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Crime and Therapy: Good News About Pharmacotherapy for ADHD

Crime and Therapy: Good News About Pharmacotherapy for ADHD

ADHD, criminality, pharmacotherapy, and substance abuse typically meet one another in media stories decrying the overuse of drug therapy for ADHD. In a welcome contrast to that popular tale, an elegant research project by Lichtenstein and colleagues1 tells a new story using the same characters. But in this story, stimulant therapy prevents criminal behavior; keeps ADHD patients out of prison; and leads to better outcomes for the patients, their families, and society.

I call the research elegant because it uses a large Swedish population registry to track verified prescriptions of stimulant medications for ADHD along with verified evidence of criminal activity. Because the large sample deflects criticisms of low power, the population sample provides a representative sample and the use of reg­istries deals with possible investigator biases in making diagnoses. And in Sweden, findings indicate that the prevalence of treated ADHD is only 0.7%2; thus, it is highly likely that the patients in the Swedish registry truly had ADHD. We cannot accuse the Swedes of overdiagnosing ADHD.

Elegance and simplicity often travel together. That they traveled to Sweden is seen in the simple statement of the main result: “Among patients with ADHD, rates of criminality were lower during periods when they were receiving ADHD medication.”1(p2006) Among 25,656 patients with ADHD, pharmacotherapy for the disorder reduced criminality by 32% for men and by 41% for women.

The reduction in criminality afforded by ADHD medications was equally high for stimulant and nonstimulant medications and for patients with and without a history of conduct dis­order. The probability of committing a crime increased when ADHD patients moved from a treatment period to a nontreatment period and decreased when they moved from a nontreatment period to a treatment period. These simple results are easy to explain and difficult to refute.

Although the work by Lichtenstein and colleagues does not explain why ADHD pharmacotherapy re­duces criminality, earlier work offers reasonable explanations. ADHD med­ications have well-documented, strong, short-term effects on reducing ADHD symptoms and both overt and covert aggression.3-5 Although long-term data are limited, Fredriksen and colleagues6 found persistent therapeutic effects of these medications. Data from naturalistic studies show that long-term pharmacotherapy for ADHD reduces substance abuse in adolescence.7 Thus, reductions in the impulsivity of ADHD, the severity of comorbid aggression, and the risk of substance abuse might mediate the link between ADHD medication use and criminality.

Studying the effects of pharmacotherapy for ADHD on crime makes sense. Decades of research show that ADHD is associated with conduct disorder in youths and antisocial personality disorder in adults.8,9 Consequently, the prevalence of ADHD in prisons is very high. Findings from a recent literature review indicate that 10% to 70% of prisoners have ADHD.10 This is not news. ADHD was reported in 25% of prisoners more than 2 decades ago.11 Consistent with the idea that failure to treat ADHD increases the risk of criminal behavior, Ginsberg and colleagues12 found that ADHD had been identified in childhood in only 2 of 30 inmates with the disorder. Sadly, the incarceration of ADHD sufferers begins early: prevalence of ADHD among adolescents in juvenile detention is 12% to 19%.13

We now know that some criminal activity can be eliminated by pharmacotherapy for ADHD. Should this information influence clinical practice? The short answer is an un­equivocal “yes.” Despite media outcries about the overmedication of youths, ADHD is not routinely managed with pharmacotherapy. In a 2007-2008 survey by the CDC, only two-thirds of children with a parent-reported diagnosis of ADHD were taking a medication for the disorder.14 The undertreatment of ADHD is greater than this suggests because many cases of ADHD are not diagnosed.


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