning problems in males and females with and without clinically diagnosed ADHD. We then investigated whether the predictive associations of these symptom domains on being diagnosed and treated for ADHD differed in males and females. Parents of 19,804 twins  from the Swedish population completed dimensional assessments of ADHD symptoms and co-occurring traits (conduct and learning problems) when children were aged 9 years. Children from this population sample were linked to Patient Register data on clinical ADHD diagnosis and medication prescriptions. At the population level, males had higher scores for all symptom domains  compared to females, but similar severity was seen in clinically diagnosed males and females. Symptom severity for all domains increased the likelihood of receiving an ADHD diagnosis in both males and females. Prediction analyses revealed significant sex-by-symptom interactions on diagnostic and treatment status for hyperactivity/impulsivity and conduct problems. In females, these behaviours were stronger predictors of clinical diagnosis , and prescription of pharmacological treatment . Females with ADHD may be more easily missed in the ADHD diagnostic process and less likely to be prescribed medication unless they have prominent externalising problems.The online version of this article (10.1007/s00787-018-1211-3) contains supplementary material, which is available to authorized users. Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterised by age-inappropriate and maladaptive levels of inattention and/or hyperactivity/impulsivity. In children and adolescents, ADHD is more commonly diagnosed in males, with the sex ratio ranging from 2:1 to 10:1 . HoweverThe findings relating to sex differences in ADHD are variable and sometimes contradictory, partly due to differences in sample characteristics. Meta-analyses tend to show less severe symptoms in females versus males with ADHD identified from non-referred, community populations, but similar levels in clinically ascertained samples—with the exception of inattention for which females had higher ratings in the more recent meta-analysis , 9. SeveSex differences in the phenotypic expression of ADHD are often proposed as an explanation for the greater rates of ADHD diagnosis in males. A common hypothesis is that females with ADHD are more likely to present with predominantly inattentive symptoms, and less hyperactive/impulsive or conduct problems than boys, and are thus perceived as less problematic , 7, 11. Studies also show sex differences in the pattern of ADHD treatment, with males being more likely to receive ADHD medication than females , 13. HowAnother consideration in the diagnostic and treatment process of individuals with ADHD is the presence of co-occurring learning problems, since learning problems represent another leading reason for identification of children with ADHD. Research has demonstrated that females with ADHD are less likely to have learning difficulties or manifest problems at school compared to males , 15, whiThis study investigated sex differences in ADHD using a large population-based sample [The Child and Adolescent Twin Study in Sweden (CATSS)] linked to Swedish National Patient Register data on clinical ADHD diagnoses and prescribed ADHD medications. Thus, enabling investigation of a population-based and clinical sample for which there is not an ascertainment bias and overcoming important limitations of studies reliant on one type of sample alone. We first described the severity of ADHD symptoms, conduct, and learning problems in males and females with and without clinically diagnosed ADHD, followed by examination of the ADHD symptom presentation. We then investigated whether the predictive associations of inattention, hyperactivity/impulsivity, conduct problems, and learning problems on being diagnosed and treated for ADHD differed in males and females. It was hypothesised that (1) at the population level, males would show greater symptom severity than females, but at the clinical level similar severity would be observed, with the exception of inattention for which levels may be higher in females as suggested by meta-analysis, (2) hyperactivity/impulsivity and conduct problems would be a stronger predictor of diagnosis in females than in males and inattention a weaker predictor, and (3) in children with a clinical diagnosis of ADHD, hyperactivity/impulsivity and conduct problems would be a stronger predictor of medication status in females than males.It is important to increase our understanding of sex effects in ADHD and whether certain symptoms are more predictive of clinical diagnosis and pharmacological treatment (including whether sex differences in such predictors exist), as it can lead to improved identification of females with the disorder. Furthermore, it may point towards certain biases in the diagnostic and treatment process which has implications for clinical practice and can inform our understanding of the way that clinicians recognise ADHD symptoms, and potentially apply the diagnostic criteria.Participants were from The Child and Adolescent Twin Study in Sweden (CATSS) , an ongoADHD symptoms and co-occurring behavioural traits The Autism-Tics, AD/HD and other Comorbidities Inventory (A-TAC) was administered to parents of twins over the telephone, and questions were asked from a lifetime perspective. The A-TAC is a broad screening instrument that encompasses multiple neurodevelopmental disorders. Two modules of the A-TAC are used to assess ADHD (one assessing inattention [9 items] and one assessing hyperactivity/impulsivity [10 items]), consisting of a total of 19 items that correspond closely to DSM-5 diagnostic criteria for ADHD [for ADHD . Questiofor ADHD –21.Using the A-TAC ADHD items, it is possible to categorise individuals based on DSM-5 symptom criteria for the three ADHD presentations: the predominately inattentive presentation, based on the presence of six or more symptoms of inattention; the predominantly hyperactive/impulsive presentation, based on the presence of six or more symptoms of hyperactivity/impulsivity (using nine of the ten A-TAC items); and the combined presentation, based on six or more symptoms of both inattention and hyperactivity/impulsivity. From the three-point scale described above, we dichotomised responses for each item into ‘symptom present’ (‘yes’ and ‘yes to some extent’ were collapsed into one category) and ‘symptom absent’ to enable categorisation of participants into one of the three ADHD presentations.The A-TAC also includes questions that target other well-described clinical features of psychiatric disorders, such as conduct problems  and learning difficulties (three items relating to reading and maths skills and slow learning), also scored on a three-point scale as above. Thus, whilst looking specifically at one disorder, co-occurring problems can also be examined. Of note, although the A-TAC also includes questions on anxiety and mood, we were unable to examine these variables due to a reduced number of CATSS participants completing these questions.Socio-Economic Status (SES) Maternal education from the Swedish Register of Education was used as an indicator of socio-economic status. A categorical variable was created .Unique personal identifier numbers enable data from participants in the CATSS sample to be accurately linked with information from National population-based registers up until December 2013. Thus, it was possible to determine whether participants in CATSS had been referred to a specialist clinic and diagnosed with ADHD, and if they were prescribed ADHD medication. Registry data were also used to identify 273 participants in CATSS who had emigrated (obtained from The Migration Register) or died (obtained from The Cause of Death Register) after their participation in the study; these individuals were excluded from analyses.The National Patient Register (NPR) The NPR contains information about all psychiatric inpatient (from 1987) and outpatient (from 2001) care in Sweden, from both private and public caregivers (primary care is not currently included). Clinical ADHD diagnoses are based on the International Classification of Diseases (ICD), code F90 [code F90 , but mosPrescribed Drug Register (PDR) The PDR contains data for all dispensed drug prescriptions to the entire Swedish population since July 2005. Information on the indication for the prescription is not recorded; however, ADHD is a group that can be identified as treatment is characterised by a few drugs exclusively used for this disorder . Participants treated with ADHD medication were identified if they had at least one prescription from 2005 to 2013.Descriptive statistics are presented to describe the severity and presentation of ADHD symptoms and co-occurring behaviours in males and females with and without clinically diagnosed ADHD. Sex differences in parent-rated ADHD symptom scores (inattention and hyperactivity/impulsivity) and co-occurring conduct and learning problems scores were tested using linear regression models (hypotheses 1), and sex differences in ADHD medication status was tested using logistic regression.To assess whether the predictive associations of inattention, hyperactivity/impulsivity, conduct problems, and learning problems with clinical diagnoses differed in males and females, we used a series of logistic regression models (hypotheses 2). The models were conducted separately for each symptom domain  using the continuous score, and stratified by sex. We also applied logistic regression models with males and females included in one model to investigate sex-by-symptom interactions on diagnostic status .Next, we used a series of logistic regression models to examine sex differences in the associations between these symptom domains and ADHD medication status in children with clinically diagnosed ADHD (hypotheses 3). The models were conducted separately for each symptom domain using the continuous score and stratified by sex. We also investigated sex-by-symptom interactions on treatment status.cluster(vce) command in Stata [All regression models were adjusted for the effects of year of birth and family SES. Furthermore, as the data were used as population data and not analysed in a twin analysis model, we controlled for the clustered data structure (to correct for the inclusion of two study children in each family) using a cluster-robust sandwich estimator (the in Stata ).n = 650) of the children had a clinical diagnosis of ADHD recorded in the National Patient Register (NPR). Clinically diagnosed ADHD was more common in males  than in females , which corresponds to a prevalence ratio of ~ 2.5:1.In the CATSS sample, 3.28% (n = 1635) than females  met the symptom criteria, corresponding to a prevalence ratio of ~ 1.8:1. Among these children, 303 (18.5%) of the males with elevated symptoms, and 111 (12.1%) of the females with elevated symptoms had an ADHD diagnosis recorded in the NPR.Based on DSM-5 ADHD symptom criteria using the parent-reported A-TAC questionnaire, 2556 individuals (12.9%) from the CATSS sample met criteria for ADHD. More males . In contrast, among children with clinically diagnosed ADHD, males and females showed similar severity across the symptom domains, except for significantly higher inattention scores in males . Females and males with a clinical diagnosis were equally likely to be prescribed ADHD medication.Table χ2(1) = 11.27, p = 0.002, d = 0.11), and a significantly greater percentage of males met symptom criteria for the combined presentation category compared to females (χ2(1) = 17.39, p < 0.001, d = 0.15). There was a similar percentage of males and females meeting symptom criteria for the hyperactive/impulsive presentation (χ2(1) = 0.19, p = 1.0, d = 0.08).Among all children from the CATSS sample meeting DSM-5 symptom criteria for ADHD as identified with the parent-reported A-TAC questionnaire, the inattentive presentation was most common (53.7%), followed by the combined 26.8%) and hyperactive/impulsive (19.5%) presentations , followed by the inattentive (36.7%) and hyperactive/impulsive (8.0%) presentations Table . Among tp = 0.03) and conduct problems , suggesting that externalising symptoms of hyperactivity/impulsivity and conduct problems are more strongly associated with the prediction of clinically diagnosed ADHD in females than in males.Using the A-TAC continuous scores, in both males and females, symptom severity with respect to inattention and hyperactivity/impulsivity increased the likelihood of receiving a clinical ADHD diagnosis Table  (for exap = 0.03) and conduct problems , suggesting that externalising symptoms of hyperactivity/impulsivity and conduct problems influence being prescribed pharmacological treatment for ADHD to a greater extent in females than males. Learning problems did not predict medication treatment in the sample overall, or for either males or females (Table Symptom severity with respect to hyperactivity/impulsivity increased the likelihood of being prescribed ADHD medication in both sexes Table . Inattend = 0.21).This large population-based study investigated the role of sex differences in ADHD symptoms and co-occurring conduct and learning problems on clinical diagnosis and pharmacological treatment of ADHD. The main finding was that the predictive association of hyperactive/impulsive and conduct symptoms on ADHD diagnosis and treatment status was stronger in females than in males. We also found, consistent with previous findings, greater ADHD symptoms and co-occurring conduct and learning problems in males than females at the population level , 14, morSeverity of all the symptom domains assessed increased the likelihood of having a clinical diagnosis of ADHD in both males and females. Across all domains, odds ratios were slightly higher for females, suggesting greater deviation from their typical behaviour, and may indicate a greater symptom threshold requirement for referral and diagnosis in females. Significant sex differences were found for the predictive value of hyperactivity/impulsivity and conduct problems, with these externalising behaviours being stronger predictors of diagnosis in females than males. This finding is consistent with a previous study showing that girls with externalising symptoms were referred at a younger age than boys with similar behavioural problems . One expBoth hyperactivity/impulsivity and conduct problems were also stronger predictors of ADHD medication status in females compared to males, despite clinically diagnosed males and females being equally as likely to be prescribed ADHD medication. This suggests that if females display less prominent externalising behavioural problems they are less likely to be prescribed medication, whereas males may be prescribed medication based on ADHD diagnostic status alone.We found no difference in learning problem scores by sex in those with ADHD, which is in contrast to previous research showing more pronounced learning and school-related problems in males with ADHD than in females , 15. FurOur study found that the combined presentation was the most common ADHD presentation in children with a clinical diagnosis. In contrast, among the children meeting ADHD criteria based on parent-rated symptoms, the inattentive presentation was the most common, which is consistent with some previous research , 27, 28,or population samples; here, we uniquely bring the two together. This enabled investigation of a population-based and clinical sample for which there is not an ascertainment bias, overcoming limitations of studies using one type of sample alone. Prevalence rates in this cohort are in line with expectations and suggest an overall reasonable detection of ADHD in Sweden. The administrative prevalence of ADHD was 3.28%, and the symptomatic prevalence based on the A-TAC was substantially higher at 12.9% as impairment criteria and symptom pervasiveness across settings were not applied, consistent with previous estimates of ADHD classification based on symptom counts alone [This study represents one of the largest samples used to investigate sex differences in ADHD. In addition, previous studies have investigated sex differences in either clinical ts alone , 9. Of tOur findings should be considered in the context of some limitations. Our findings are telling us about diagnosis patterns and do not provide information about referral patterns. It is possible that a number of children are referred but receive alternative diagnoses or are not considered sufficiently impaired by symptoms to obtain a diagnosis. Future studies should investigate such hypotheses. We were also unable to confirm whether additional children from CATSS should have a clinical diagnosis of ADHD ; as an epidemiologic cohort, our study did not have objective clinician or research interviews. Furthermore, we relied on parent-ratings of ADHD symptoms and co-occurring problems, which may be influenced by sex-specific biases and expectations , 32. ForThese limitations notwithstanding, overall the current findings highlight the importance of the clinical presentation of ADHD as it can influence diagnosis and treatment decisions differentially in males and females, and the prominence of different symptoms clearly matters. Externalising behavioural problems were more predictive of diagnosis and pharmacological treatment in females than males, perhaps because they contrast more with perceptions of normative behaviour in females. One interpretation of these findings is that females with ADHD may be under-identified in the absence of prominent externalising problems.We hope that our findings encourage more research in this area to foster greater understanding of sex-specific diagnostic patterns and more effective recognition, diagnosis, and treatment of ADHD in females in clinical, educational, and other settings.Paul Lichtenstein has served as a speaker for Medice. King’s College London received funds for consultancy and other work by Philip Asherson, which has been used to support departmental research on ADHD: consultancy to Shire, Eli-Lilly, and Novartis, regarding the diagnosis and treatment of ADHD; educational/research awards from Shire, Eli-Lilly, Novartis, Vifor Pharma, GW Pharma, and QbTech; speaker at sponsored events for Shire, Eli-Lilly, and Novartis—all outside the submitted work. Henrik Larsson has served as a speaker for Eli-Lilly and Shire and has received a research grant from Shire; all outside the submitted work. Florence Mowlem, Mina Rosenqvist, and Joanna Martin report no potential conflicts of interest.Supplementary material 1 (DOCX 17 kb)Below is the link to the electronic supplementary material.


Licensed Vocational Nurses (LVNs) are the frontline staff communicating with off-site physicians to manage new or unexpected symptoms in nursing home (NH) residents. Care decisions following physician-LVN conversation impact Alzheimer’s disease (AD) resident quality of care. LVN difficulties using standardized communication forms (e.g. SBAR) spurred creation of an alternative not requiring high levels of RN supervision. The aim of this study was to examine the feasibility of an algorithm guided assessment support tool (AGAST) to help LVNs collect and cluster information using a simulated clinical scenario. A descriptive, participant observation design (video-taped) was used with ten practicing LVNs. AGAST was implemented in the Simulation Center in a clinical scenario of a NH resident with AD experiencing a urinary tract infection. The algorithm was placed within an online survey and participants were directed through a series of sequenced question and answer choices to identify and collect information pertinent to describing a change in resident condition. Duration of videos, description of AGAST-linked assessment behaviors, and content analysis of post-intervention transcripts were reported. AGAST prompts were seen with LVN physical assessment behavior and followed by questions about relevant day-to-day activity/level of performance. AGAST mean completion duration was 11.20 (SD=4.67) minutes. AGAST was rated as easy or very easy (90%). Major concerns included small font size on lab screens, insufficient open text space to add more information, and direct computer input. AGAST was a feasible alternative for assessment by LVNs. Further testing is needed in a variety of conditions.


Around 25% of prisoners meet diagnostic criteria for attention-deficit/hyperactivity disorder (ADHD). Because ADHD is associated with increased recidivism and other functional and behavioural problems, appropriate diagnosis and treatment can be a critical intervention to improve outcomes. While ADHD is a treatable condition, best managed by a combination of medication and psychological treatments, among individuals in the criminal justice system ADHD remains both mis- and under-diagnosed and consequently inadequately treated. We aimed to identify barriers within the prison system that prevent appropriate intervention, and provide a practical approach to identify and treat incarcerated offenders with ADHD.The United Kingdom ADHD Partnership hosted a consensus meeting to discuss practical interventions for youth (< 18 years) and adult (≥18 years) offenders with ADHD. Experts at the meeting addressed prisoners’ needs for effective identification, treatment, and multiagency liaison, and considered the requirement of different approaches based on age or gender.The authors developed a consensus statement that offers practical advice to anyone working with prison populations. We identified specific barriers within the prison and criminal justice system such as the lack of adequate: staff and offender awareness of ADHD symptoms and treatments; trained mental health staff; use of appropriate screening and diagnostic tools; appropriate multimodal interventions; care management; supportive services; multiagency liaison; and preparation for prison release. Through discussion, a consensus was reached regarding prisoners’ needs, effective identification, treatment and multiagency liaison and considered how this may differ for age and gender.This practical approach based upon expert consensus will inform effective identification and treatment of offenders with ADHD. Appropriate intervention is expected to have a positive impact on the offender and society and lead to increased productivity, decreased resource utilization, and most importantly reduced rates of re-offending. Research is still needed, however, to identify optimal clinical operating models and to monitor their implementation and measure their success. Furthermore, government support will likely be required to effect change in criminal justice and mental health service policies.The online version of this article (10.1186/s12888-018-1858-9) contains supplementary material, which is available to authorized users. Effective identification and treatment of offenders with attention-deficit/hyperactivity disorder (ADHD) in the prison population is likely to have a positive impact on the offender and society. ADHD is associated with early age criminality , a high ADHD is characterized by symptoms of pervasive and impairing inattention and/or hyperactivity and impulsivity  that staWorldwide prevalence rates estimate that 5.3% of children and 2.5% of adults meet diagnotic criteria for ADHD , 11. MetAmong incarcerated adults with ADHD, there is an increased risk of associated coexisting psychopathology  that oftAlthough there is a large evidence base for ADHD treatments for individuals in the community, similar evidence is limited for those in the prison population. A literature review of non-offender populations with ADHD reported that the combination of pharmacological and non-pharmacological treatment was most consistently associated with improved long-term outcomes and large effect sizes . An IcelAs of October 2015 the World Prison Population List conservatively estimated that up to 11 million people were held in penal institutions throughout the world . With arGiven the large population of prisoners with ADHD combined with their increased risk of recidivism, appropriate intervention is crucial. By expanding upon the consensus of the United Kingdom Adult ADHD network (UKAAN) on the identification and management of offenders with ADHD , we aimewww.UKADHD.com) hosted a meeting in November 2016, where researchers, prison staff, clinicians, and patient representatives with expertise in offender mental health and ADHD, convened to discuss identification and treatment of youth and adult offenders with ADHD in the prison population. Each author attended the meeting. The authors represent a multidisciplinary group including both prescribing and non-prescribing clinical and academic experts, with extensive experience working with individuals with ADHD, including prisoners (for further details see Authors’ Information subsection of the Declarations section). The meeting included presentations with electronic slides, discussions, and group work. Presentations and discussions were recorded and later transcribed.The United Kingdom ADHD Partnership  of ADHD among prisoners is a process reliant on the availability of medical records, mental health clinicians trained to conduct interview assessments for ADHD, prison staff trained to recognise potential patients with ADHD, and suitable screening and diagnostic instruments. It will be necessary to use identification and assessment tools that are specific to youth or adult offenders. According to best practice all new prisoners should receive an initial reception screen for mental health problems, including ADHD, followed by a comprehensive second screen shortly after their reception screen , 26.Symptoms of inattention, which are often missed among offenders of both gendersSymptoms of impulsivity, emotional dysregulation, and poor self-control, which are especially important to recognize as the prisoner may be at risk of aggression and violence towards others, or self-harm and suicideA history of educational failure, school expulsion, inability to work, driving offences, and impulsive aggression, and/orA history of chronic mental health problems or a history of failed treatment programmes for conditions such as mood disorders, anxiety, depression, post-traumatic stress disorder, emotional instability, self-harm, and/or borderline personality disorder.While some prisoners present with a history of ADHD diagnosed during childhood, others present with no history of ADHD, or alternative diagnoses such as specific learning difficulties  or conduct problems. It is therefore important to review the medical history and confirm the presence of other common mental health and neurodevelopmental disorders that may overlap with ADHD — highlighting the need for a careful diagnostic assessment. In our experience, many offenders who had a prior diagnosis of ADHD were untreated or failed to adhere to their treatment programme. In making a new diagnosis, there are specific indicators among the prison population that, in our experience, suggest the presence of ADHD and are as follows:We have observed that assessors commonly view hyperactivity as a ‘male’ ADHD symptom and inattention as a ‘female’ ADHD symptom. This bias may interfere with making an accurate diagnosis of ADHD in males who lack overt hyperactivity and in females who display hyperactive behaviour. Diagnosing ADHD in offenders can be additionally challenging because it is often complicated by the high frequency of co-occurring conditions. In addition to common disorders seen in the prison population such as anxiety, depression, post-traumatic stress disorders, substance abuse and self-harm, borderline personality disorders are commonly found among female offenders , 28, andCurrently there is very limited training about ADHD for prison staff. Raising awareness of ADHD was however considered to be essential by the consensus group. ADHD awareness training is likely to reshape misconceptions or stereotypes of ADHD and may improve the outcomes of offenders with ADHD within the criminal justice system. It is important to understand that although ADHD is a pervasive condition that persists into adulthood in around half of cases, it is treatable at all ages. Prison officers, clinicians, educators, therapists, and mentors therefore should be trained to recognize the signs and symptoms of ADHD and further educated on available treatments and expected outcomes.ADHD awareness training should ideally raise the visibility of the disorder. Increased understanding and recognition of ADHD will likely help prison staff to better manage offenders with ADHD presenting with difficult behaviours that were previously unattributed to the disorder . While aDelivery of ADHD awareness training  in the prison setting may have logistical challenges, such as lockdown requirements to allow staff to attend workshops. However, training in mental health issues, including ADHD, is essential for this high-risk population and needs to be addressed at each institution.As is the case for many prisons, all youth offenders are subject to a reception screen upon admission. Screening preferences and practices vary greatly between institutions world-wide, and while no evident gold standard method exists, healthcare standards offer guidance for best practices for youth in secure settings . Nurses The National Health Service England (NHSE) mandates using the comprehensive health assessment tool (CHAT) in youth offender institutions throughout England and Wales. Because of the NHSE requirements, we recommend using the CHAT as the primary screen in all youth offender institutions. The CHAT is a validated semi-structured interview designed to screen for health issues among all young offenders admitted to a secure facility . CHAT isQuestions pertaining to ADHD symptoms are included in the mental health section of the CHAT, but because they focus on externalizing rather than internalizing symptoms the assessors will need to take extra care in considering all symptoms, including the inattention symptoms of ADHD. While we acknowledge the poor specificity of CHAT, it is a sensitive tool for detecting mental health problems that include ADHD. It is therefore important to emphasize that the CHAT should be used as a primary screen to flag potential mental health issues before going on to more detailed assessments.If any chronic or serious mental health issue is suspected, then the offender should be referred for a secondary screen involving a more comprehensive assessment by a multidisciplinary mental health team including nurses, psychologists, and psychiatrists who are specially trained to recognize ADHD as well as other mental health conditions commonly seen in young offenders.At the time of clinical assessment, we recommend that a trained clinician administer a standard validated rating scale such as the Swanson, Nolan, and Pelham teacher and parent rating scale (SNAP-IV)  and/or tIn adult prisons offenders are subject to a reception screen upon admission, to review their overall physical and mental health. In most institutions, however, the mental health section of the primary screen for adult offenders does not include questions pertaining to ADHD symptoms. For example, the screening tool Health & Wellbeing Needs Assessment Toolkit (HWBNA) published by the Public Health England Health & Justice Team, to be used in all 118 adult English Prisons, has no mention of ADHD. Screening preferences and practices vary greatly between adult institutions world-wide and while no evident gold standard method exists, several valid tools are available .Some prisons have adopted the short screening version of the Adult ADHD Self Rating Scale (ASRS),  yet in oIdeally, nurses with mental health experience should administer the primary screen in adult institutions as this increases the validity of the screens by ensuring questions are understood and properly rated by the offenders ; howeverIf any co-morbid mental health disorder is suspected, then the offender should be referred for a secondary screen involving a more comprehensive assessment by a multidisciplinary mental health team including nurses, psychologists, and psychiatrists who are specially trained to recognize ADHD as well as other adult mental health conditions.In cases where a B-BAARS score or results from another screen indicate a likely ADHD diagnosis, we recommend a clinician trained in the assessment of ADHD conduct a full diagnostic interview. This may include the full 18-item version of the BAARS to ascertain the severity of ADHD. Whenever possible, the interview should be supported by collateral reports  to gain a comprehensive description of their symptoms and impairments across the lifespan. While informant reports are not always required, they can be particularly useful as offenders with ADHD often have very poor recollections of their childhood behaviour and tend to minimise impairments arising from ADHD. Extra care is needed when evaluating all of the offenders’ symptoms to avoid focusing only on externalising behaviours.We have identified three comprehensive semi-structured diagnostic interview tools that are suitable for adult prison populations: the Conners’ Adult ADHD Diagnostic Interview for DSM-IV (CAADID) , the DiaEach of these interviews provides age-appropriate examples of each of the ADHD symptoms that can be applied when evaluating adults. Relevant descriptions of adult ADHD symptoms include: internal restlessness; excessive mind wandering that interferes with tasks such as reading, writing and listening to TV or conversations; getting bored quickly then losing ability to focus; and feelings of irritability and impatience when waiting in queues. Clinicians also need to be aware that symptoms of emotional dysregulation such as frequent inappropriate levels of irritability, frustration, and anger  can be used to support the diagnosis .While continuous performance tests (CPT) perform reasonably well at discriminating between people with ADHD from non-psychiatric controls, and may contribute to the diagnostic assessment, they are far less able to discriminate ADHD from other common psychiatric disorders seen in prison populations . Given tProviding appropriate pharmacological and non-pharmacological interventions in prison populations is a process reliant on prison staff and offender self-awareness of ADHD symptoms and treatments, the availability of trained mental health clinicians, and the administration of specifically targeted multimodal treatments. Although female offenders often present with a more complex profile due to pregnancy, motherhood, and high levels of co-morbidity , all phaIt will be necessary to educate offenders on the efficacy of multimodal treatments and expected outcomes and to obtain informed consent for permission to treat. Following a new or confirmed previous diagnosis of ADHD and a careful evaluation of possible co-morbid conditions, we recommended the following multi-modal treatment for incarcerated offenders, as summarized in Fig. We have observed that staff support in pharmacological treatment and involvement in psychological treatment programmes has a positive and direct impact on offender adherence to and engagement in the prescribed treatment plan. Staff lack of knowledge about ADHD can interfere with medication administration and offender engagement in psychological treatment programmes. Conversely, staff awareness of ADHD symptoms, and observation of positive treatment effects, usually increases engagement with and support for the treatment process, and makes it much more likely they become involved in the delivery of offenders’ psychological treatments.According to principle and law, punishment for criminal offence is the loss of liberty, and prisoners’ human rights are fully protected unless restrictions are unavoidably and demonstrably ‘necessitated by the fact of incarceration’ . The ManGiven the high prevalence of neurodevelopmental disorders  among young offenders , it is eTreatment with ADHD medication is effective in reducing symptoms of inattention, hyperactivity, and impulsiveness  and is aGiven the lack of sufficient high quality evidence from randomized-control trials for treatment among prisoners, it is important to emphasize that clinicians trained in the diagnosis and treatment of ADHD should administer ADHD medications, to carefully asses for risks of abuse potential and possible risks of exacerbating other co-morbid conditions. Medication can be administered to all offenders irrespective of age and gender, but type and dosage should be made on an individual basis, especially in the case of pregnancy.With respect to psychoeducation, the offender needs to be educated on the benefits and side effects of pharmacological treatment and the implications of remaining untreated or discontinuing treatment. This education is not only necessary in obtaining informed consent to treat, but is important in engaging them in their own treatment. Such engagement will encourage offenders to take an active role in their treatment and can cause them to perceive some control over their situation, which can have an empowering effect. Offenders need to be given adequate opportunities to provide feedback on the medication’s effect and to titrate for therapeutic doses. Support during the early stage of treatment is critical in helping offenders take full advantage of the reductions in ADHD symptoms and in helping manage the medication's side effects.We recommend prescribing stimulant medications first line because these have a quicker response than non-stimulants and a greater average effect size. Drugs with a high risk of abuse, such as immediate release preparations of methylphenidate (MPH) and dexamfetamine (DEX), should be avoided in prison populations due to the potential for abuse. Injected or insufflated (snorted) MPH and DEX cause a rapid release of dopamine that can give the user a ‘high’. This does not occur, however, when these medications are taken orally. The oral administration of therapeutic doses of MPH or DEX is therefore essential in reducing the abuse potential of stimulant medications .We recommend prescribing long acting or modified release preparations of methylphenidate (MR MPH) that are difficult to take in any other way than by mouth (e.g. Concerta XL). Lisdexamfetamine (Elvanse) is a long acting preparation that has a unique advantage, because even if injected, the active drug is released slowly at a similar rate in to the brain as when taken by mouth. These extended release formulations are usually taken in the morning and give active control of symptoms for 8–14 h in most cases.MR MPH, lisdexamfetamine, along with all other stimulants, are controlled substances and thus subject to strict dispensary logistics that often interfere with treatment compliance and efficacy. Restrictions on movements within the prison can limit the regular and timely administration of stimulant (and other) medications. In some cases, staff are needed to escort prisoners to the healthcare unit to receive medication, although in most cases prisoners can take themselves to a dispensary, or receive medication from a wheeled cart. Escorting not only over burdens the staff, but stigmatizes the offender and further complicates adherence. Although stimulants are controlled substances, they can usually be dispensed in the same manner as other non-stimulant medications that are not kept in possession, which improves adherence. The practice of dispensing drugs varies by prison, but non-stimulants are easier to dispense as there are less procedures for nursing staff to follow.Preliminary results of a pilot study of Concerta XL in adult offenders with ADHD (CIAO) indicated a significant reduction in total critical incidents  among prisoners in the UK who were treated for 12 weeks. In relation to dose, over half of the prisoners took 18-36 mg and only 4% took the maximum dose of 90 mg, indicating a lack of drug seeking behaviour with regard to Concerta XL in this population. This was in line with our clinical experience that suggests greater abuse potential for sedative antidepressants and antipsychotics than stimulants within the prison population. The findings from this study were successfully used to secure further funding the National Institute of Health Research (NIHR) for an ongoing randomised controlled trial in 200 young adult offenders following a similar study design. We anticipate that the reports from these studies will inform optimal medical treatment of ADHD in prisons and raise public awareness for the need for effective treatment of offenders with ADHD (unpublished report for pilot study available from PA).In alignment with national guidelines , we recoIn the presence of co-morbid anxiety, autism spectrum disorder (ASD), aggressive behaviour, or mild affective symptoms, ADHD should usually be treated first, followed by a careful evaluation of the medication’s effect on the co-morbid symptoms. While adults with ADHD are reported to misuse drugs , 51, detSymptoms commonly shared between ADHD and co-morbid disorders may be better managed with pharmacological treatments for ADHD rather than with pharmacological treatments for the co-morbid disorders themselves. For example, irritability and low mood symptoms secondary to ADHD are alleviated more effectively by ADHD medication than with antidepressants or antipsychotics. Similarly, we have observed that conditions such as post-traumatic stress disorder and borderline personality disorder sometimes improve following treatment of concurrent ADHD. Subsequent treatments for co-morbid disorders may be required and can be added one at a time to discriminate their effects. Conversely, in the presence of psychosis, bipolar disorder, and/or a clear depressive episode, ADHD should not be treated first. Care should be taken, however, to avoid mistaking the ADHD symptoms of emotional instability for the episodic mood changes of bipolar disorder or the chronic symptoms of a personality disorder.In the case of co-morbid anxiety disorder, pharmacological treatment for the anxiety can be added if the stimulant exacerbates the anxiety. Alternatively, the stimulant can be discontinued and replaced by atomoxetine. In the case of co-morbid symptoms of aggressive behaviours, a low dose of quetiapine or risperidone may be added if the symptoms are not adequately treated by stimulants or atomoxetine. While high doses of quetiapine are sedative and are used to treat psychosis, low doses have a mildly sedative effect that can help reduce irritability and emotional liability associated with ADHD.Unfortunately, there are insufficient studies of the treatment of ADHD in co-morbid cases, and offenders presenting with complex mix of co-morbidities. Our recommendations are therefore based on the experience of the authors, which are aligned with recommendations from guideline groups such as NICE . In our Non-pharmacological treatments in the prison setting consist of psychological, educational, and occupational treatment programmes. These interventions should aim to: facilitate changes in life-long patterns of poor behavioural control, increase life satisfaction, build useful skills, and help the offender plan for civilian life after release. Mentorship programmes embedded in the treatment plan are likely to be additionally beneficial. Pharmacological treatment of ADHD symptoms will enable offenders who respond to such treatments to better engage in and benefit from non-pharmacological interventions in this setting. It is important to emphasize that, although ADHD medication can improve symptoms, concomitant non-pharmacological treatments are nearly always necessary to help the offender manage ADHD related problems and improve their behaviour.There is a need to change common misconceptions and stereotypes about ADHD symptoms and treatments. Young people and adults find it helpful to understand that ADHD is a neurobiological disorder evident early in life and distinct from other behavioural problems. It is especially important for offenders to understand that although ADHD is pervasive, treatment may help improve self-control and level of function. In our experience prisoners value improvements in attention span and reduced levels of physical restlessness and emotional impulsivity that would enable them to benefit from education. Mental health professionals working with prisoners with ADHD should provide a clear explanation of ADHD symptoms, treatments, and expected outcomes, and educate the offender on the potential risks of remaining untreated or discontinuing treatment. Additionally, we recommend giving offenders an easy-to-read pamphlet that briefly highlights some facts about ADHD.Offender psychoeducation is an integral part of intervention that should be initiated during imprisonment to increase its efficacy and to avoid overwhelming the offender upon release. We commonly observe that offenders are not adequately educated about their condition and take a passive role in their treatment plan. Furthermore, we have observed that an offender’s increased understanding of their condition helps them to engage in their pharmacologic and psychological treatment programmes and increase their sense of self-empowerment.Many UK prisons implement offending behaviour programmes that focus on addressing the risk of future offending behaviour, but these do not provide treatment for clinical conditions for offenders with ADHD. We recommend implementing a neurocognitive intervention that addresses offending behaviour and ADHD related and other behavioural co-morbid executive function deficits such as: difficulty with time-keeping, organizing, planning, and self-regulating emotions and behaviour.Given the logistical limitations inherent in correctional institutions (e.g. restrictions on movement and variations in sentencing), it is important that treatment programmes are suitable and feasible for the prison environment. Appropriate programmes include those that can be: completed in a relatively short amount of time (less than 4 months), delivered in a small group setting with about 10 to 12 inmates once or twice per week, and administered to all offenders irrespective of age and gender.To augment and fortify interventions we recommend providing the offender with personal support from a mentor (i.e. coach or champion). Prison staff, officers, substance abuse staff, primary and secondary care clinicians, educators, volunteers, and when appropriate even fellow prisoners, can be trained to provide one-on-one skill-building sessions. These one-on-one sessions emphasize a personal approach and can help the offender bridge lessons from the therapy room to daily life.To the best of our knowledge the only psychological treatment programme developed to address antisocial behaviour and executive functioning deficits is Reasoning and Rehabilitation 2 ADHD (R&R2ADHD). R&R2ADHD is a treatment programme based on cognitive behaviour therapy designed to build pro-social competence  and may While the evidence for R&R2ADHD efficacy is predominantly community based with a majority of male samples –21, resuOther psychological approaches that may be helpful include cognitive remediation therapy (CRT)  and dialChildren with ADHD are at an increased risk of academic underachievement  and repeIt is important that the education plan addresses gaps in the offenders’ academic core skills, focuses on strengths, includes ADHD support strategies, and is appropriate for those disengaged from the education system. Education support workers and volunteers from outside private organizations can be helpful with implementing the education plan. While education services have information pertinent to learning difficulties, they do not automatically liaise with mental health services. We have observed that problems with information sharing are primary barriers that need to be to overcome. Therefore, we recommend an ad hoc liaison between mental health and education services to ensure effective intervention.Prison rules most often require that offenders complete an academic course (related to reading and writing) before participating in technical skill-building workshops. Because symptoms of inattention, hyperactivity, and behavioural difficulties can prevent the offender from meaningful participation in academic courses, this requirement is inherently biased against them. Imposing this requirement upon offenders with ADHD who are at risk of disengaging from and failing the academic course may result in extended prison time. For example, in England and Wales, if an offender fails the Imprisonment for Public Protection (IPP) course they are subject to an increased prison sentence.We recommend waiving the requirement to complete an academic course and directing offenders towards educational and occupational programmes that suit their strengths . Focusing on their strengths may not only reduce the occurrence of extended sentencing, but also the rate of offenders with ADHD in solitary confinement. In cases where solitary confinement has not been averted, we recommend shortening the period(s) of isolation and giving the offender an activity to occupy them while confined.Participation in technical skill-building workshops can provide hands on experience and the opportunity to learn occupational and technical skills useful for life during and after prison. In our experience, maintenance jobs throughout the prison  that provide the opportunity to be physically active and occupied, are highly sought after by ADHD offenders.In addition to acquiring technical skills, it is important that offenders are taught necessary personal life skills to equip them to successfully navigate civilian life after prison and not re-offend. Given the likelihood of executive function deficits, offenders with ADHD most often need help planning how to attain their goals. Long-term desires and goals  need to be broken down into realistic achievable short-term plans and goals . R&R2ADHD  notably As for people with mental health problems or related complex needs, offenders with ADHD require assistance from a wide variety of supportive services and agencies. It is important that these services are accessed and coordinated during imprisonment, not only to infer maximal benefit, but to ensure continuity of care once the prisoner is released. Supportive services and agencies, although distinct and separate entities, will need to liaise with each other to exchange information and help ensure comprehensive care. For example, education services should automatically be contacted when an offender with mental health issues is identified.In England people having complex needs are often eligible to receive a Care Programme Approach (CPA). A CPA is a structured multidisciplinary care management format designed to support people with severe and enduring mental health problems. Service users are allocated a care plan coordinator  who is responsible to review, access, and coordinate multiple available services on their behalf . The strA CPA is routinely implemented for high risk patients in inpatient settings, yet less commonly in community mental health settings. Although the National Institute for Health and Clinical Excellence 2018 (NICE) guidelines  recommenWe recommend offenders with ADHD receive a CPA or similar care management plan and are assigned a care plan coordinator to oversee the plan. We also recommend implementing a medication management plan, which should be a core component of the care plan. A medication management plan addresses the need for regular built-in reviews by a suitably trained psychiatrist, and the need for monitoring medication adherence, which should be a key task of the care coordinator. When transitioning from youth to adult or between different institutions or out of prison, it is vital to maintain robust care coordination, continuity of care, and uninterrupted treatment with ADHD medication; using the CPA format can be effective in mitigating problems with service discontinuity that can arise during transitions. A sample CPA based on numerous ‘real life’ cases is provided in the supplementary material, see Additional file Parents and carers — adults responsible to provide general support at home and, where appropriate, give consent to treatCare plan coordinators — trained workers designated as the main point of contact responsible to develop a care plan and review, access, and coordinate appropriate available servicesCriminal justice services including diversion services — police, court, prison, and offender management unit staff responsible to move offenders through the offender pathway while safeguarding rights; an intermediary may be requiredMental health services, including forensic mental health services — trained physicians, psychiatrists, psychologists, nurses, and therapists responsible to provide appropriate evaluations and treatmentsPrimary and secondary care physicians — paediatricians, general practitioners, psychiatrists, and specialist physicians responsible to provide appropriate evaluations and treatmentsSocial services — social workers responsible to access available financial support for appropriate healthcare, housing, and child care needsEducational services — teachers, therapists, nurses, and trained volunteers, responsible to provide appropriate evaluations and develop and implement individualized educational plansMentorship programmes — trained coaches or champions responsible to provide one-on-one treatment or skill-building sessionsAddiction services — trained clinicians, officers, or workers responsible to provide appropriate interventions and recovery support servicesAdoption and foster care agencies — trained workers responsible to access appropriate placements for youth offenders or children of offendersProbation services — trained officers responsible to supervise offenders and provide appropriate interventionsOccupational, rehabilitation, and therapeutic services — trained workers, therapists, job coaches, and volunteers responsible to provide and/or access appropriate skill-building courses and employment opportunities to help the offender regain independenceImmigration services — trained workers responsible to administrate and adjudicate cases of foreign offendersThe following people, services, and agencies may need to be accessed and coordinated according to the offenders’ individual needs:Despite women’s inclination to seek help, female offenders with ADHD may be less likely to be identified  and consIn developing a care plan for youth offenders it is important to involve parents or carers, whenever appropriate or possible. They can be helpful in supporting the youth once released, especially when it comes to medication compliance. Additionally, parents or carers may be required to give consent for treatment when the youth is under 18 years old, however, obtaining consent may be problematic in some cases. When the family is a part of the offenders’ problems or a family member is the victim, careful consideration is required before contacting and involving them. In addition to providing psychoeducation for the offender, families need to be educated on the facts about ADHD symptoms, treatments, and expected outcomes. The care plan coordinator should direct families to parent groups or other supportive organizations and resources to help them meet their child’s complex needs. The CHAT screening tool includes a care plan summary that highlights the young person’s needs. This information should be communicated to all professionals working with the young person in secure care, and to parents, carers, and care plan coordinators following release to ensure good continuity of care.In developing a care plan for adult offenders it is important to encourage them to take an active role in their care management. When adults have been in the prison system for many years, it can be difficult to motivate them to engage in intervention and supportive services. We have observed that youth offender services and pathways are generally more developed and effective than those for adult offenders. Therefore, we recommend adult prisons adopt many of the same models and tools, such as mentorship programmes and comprehensive screens like the CHAT, which are used in youth offending institutions.Prison release and the transition into civilian life is a period of increased vulnerability requiring offenders with ADHD to receive specific timely support. There is a need for further research on ways to best support offenders with ADHD who are released from prison; meanwhile we recommend implementing a critical time intervention approach , in whicThere is strong evidence of a high prevalence of offenders  with ADHD in prison and who have increased risk of associated coexisting conditions and higher rates of recidivism. Paired with the evidence that treatment improves symptoms and outcomes, accurate identification and comprehensive treatment is warranted. Effective intervention is expected to have a positive impact on the offender and society and lead to increased productivity, decreased resource utilization, and most importantly reduced rates of re-offending.The United Kingdom ADHD Partnership therefore hosted a meeting of experts on the topic who reviewed the literature and shared personal experiences. It was concluded that there were specific barriers within the prison that hindered the recognition of offenders within the system with ADHD. These include inadequate staff and offender awareness of ADHD symptoms and treatments; lack of training for mental health staff; inappropriate use of screening and diagnostic tools; inappropriate multimodal interventions, care management, supportive services, and multiagency liaison; and a lack of preparation for prison release to address the ongoing needs and care of prisoners with ADHD.We successfully came to a consensus on practical ways to address these problems and it was clear that the work needs to commence with recognition and identification, and this will involve training. To appropriately care for the individual needs of each offender we recognize that a separate pathway for each mental health disorder (including ADHD) would need to be created. Realizing this may be a problem, we therefore aim to influence criminal justice systems to create a unifying mental health approach with different interventions that address each disorder. We envision a fully integrated intervention pathway—in which the information gathered from screenings and assessments is automatically shared with appropriate service departments for the immediate and coordinated implementation of necessary interventions.The increased use of the CHAT screening tool, the launch of healthcare standards and commissioning guidance, and the development and implementation of the SECURE STAIRS (an integrated framework of care funded by the NHSE) together are supporting a unifying mental health approach within the secure estate for children and young people in England. Additionally, the NHSE’s report The Five Year Forward View for Mental Health  outlinesThe outcome of the review and consensus is detailed above and the key conclusions and recommendations that arose from it are briefly summarised in Table While a practical approach to effectively identify and treat offenders with ADHD was achieved at the meeting, it was clear that future research is needed to identify optimal clinical operating models and monitor their implementation and measure their success. It will be valuable to investigate the impact of accurate identification and specifically targeted multimodal treatments on offender health, behaviour, and offence related outcomes. Further research on the needs of female offenders is needed.A recent study investigating the economic consequences of ADHD in prison has conservatively estimated that the financial burdon of medical and behaviour-related prison care is £11.7 million per annum  and futuThis consensus will inform effective identification and treatment of offenders with ADHD. Appropriate intervention is expected to have a positive impact on the offender and society and may lead to increased productivity, decreased resource utilization, and most importantly reduced rates of re-offending.Additional file 1:Care Programme Approach (CPA) report. This is not an actual CPA, but is a sample CPA report based on ‘real life’ cases. (DOCX 12 kb)