A Plea From A Friend With ADHD, in Jail—Again

It’s a tragic fact: People with poorly managed ADHD are over-represented in the prison population. Some of these people are my acquaintances who have reached out for help before, during, and/or after their incarceration.  I do what I can.

Recently, I received an e-mail notifying me that one of my friends had ended up in county jail on what could be a felony charge. Perhaps, though, there was a possibility of his case being tried in mental-health court. Could I help?  I wrote this letter, which I am sharing with ADHD roller coaster readers, in case it is somehow helpful. His name has been changed.

To Whom It May Concern:

I am writing on behalf of John Smith, whom I have known for several years.

I understand he is being held in county jail, in part for drug paraphernalia-possession charges (but reportedly no drugs). I do not know the full details of his arrest.

My credentials are that of an internationally recognized expert on Adult ADHD, author of two books on the subject, and editor of a book specifically on Adult ADHD and the criminal justice system.  John has asked me, through a family member, to provide the information, as I understand it, about his long-running struggles with Attention-Deficit Hyperactivity Disorder (ADHD) and potentially bipolar disorder as well.

I hope to shed a little light on the issues John faces and why I encourage you to please consider categorizing his case as “mental health.”

With 20 years of experience in trying to help people with ADHD nationwide, of all socioeconomic levels, I can assure you: It is difficult for even people with lots of money and resources to find competent ADHD treatment.

Unless you have been in the trenches, as I have for 20 years, it is very hard to believe the deplorably low standard of ADHD medical care, even here in Silicon Valley. We as a country would never accept other physical conditions—heart disease, diabetes, or even cancer—treated so poorly. Apparently, when it comes to brain disorders that, to the untrained eye, resemble age-old human challenges around impulse-control and willpower, it is tolerated.

Too many physicians have actually contributed to making a big mess of ADHD treatment, leaving patients vulnerable to poor outcomes via prescribing medications at too high a dose and completely ignoring the co-existing conditions (depression, bipolar disorder, etc.) that can actually be exacerbated by the stimulants (the first-line medication for ADHD). These patients should be treated for their full range of symptoms – that is, treating the depression, anxiety. But it seldom happens. It is a huge problem, and it is one that we cannot blame on the patients.

ADHD Treatment Difficult To Find, Even for Wealthy

For someone like John, who as I understand was depending on county mental-health services,  the picture is particularly dire. There is insufficient staff, and certainly few or no staff competent to treat ADHD. Sub-standard treatment typically not only fails to help ADHD, however, it can also actually exacerbate problems. Including creating a downspiral of futility and hopelessness.

I met John about five years ago, through the Adult ADHD discussion group that I’ve moderated for more than a decade in Palo Alto (free and open to the public).

He had recently been made aware of his likely ADHD diagnosis by his friend’s reading of my book. Amazingly, this is how many adults have been diagnosed: by happenstance.

[Today’s children with ADHD are being screened more regularly. But only 1 in 10 of today’s adults with ADHD is diagnosed. And that is considering the “strict” criteria, not the more broad criteria. In other words, these are people suffering the most impairing symptoms, but there are many more suffering less-severe but still impairing symptoms. It has been estimated by experts that at least half the incarcerated population has unrecognized or poorly managed ADHD.]

Smart, Well-Intentioned—And Impaired

As smart and well-intentioned as I believe John is, he still suffers from a condition that the field’s foremost research scientist has called “the most impairing outpatient psychiatric condition.”

• More than anxiety and depression, ADHD can create highly adverse outcomes in life, around education, employment, driving, divorce, bankruptcy, and substance abuse.
• Moreover, ADHD seldom travels alone: 75 percent of adults with ADHD have a co-existing condition.
• People with ADHD are also more vulnerable to developing PTSD. And poorly managed ADHD itself can lead to traumatizing situations. It is a constantly compounding problem. So, reactions can be outsized and “hair-trigger.”

Please imagine John—a very dark-skinned, athletically built African American—living in an overwhelmingly white area. You can see how the reality of “racial profiling” can justifiably exacerbate his fear and potential hair-trigger reaction, especially after past encounters with law enforcement. People with ADHD can seem to be “acting guilty” when they are simply terrified and feeling powerless.

At the last meeting he attended, John told me about a recent incident. He was just standing in the driveway of his girlfriend’s residence and a police officer came up to talk to him. He broke out in a sweat, no doubt appearing “suspicious.” But he was scared, scared of being helpless in an overwhelming situation and knowing that he might not be able to control his responses.

When you have been in prison under California’s draconian “Three Strikes Law,” as John was, I think this fear is well-founded. But ADHD compounded by PTSD can make the fear—and response—even more extreme.

Medication As “Rational-Brain” Booster

In part, we can think of ADHD as presenting an imbalance between the “old brain” (the instinct-driven limbic system) and the “new brain” (the prefrontal cortext, or rational part of the brain). Reactions and responses tilt heavily toward the “old brain.” Medications, when well-prescribed, can help tamp down the instinct-driven responses and boost the rational-brain functioning.

The very neurobiology of ADHD, however, also creates a very real vulnerability for substance abuse. Not knowing that one has ADHD—or what that actually means— the slippery slope to substance abuse can begin simply with a desire to quiet the “noise” in one’s brain.

Many start with cigarettes. Children often start with sugar, which is a stimulant. Then it’s onto other dopamine-boosting substances and behaviors (gambling, sex, alcohol, driving fast, cocaine, meth, getting angry or provoking others to anger, etc.) These behaviors and substances actually can calm the brain of some people with ADHD. But of course, because they suffer from the core deficit of “self-regulation,” they don’t know when to stop.

Legitimate medications for ADHD are the central-nervous-system stimulants (CNS). These include Adderall, Concerta, Ritalin, and the like. So, it is easy to understand how abuse behaviors begin around substances that are chemically in the same ballpark as CNS medications: cocaine, methamphetamine, etc.—and regrettably very easy to procure.

Legitimate medications, however, operate differently, primarily because their delivery systems slow the release in the brain.   (Though of course, some of the immediate-release medications can be abused. Newer delivery systems have novels ways of preventing abuse.)

“Self-Medicating” To Focus, “Feel Right”

My larger point is this: Many adults with ADHD “self-medicate” with substances and behaviors—simply in an ongoing effort to focus. From cigarettes to cocaine, these substances actually seem to improve symptoms—at least initially. Of course, they lead to bigger problems. Because they are not actually medications. But substance-abuse is a well-known risk for people with ADHD. The literature is there.

I hope this information has been helpful to John’s case and his future. Please feel free to contact me if I can be of assistance.

For ADHD Roller Coaster readers, I add these resources:

• ADHD and Crime:_Considering the Connections (printer-friendly) – a paper prepared for Medscape by ADHD Expert Joel L. Young, MD
• Paperback book: I have long been an advocate for increased awareness of the higher risk ADHD carries for landing a person in the criminal-justice system. Back in 2004, when I heard that Patrick Hurley and Dr. Robert Eme were planning a book on the topic, I offered to edit it (free of charge) and they agreed. The book is still available on Amazon:  ADHD and the Criminal Justice System: Spinning Out of Control.
• United Kingdom-based Justice and ADHD – this organization was founded and is led by my longtime friends Philip Anderton and Steve Brown. They are a powerful force in the UK and throughout Europe for educating police forces about ADHD. They have focused recently on identifying the ADHD-related “Tipping Points” and risk-taking behaviors and moving toward a model of working that empowers parents and care providers to have a greater level of achievement toward the proactive redirection of youth.
• Please share this post with anyone who might be better informed by it: attorneys, parole officers, juvenile detention centers, parents, etc.

—Gina Pera