Lorana, who is a professor in criminology and a deputy director at the Centre of Social Policy Research at Australian National University. Thank you, Lorana, for joining us today. You have exceptionally impressive background with, you know, a huge amount of work that you yourself have done across the board in terms of research. There's been a 122 peer reviewed books, various chapters and journals. It's it's it's I I could go on. It's seriously really impressive, and, we are so fortunate to have you here. So super excited, to be able to ask you some questions, if I may.

Yes. That's not a 122 books. That's a 120 or something.

Chapters and journal articles. I think you've stated Book chapters. Oh, I was like, jeez. Gosh. Can you tell that we've been twelve hours doing this now and doing different things?

Give it a touch tone. It's actually Lorana Bartels is is how you pronounce it, but that's fine. Look. Thank you for having me here, Mel. And it's it's really lovely to be with you and a little unusual for me because what I normally do is I've been working in the criminal justice system for nearly twenty five years now. And for the last few years, I've been talking to people about ADHD, but the audience I'm usually speaking to is people who know a lot about the criminal justice system and not much about ADHD. So I sort of start with, well, who knows what ADHD is?

But I'm talking to people who work in prisons or work in the courts and things like that. Whereas here, I've got an audience where I think it's safe to assume you all know a lot about ADHD, and many of you may have ADHD yourselves, which I don't, but you don't know necessarily that much about the criminal justice system. So it's a little different from what I would normally do, and hopefully, you'll come away understanding a lot more about the justice system and why this is so important when we're talking about ADHD. So I'd like to start by acknowledging the country as we do traditionally here in Australia. Canberra is none all in the Anambra country. And for those in Australia.

I'd like to pay respects to all Aboriginal and Torres Strait Islander peoples joining us. So launching Right In, why am I talking about the criminal justice system? Well, because that's what I do all day, every day. But the reason it matters so much and why it's so central, to, people who work in the criminal justice system, and now so much of the time when I talk to people, they're like, like, oh, a friend of mine who's a magistrate says, oh, now they understand what you're talking about. I think it's every second person in my court. Okay? So what are we talking about and why, does ADHD present so much in court? Well, Phil Anderton, who was a police officer for many years and now works in The UK running an ADHD clinic said.

It's now well established that ADHD, if untreated, poorly treated, or mismanaged, has a causational link to the conduct of criminal behavior. Why is that? Well, as many of you may know, people with ADHD are more likely to, and that's, you know, not to say everyone with ADHD does or the people with ADHD don't, without ADHD don't, also do these things, but they are statistically more likely to be excluded from school. Now that's in and of itself a really, really significant factor. In fact, in The UK, people with ADHD are a 100 times more likely to be excluded from school than those without ADHD. And there's a really well established thing called the school to prison pipeline.

So if you're not engaged in education in a constructive way, you're more likely to end up in the criminal justice system. And if you've been excluded from school, that's a really clear pathway. And I've I don't have the empirical data to back this one up, but I have a working hypothesis that so many kids whose first criminal act was property damage to which them scribbling on a desk in the corner of a classroom, you know, that's the beginning of a one way trajectory. Right? They're more likely to be unemployed. They're more likely to have accidents, especially driving accidents. So in instance like dangerous driving causing death, those sorts of incidents, Injuries, teen pregnancies, which for girls and women is itself an independent.

Factor associated with criminal justice system involvement. Gambling. And, again, if you think about, you know, what you do if you're dopamine hit, gambling's a pretty obvious one, and gambling's likewise a really significant risk factor when it comes to justice system involvement. And there's some really interesting research and really concerning research about domestic and family violence, where people with ADHD are both more likely to experience as victims and more likely to perpetrate it. And there's research that I'll speak about in a moment about unpacking that and then what that has implications for treatment responses and engagement with perpetrators. And in particular, addiction issues. Substance abuse disorder vastly.

Elevated amongst people with ADHD. And again, you know, you may have heard this depending on how long you've been online, ADHD tends not to just come in and of itself, tends to be wrapped up in a package with a bunch of other things, ASD, autism spectrum disorder, which is also associated with increased involvement in the justice system, oppositional defiant disorder, suicidality, self harm, personality disorders. Okay. That's substance use disorder. So someone with ADHD is at four times increased risk of having a substance use disorder, and I could talk till the cows come home about drugs and the criminal justice system. There's ample data out there, you know, when I'm in prisons, know, correctional staff will say.

Eighty, ninety percent of the people in prison have have drug use issues. So, you know, that link is really, really important to understand. So just they're the risk factors. How does this play out for someone in the criminal justice system? Well, in a variety of ways. So ADHD increases the risk of false confessions and don't know answers, and a lot of behaviors that can be really problematic for the investigation stage. So for example, inability to sit still, inability to listen to questions. Had a friend who.

Was interviewing a client in prison, and, you know, he was pacing around and she couldn't just she just couldn't get him to give her instructions. Right? Which is a lawyer you really need. And she's like she'd been treating him for years engaging with him as his lawyer for years. And she's like, what's going on? Right? And he said, oh, I haven't haven't got ADHD. Means I just I can't focus. I can't focus. The sheet actually been his lawyer for years and didn't even know he had ADHD, but she'd previously worked with him in the community when he was medicated. And then she just it's like chalk and cheese when he was in prison and didn't have his meds. This is a Western Australian study, which found that young people with ADHD.

And this was actually young kids who were medicated, they they so for boys, it was two and a half times more likely to land in youth detention. And for girls, it was the risk was even higher. It was seven times higher, and I heard some of that some of the previous presentation about girls. Again, I could I know so many girls and women in the criminal justice system with ADHD where it's it's really flown under the radar. This study, the next one, from New Zealand's a pretty new paper, which is a birth cohort study. So they're they're looking at everyone born in in a particular area, in a particular birth year, and comparing those with ADHD and those without ADHD. And the the figures there are just extraordinary. So by the age of 25.

Over fifty percent of people with ADHD had been proceeded again proceeded against by the police compared to twenty eight percent of people without ADHD, which I might add is also pretty pretty high. And then if you proceed up the line all the way to incarceration for people with ADHD, that was eight and a half percent of everyone in that area who was born in that particular year compared to one and a half percent of people without ADHD. And numerous data sets demonstrate that upwards of twenty percent, twenty, twenty five percent are pretty standard figures of the prison population having ADHD, and that's five to 10 times higher than the general population. And that's where the screening or testing is done. So a lot of the time.

There's no standardized screening. Okay? So it's not like you you come in, they do tests, and then they treat you. So for example, recently, I was at a conference. I wasn't speaking about ADHD, but someone else there was. And at the lunch afterwards, was at my table with two fellows who'd been to prison. They were only diagnosed with ADHD after they'd been to prison. So they went all the way through the system. It was never picked up up that they had ADHD. Now in all of this, there's some really interesting research, especially the paper that I've hyperlinked there from Sweden, which has shown the impact of receiving medication either either in prison that reduces, you know, things like assault in custody.

And participation in programs in custody, but also upon release. So a large study in Sweden found that during periods of treatment, men were thirty two percent there was a thirty two percent reduction reduction in offending, and for women, 42 41% reduction, which is really quite extraordinary. A lot of sort of criminal justice interventions programs, you know, they they kinda shout from their afters if there's a 15% reduction. So something like this is it's really surprising to me that this is not more widely known, and I've spoken to, you know, corrections ministers and justice health ministers about this sort of information, why this should be more widely recognized and taken into account.

In the public health planning and and and administration across Australia. Okay. So sorry. It's just taking a while to load. There we go. So I wanted to drill down a little more into what this how this plays out across the criminal justice system. And, again, I I won't assume that you know that much about how the system operates, but there's sort of pipeline or trajectory. The first stage.

Is police, the second stage is court, and the third stage is custody. But there's often a lot of intermingling because you could be going across these different things that that times. Right? You could be in custody and then taken back to court or you're released from custody and then you're up by the police. So I'm presenting as a linear thing, but it's a little more fluid than that. So what I wanted to show you is just some examples of where we have seen some innovations and and promise. So The UK is really leading the charge here. Last year and I was over in The UK and and and giving some talks on on the ADHD just before this just after this happened, sorry, they announced that the city of London police would do a screening for everyone.

Who's coming in to custody, and they would pilot. Then, you know, if someone has a I don't know if they can use the World Health Organization six question screen or whatever, but, you know, if it looks like someone might have ADHD, then they would do a more comprehensive screener and link them in with support. Right? So that was announced early last year. And then out of that, they've rolled that out. And if you can see in the bottom of that slide, they found that up to two thirds of people coming into a police station had undiagnosed ADHD. Right? That's and that's not the people who already knew they had ADHD. That's pretty staggering. Right? Two thirds of people coming into contact with the police.

Having ADHD, and they don't know that they've got ADHD. And then on the right hand side, where I was looking at what was going on in The UK, I saw this really interesting it was just a a LinkedIn post or something from an ADHD charity in The UK around some ideas that they had of how police and corrections agencies could engage with neurodivergent people in ways that are a little bit more, you know, neuro neuro affirming, recognize needs for stemming, sensory needs, and the like. Because, again, it's it's really abundantly clear to me how little training most people in the criminal justice system have, little understanding of the complexities and the needs. And what often ends up happening is there'll be a a a use of force, a conflict result.

Where you sort of think, well, actually, with a different way of managing this, I think you could have headed this off of the past. So, you know, I'll talk to people I do more work in prisons than with police, but I'll talk to people in in prison setting and say, well, you know, do you have some people where, you know, they're the ones where they're always they're always picking the fight. They're they're always talking back. They're not listening to, you know, to instructions. In fact, they're acting against their own interests, and they're like, oh, yeah, man. Oh, they're they're they're a pain the ass. Yeah. I don't know what to do with them. Oh my god. They're always, you know, the the you know.

Destroying the damaging the cells, doing this and the other. And then, you know, once you sort of talk about what some of the issues might be, what ADHD might look like, you know, are they the ones with the extra energy? Would it be possible for them to have a bit more time in the exercise yet? Oh, yeah. Yeah. Yeah. He's got energy to burn. Yeah. Yeah. Yeah. And then, you know, I'm not oversimplifying. I'm not saying this is the sum total of the solution.

But, you know, once you you get staff who who engaging with people all the time, but don't actually understand what an ADHD brain looks like, they're like, oh, yeah. Okay. Yeah. You're right. After after a gym session, he is a little bit easier to deal with. And so, you know, a lot of training around what are some of the techniques that could take this from a conflict meltdown situation to we've just actually navigated this and managed this in a, you know, in a perfectly reasonable way. Okay. So then a couple of years ago, I was trying to get a sense of just how many cases that were going through the courts with a d h where ADHD was mentioned, and it had never been looked at in a systematic way. So the ACT where I live.

I just looked at every single court decision in the ACT Supreme Court over 2021. This is nearly 2022, and scanned for ADHD and variations on the words, and found there were two hundred ninety one cases. I got rid of the civil cases, and that left me with two hundred eleven criminal cases. And so I checked all of them for reference to ADHD, and I found that there were fifteen percent for those cases where they mentioned ADHD, which is pretty high.

And, again, that's where it's mentioned in the decision where the judge is talking about it. They need plenty, of course, where they wouldn't know about it. I got rid of two where they weren't referring to the person who's before the court, the defendant, like they're talking about the defendant's child. That might might not mean that defendant also has ADHD, but we'll put that to one side. And so that left thirty two cases involving thirty four people. Twenty eight of those cases, eighty eight percent of them related to sentencing decisions. So then I did a deep dive into those thirty two cases in this article, paying attention to attention deficit disorder, abrective disorder, and examination of cases in the Australian Supreme Court.

And these were the key themes that I identified. So comorbidities. Ninety four percent of the cases mentioned some other mental health conditions. So pretty standard. Right? And here's an example. So in this one case, b 10. Right? Counsel referred to his mental health issues, including ADHD, conduct disorder, and schizophrenia. And so what I found across all the cases was very little insight into ADHD. It was generally just sort of a throwaway line. There was no reference to DSM, research on understanding what ADHD is or how it may play out. It's generally like one or two comments. It's very, very brief. Substance use. Ninety one percent of the cases mentioned that the person has some kind of substance use issue. So again, kind of links.

In with what we would see generally in the in in other studies. The defendant asserted he had used just about every illicit drug there was. Right? And that's on his own admission. I was looking at what evidence there was in relation to medication. And what mostly there was was that the person wasn't using medication. So statements like this, you were diagnosed with ADHD and Medicaid. You stopped taking dexamphetamine for your ADHD after about six months. So a lot of comments about how the person's not taking their medication. And also a lot of cases where there was a reference to ADHD, not of confirmed diagnosis, but they think they've got ADHD. And in particular, some cases like this one where.

There was lack of access to treatment. And again, for people in Australia, I think that won't come up as any massive surprise. Right? Because especially to get a diagnosis in Australia as an adult, that's very expensive. It's in the private sector, and in particular, you're involved in the criminal justice system, you know, you often don't have a lot of money. Your organizational skills are probably not great. So you have something like this. He was younger. He might have had ADHD, hasn't had a formal diagnosis, unable to take undertake further testing in Sydney. And part of this is just a local variation. Here in the ACT, there's a real shortage of ADHD.

Practice practice is all diagnosed. So a lot of people go to Sydney, which is a three hour drive away, and nor any treatment because of the difficulty of obtaining it here in Canberra. Some of the other themes that came out, and this again links with some of the earlier presentations that I caught, was around education. So professor Susan Young has commented too many young people with ADHD are moving from classroom to courtroom. So that that school to prison pipeline is really the ADHD school exclusion prison pipeline. Right? So there are a lot of cases where there were references to the person before the court having had education issues. And that in and of itself is not surprising.

Many people who go through the courts have had very limited education. But what was really striking was how few made that link with ADHD explicit or seem to understand it. So this person struggled at school with poor concentration. He was diagnosed as suffering from ADHD. You know, so it's it's there, and I'll and I'll let some of the other decision cases. They, you know, they won't mention the same sentence. They'll mention the kind of paragraphs apart. So if you weren't looking for it, you would notice it, but they weren't sort of drawing a nexus of this person's got ADHD, that explains why they're excluded from school.

This is a disability that's not being picked up and treated, and this is part of their trajectory of how they've landed in the criminal justice system. And then another really interesting dimension was family violence. As I said, that plays out in terms of both perpetration and victimization. And there's some really interesting research that shows that if you treat ADHD amongst people who commit family violence offenses, that really increases program effectiveness. And there's also research showing that the way programs are running now, men's behavior change programs, they're really not targeted to the needs of neurodiverse clients. And I had a a really interesting interchange with a a woman who ran a a court mandated program.

She's a disability liaison officer, a kid with ADHD, and and she was saying, yeah, absolutely. I've got 12 men in my program. Eight of them have an ADHD diagnosis. Another two, I reckon they've got it. You know? So at the end of the day, if they're on meds, they've worn off. We expect them to sit still for an hour and a half. They can't sit still. You know, they're staring out the window. They're not focused. It's the way it's delivered is boring. It's you know, no wonder these programs don't work. We are not tailoring them for the needs of these men. Right? And so in the cases I looked at, eight of the cases, I quoted the cases, mentioned family violence. But, again, there was very little awareness of any link between ADHD.

And family violence. And so there, for example, are two cases where the person had previously breached a family violence or that wasn't why they were before the court, but it was just a sort of throwaway line. But, you know, I'd like to see a bit more insight into someone who's maybe not really good at understanding consequential thinking or impulse control. You know, how does that play out with something like a family violence order, for example? Oh, and sorry. Before I move off that part of the paper, just in light of the comments about gender, another part of this paper was me looking at gender. Only one of the papers.

One of the cases involved a female dependent. And so in in my article, I hypothesized on how many women are are going under the radar. Yeah. The next the next thing I wanted to speak about was custody. I've already spoken a little bit about people in prison with ADHD. So this is a study in prisons in New South Wales. A hundred percent of people with ADHD have some life other life time mental health disorder compared to seventy one percent of people without ADHD, which is already very high, of course, but it's just everyone with ADHD has some of the mental health condition. And, again, that that figure with drug dependence also higher. Eighty seven percent of people with ADHD compared to sixty three percent of those without.

In another study that's just come out recently, most young people in custody in New South Wales, also New South Wales, who had ADHD also had conduct disorder, while those without ADHD did not. So, again, you're seeing that link with other serious mental health and behavioral conditions. Now the next thing, if you can see them on the slide, that's actually I mean, it's extremely distressing. I I deal with this sort of subject matter all the time. I probably should give a bit of a content warning here. It's the sort of thing that I'm surprised people were not rioting in the streets. But there was an inquiry in Tasmania into Tasmania's youth detention center, Ashley.

Youth detention centre, and the government has now committed to closing that down. It emerged that there had been abuse, including sexual abuse of the children held there for decades, in fact. And this one young man who gave evidence before that inquiry talked about the fact that he'd been subjected to, you know, rape by staff where they would withhold his ADHD medication for sex. You know? So things like that, you know, horrific in the extreme, but also demonstrate just how incredibly vulnerable young people with ADHD in the justice system are. And there's this really interesting paper that just came out about.

The ways in which prison is particularly challenging for people with ADHD. Again, I've spoken a little bit about this due to the difficulties of following rules, impulsivity, sensory issues around noise, for example. And for a peer reviewed paper, it's really interesting that that's I've got their first names there. That was a special issue of the prison service journal in The UK, and some of the articles were co written with people with lived experience of prison. And it's a it's a journal that's put out by the time well, no. Last time it came out, it's his majesty's prison service in The UK. And because they didn't want the prisoners' surnames to be used.

In the end, the academics and everyone who published it will will all go by first names. So it's quite unusual in academic circles to have your first name. My papers aren't kind of out there as Lorana. They're out there as Bartels. But Lucy James and Chloe, who are the co authors of this, talk talking about ADHD in prison. That's why it's presented that way. The UK just recently started introducing so called neurodiversity officers in all public prisons. I've heard mixed things about that. I've heard, you know, really important development, and the the policy recommendation that underpin that, that was informed by the perspectives of people with lived experience of neurodiversity and justice systems.

But I've also heard anecdotally that it's a bit of a ticker box exercise, and it's not actually transferring transferring into a kind of meaningful adaptation. So I think it's a bit of a work in progress to see how that would play out. And I wrote a a paper with with a student that came out earlier this year where we did a narrative review of the literature around the impacts of treatment medical treatment in prison. I talked about the Swedish study earlier. There are a whole lot of caveats, but generally speaking, treatment in and out after prison with medication does reduce ADHD symptoms, improve cognitive functioning, and lead to lower reoffending rates and reduce cravings for amphetamines.

Now I wanna leave some time for questions. So I might whip through the next bit a bit faster. This is the ADHD guideline, which I think might be familiar to lot of them. So I just wanted to say there's a lot in there. Many of you will be familiar with that. I just wanna say there's there's stuff in there that's on the criminal justice system that is really, really important. So talks about how clinicians should be aware of the increased incidence of ADHD amongst people in out of home care, people who are in prison. Right? The need for universal screening should not occur at the general population level. However, they do call for it how they say it could be done. I think it should should be done in high risk groups.

Should then be done if the person's not responding to treatment or often have problems forgetting things and things like that, or have clinically significant impairment in educational settings. So, you know, that's where you should really be looking at. I think we should be doing screening here. So certainly in the criminal justice setting, I think that we should be looking at widespread screening. There's a whole section of the guideline on the criminal justice system. This is obviously the part that's of most interest to me. So it should establish screening protocols amongst people entering the criminal justice system, training for police magistrates and custodial staff.

That treatment has to should include pharmacological and non pharmacological approaches. There should be education, occupational approach programs, and, obviously, prisons need adequate resources for that. I haven't spoken about this yet, really, but I think many of you would be aware that Aboriginal and Torres Strait Islander people are vastly overrepresented in our criminal justice system and make up about 3% of the adult population in Australia and about 30% of the prison population, and about 5% of the youth population over 50% of the youth detention population. The reasons for this are many and long and complex, but they underpin the need for culturally appropriate approaches when it comes to ADHD and indigenous young people.

And then section six three of the guideline is around substance use and ADHD in that intersection. And so here they talk about the need for those working in public, mental health and alcohol and other drug settings should be aware of the higher occurrence of substance use disorders and ADHD, and treatment needs to focus on both. You know, the number of people I know who've been involved in the criminal justice system who have ADHD, who use illegal substances, principally ice, methamphetamine, when they are unable to get access to ADHD treatment. In fact, I know a a woman who yeah. She came out of prison. She had a court order saying take your ADHD medication.

And she couldn't find a psychiatrist anywhere prepared to prescribe that. So she actually had to breach her court order because no one would prescribe the medication because of her substance use history. And then there's just some more general ones. Cross border dispensing is a real issue with this population. So people might move from one state to the to another to have a fresh start. They don't wanna be near their old peer group. They want to start over. They wanna take their ADHD medication, and they cannot get their script transferred across. That's a real issue. And then we also need treatment and support services and education.

In areas that intersect with the justice system, like child protection and social work. It's really important as well. So just in conclusion, the guideline provides a really clear roadmap when it comes to ADHD and the criminal justice system. There's a real need for early intervention, education and training, screening and diagnosis at all stages. I mean, if we get it right at the policing stage like they're starting to do at The UK in The UK, that would head a lot off at the past, but for people who've obviously been in the criminal justice system for a while. And I'll just take a minute or so to tell you a really poignant anecdote. There's a there's a gentleman I've known for a while. He's been in prison for over a decade, and.

He's he's in for murder. We've talked about that. He takes full responsibility for his actions. He says, you know, I'm a murderer and I have to live with that. But as I was writing the article, the court paper, he said, I think I might have ADHD. And I said, I don't know. I'm a lawyer, not psychologist. I can't tell you that. But in the course of me writing it, he he sought out a diagnosis. He was lucky enough to be able to do this privately. And he was actually able to get medication, which is hard to do in a prison setting, I might add. And I saw him when he started. He'd started taking Vyvanse, and and I went to see him in prison.

And I said, how how is it? You know, what's it like? And he said, my head's my head's completely clear. And, you know, this is something he really had thought long and hard about what he'd done. And he said, you know, I know what I did, and I I think if I'd have been on these meds, that guy would be alive, and I wouldn't be here because I would have been able to stop myself. And that I just thought was so telling about the the harm that we are causing to countless people by not intervening appropriately. So individual economic social benefits from from actually treating this appropriately. And Anderton, who might include that quote from before, as he said, the responsibility lies with us, clinicians.

Public services, teachers, employees, everyone, really, to change our behaviors, to accommodate the people with ADHD, not expect them to change to meet our expected norms. It's now time for the many diverse pathways into the criminal justice system for people with ADHD to be gated off and closed for good. So thank you very much. If there is any time, I'm very happy to take a few questions, but I think you're on a tight time schedule.

Lorana, it's as I've said to you before, it's a stunning presentation. It it a, it's fascinating. Secondly, I it strikes me as extraordinary that there are real low hanging fruit opportunities for the benefit of those living with ADHD, but society as a whole. Four, not much cost and not much difficulty. I I I think it's extraordinary. And it's great to see that there are some other countries that are starting to explore that, such as Sweden and The UK and, of course, through your work here, but amazing opportunities.

I think that's right, Robin. Here's one of the things that really, I must say, frustrates me having worked in this space for over twenty years. There's a lot of trauma. There's a lot of know, it's a real I could talk to a different audience and have about issues around housing and criminal justice system. There are so many aspects of the criminal justice system where there are not very many easy fixes. Here, we could actually fix a significant not the whole, but a significant, you know, part of the problem. The number of people where, you know, they're in the justice system, they get their meds. It's not the answer to everything, but, you know, get their meds, you know, and then they can start to build the life.

And Yeah. We're just not doing it. It's it's extraordinary. It's it's drives me crazy.

Now there's opportunities. Step one is illumination, and that's what you're doing, and we appreciate that. Yeah. We've actually got a lot of questions. It's generated a lot of questions. But what we might do because the Northern Hemisphere is starting to wake up, and we've got some some, segments within that we have to dovetail shortly. But what we'll do is we'll publish those quest well, we'll share them with you, and and we'll publish the questions and the answers if you don't mind on our ADHD website.

Yeah. Absolutely. I'll do my best to answer them. Thank you. Thank you. Great talking to you again. Take care. Thank you very much.