Psychiatric assessment essential for sexual offenders or victims with ADHD: Study

14 Sep 2021

Psychiatric assessment essential for sexual offenders or victims with ADHD: Study

14 Sep 2021

By Ruwan Laknath Jayakody Owing to neuro developmental disorders such as attention deficit hyperactivity disorder (ADHD) in turn being associated with sexual abuse and related offences in the Sri Lankan context, it is recommended that children and adolescents who are either victims of sexual abuse or offenders of the same, undergo psychiatric assessment, a local study noted. This point was raised by M. Chandradasa and R. Fernando (Lecturers at the Kelaniya University’s Psychiatry Department), D. Hettiarachchi and S. Wijetunge (Senior Registrar in Child and Adolescent Psychiatry and Consultant Child and Adolescent Psychiatrist at the Lady Ridgeway Hospital for Children, respectively), M. Gunathilake (Senior Registrar in Psychiatry at the National Institute of Mental Health), and A. Tennakoon (Chief Judicial Medical Officer and Head of the Institute of Legal Medicine and Toxicology, Colombo) in an article on “A juvenile sex offender with ADHD” which was published in the Journal of Clinical and Nursing Research’s Second Volume’s First Issue in 2018. ADHD has its onset in early childhood with more boys than girls having such, according to A. Thapar and M. Cooper. It is characterised by, as per the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders Revised Fifth Edition (DSM-5), inattention, hyperactivity, and impulsivity. By the time the child reaches adolescence, while the hyperactivity usually wanes, inattention persists, as noted by A. Koumoula in “The course of ADHD over the life span”. ADHD is associated with academic impairment in children, as noted in “A longitudinal study on the neuropsychological functioning and academic achievement in children with and without signs of ADHD” by B. Rennie, M. Beebe-Frankenberger, and H.L. Swanson. Therefore, when parents and teachers of children with symptoms fail to identify manifestations of this illness, especially the early detection of symptoms, its diagnosis and treatment is missed, and the resultant impact on school performance can be detrimental due to the serious consequences that are involved. In “The knowledge and attitude of primary school teachers in Sri Lanka towards childhood ADHD”, M.D. Rodrigo, D. Perera, V.P. Eranga, S.S. Williams, and K.A. Kuruppuarachchi, found that the majority of school teachers believed that ADHD symptoms occurred due to the fault of the parents. In turn, as M. Blachno, U. Szamanska, A. Kolakowski, and A. Pisula noted in “Parental corporal punishment in children with ADHD”, such behaviour may be branded as delinquent behaviour and the child may be subjected to disciplinary action rather than to appropriate care. Also, K. Sayal observed in “Epidemiology of ADHD in the community”, a significant proportion of children with ADHD may not be referred to psychiatric services even when the child has, as per C.K. Berenson’s “Frequently missed diagnoses in adolescent psychiatry”, prominent features of inattention and minimal hyperactivity-related symptoms are exhibited. Another issue delaying diagnosis is the ratio of psychiatrists per population. R. Jenkins, R. Kydd, P. Mullen, K. Thomson, J. Sculley, S. Kuper, J. Carroll, O. Gureje, S. Hatcher, S. Brownie, C. Carroll, S. Hollins, and M.L. Wong’s “International migration of doctors, and its impact on the availability of psychiatrists in low and middle income countries” noted that the psychiatrist to population ratio in the country is low in non-Western countries. As a result, the mental health gap is significant and the majority with major psychiatric disorders present to health services after many years of illness, as noted by M. Chandradasa, L. Champika, K. Gunathillaka, and J. Mendis in the “Association of the duration of untreated psychosis and functional level, in the first episode of schizophrenia attending an outpatient clinic in Sri Lanka”. Exacerbating this problem is the fact that the availability of child and adolescent mental health professionals is even fewer as per M. Chandradasa and K.A.L.A. Kuruppuarachchi’s “Child and youth mental health in post-war Sri Lanka”. The Lady Ridgeway Hospital for Children (LRH) is the only hospital that has inpatient child psychiatry facilities, and the child and adolescent mental health services receive about 2,300 new enrolments per annum to the outpatient clinic. Sexual abuse and related offences have been recognised in children with ADHD (I. Tidefors and J. Strand’s “Life history interviews with 11 boys diagnosed with ADHD who had sexually offended” and M.C. Reinhardt and C.A. Reinhardt’s “ADHD, co-morbidities, and risk situations”). As explained by Chandradasa et al., impulsivity in ADHD likely contributes to the lack of inhibition in sexual responses, which may in turn lead to being victimised by sexual abuse due to unsafe and risky behaviour. On the other hand, children and adolescents with ADHD may seek sexual pleasure impulsively and be more prone to sexually offend than other children (D. Blotcher, K. Henkel, W. Retz, P. Retz-Junginger, J. Thome, and M. Rosler’s “Symptoms from the spectrum of ADHD ion sexual delinquents”). Case report A 14-year-old boy was referred for an opinion on his psychological status. He was the perpetrator of an incident of sexual abuse involving another boy from the same school. According to the perpetrator, he has engaged in penetrative anal intercourse as the passive partner within the school premises. The 14-year-old boy claimed that he had persuaded the other boy to accompany him to an isolated area of the school where he had forced the younger adolescent to engage in the alleged act. He also divulged such incidents in the past involving a teenage male relative and the repeated insertion of foreign bodies by him to his anus. On forensic physical examination of the alleged perpetrator, there was evidence of repetitive anal intercourse in the recent past. On the assessment of the mental state of the perpetrator, he had features of inattention such as difficulty in sustaining attention, failing to finish work, getting easily distracted by extraneous stimuli, and being disorganised in his activities. There were features of impulsivity such as difficulty waiting for his turn and intruding on others. However, there were no features of hyperactivity. The perpetrator met the criteria for ADHD as per the DSM-5. The diagnosis was achieved after a detailed assessment by the child and adolescent psychiatrist. The boy scored higher than normal in the inattention subscale, but not in the hyperactivity subscale. The assessment of non-verbal intelligence indicated average intelligence. However, school test marks were far below average. The boy’s inattention was contributing to his inability to grasp things that he was being taught. The boy was commenced on behaviour therapies and stimulant medication (a central nervous system stimulant that affects chemicals in the brain and nerves that contribute to hyperactivity and impulse control). With treatment, there was a significant clinical improvement of the ADHD symptoms. According to Tidefors and Strand, Reinhardt and Reinhardt, and Blocher et al., children and adolescents with ADHD are more likely to become sexual offenders and become victims of such abuse. The instant case described an adolescent who allegedly sexually abused another schoolboy in the context of previously undiagnosed ADHD. Child sexual abuse is the involvement of children and adolescents in sexual activities that they cannot fully comprehend and to which they cannot consent as a fully equal participant. Regarding the alleged offender, Chandradasa et al. observed that it is possible that his impulsiveness and inattention contributed to his academic failure despite having normal intelligence, while these same psychological impairments may have led to the risky sexual behaviour. As found by B.B. Muld, J. Bokinen, S. Bolte, and T. Hirvikoski’s “Long term outcomes of pharmacologically treated versus non-treated adults with ADHD and substance use disorder: A naturalistic study” effective treatment reduces risky behaviour such as substance use. While early detection and the proper management of this disorder may have reduced the propensity for risky sexual behaviour on the part of the offender, a clearer understanding of the illness by the parents and more vigilance by the school authorities could have prevented the alleged incident at school. Therefore, as pointed out by C. Kleemeier, C. Webb, A. Hazzard, J. Pohl’s “Child sexual abuse prevention: Evaluation of a teacher training model”, the improvement of awareness among parents and teachers about psychiatric disorders may be an effective way of preventing sexual abuse among schoolchildren. A person who is of unsound mind or insane at the time of the offence (the 1843 English case of Daniel McNaughton regarding the insanity or unsound mind criminal defence) is unable to form the “mens rea” (guilty mind). Thus, such a person is not subjected to punishment by the law. The Penal Code states that: “Nothing is an offence which is done by a person who, at the time of doing it, by reason of unsoundness of mind, is incapable of knowing the nature of the act, or that he/she is doing what is either wrong or contrary to law.” Mental illness is not defined in the Penal Code. The Sri Lankan law, as Chandradasa et al. explained, considers the cognitive aspect of an offence for criminal responsibility and not impairment of volitional control. However, insanity does not provide for the mitigation of punishment in circumstances that lead to impairment but not a deprivation of legal capacity (A. de Alwis and N. Fernando’s “The insanity defence and the assessment of criminal responsibility in Sri Lanka”). Therefore, in the case of this alleged juvenile offender, the question is whether the boy’s mental disorder has contributed to the alleged act, which has to be determined by the forensic and psychiatric specialists. If you feel that you or someone you know may be dealing with mental health issues and/or sexual abuse, the following institutions would assist you. The National Institute of Mental Health: 1926 Sri Lanka Sumithrayo: 0112 682 535 Shanthi Maargam: 0717 639 898 Police Child and Women Bureau: 011 2444444 NCPA: 1929 LEADS: 011 495 4111

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Psychiatric assessment essential for sexual offenders or victims with ADHD: Study

Psychiatric assessment essential for sexual offenders or victims with ADHD: Study

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