While I was the first Artist in Residence of the world-leading Social, Genetic and Developmental Psychiatry Centre and Visiting Fellow of King’s College London to lead the art-psychiatry creative research programme #MagicCarpet (funded by Unlimited and King’s’ College London 2017-2019; National Coordinating Centre for Public Engagement Images Culture Change award winner 2018), I also worked with King’s colleagues and students on various related projects in different capacities, as part of my undercover gatecrashing to learn/unlearn about the diversity of the human mind. One of these activities was with my mentor Professor of Neurodevelopmental Psychiatry Philip Asherson, on a £1,397,685 National Institute for Health and Care Research (NIHR) project entitled CIAO II Version 1.0 Randomised controlled trial of the short term effects of OROS-methylphenidate on ADHD symptoms and behavioural outcomes in young male prisoners with attention deficit hyperactivity disorder. My role was as to assist in public and patient engagement with people with ADHD through the creation of artistic/design outputs. My practice-related research process involved visiting a Her Majesty’s Prison Service for young men in London, talking with a few of these men with Philip, reflecting on my own lived experience as someone with ADHD, continuing to read and learn critically about psychiatry (and its constructs of the boundaries of normality), ADHD and ‘public engagement’, as well as drawing on my 24-years of professional portfolio as an artist. Philip and the participants he worked with granted me permission to join them in their clinical sessions. It was a powerful experience – I left feeling warm (of the level of care and kindness Philip showed) and infuriated (that it is because of the participants’ class and colour that they are incarcerated). The project is now complete, and the 146-page report has just been published (June 2022), which describes my involvement as follows:
We worked closely with Dr Kai Syng Tan, a King’s College London artist in residence with lived experience of ADHD. Kai visited HMP YOI Isis during the trial to understand the prison environment and what might motivate participants to engage in the trial. Following this, Kai generated images that emphasised choice, control, autonomy, self-care, self-respect, and, at the same time, was mindful of the stigma attached to ADHD. She designed an image that was used during the trial to remind participants of medication times for all their medications. The image was produced in the form of a flyer that prisoners could stick on the walls of their cells or use as a coaster.CIAO-II report
Click below to find out more about:
Citation and link to report
Asherson P, Johansson L, Holland R, Bedding M, Forrester A, Giannulli L, et al. OROSmethylphenidate to reduce ADHD symptoms in male prisoners aged 16–25 years: a RCT. Efficacy Mech Eval 2022;9(6). https://doi.org/10.3310/THEI8200
Philip Asherson, Lena Johansson, Rachel Holland, Megan Bedding, Andrew Forrester, Laura Giannulli, Ylva Ginsberg, Sheila Howitt, Imogen Kretzschmar, Stephen Lawrie, Craig Marsh, Caroline Kelly, Megan Mansfield, Clare McCafferty, Khuram Khan, Ulrich Müller-Sedgwick, John Strang, Grace Williamson, Lauren Wilson, Susan Young, Sabine Landau and Lindsay Thomson
- Background: It is estimated that 20–30% of prisoners meet diagnostic criteria for attention deficit hyperactivity disorder (ADHD). Methylphenidate reduces ADHD symptoms, but its effect among prisoners remains uncertain.
- Objectives: The primary objective was to estimate the efficacy of osmotic release oral system (OROS) methylphenidate in reducing ADHD symptoms in male prisoners aged 16–25 years who met diagnostic criteria for ADHD. Secondary objectives investigated change for associated clinical and behavioural problems and the role of ADHD symptoms in mediating change in behaviour. Design: A Phase IV, 8-week, parallel-arm, double-blind, randomised, placebo-controlled trial of OROS-methylphenidate, compared with placebo, in young male adult prisoners with ADHD. Participants were randomised in a 1 : 1 ratio of OROS-methylphenidate to placebo, stratified by prison.
- Design: A Phase IV, 8-week, parallel-arm, double-blind, randomised, placebo-controlled trial of OROS-methylphenidate, compared with placebo, in young male adult prisoners with ADHD. Participants were randomised in a 1 : 1 ratio of OROS-methylphenidate to placebo, stratified by prison.
- Setting: Participants were recruited from Her Majesty’s Prison and Young Offender Institution Isis (London, England) and Her Majesty’s Young Offender Institution Polmont (Falkirk, Scotland).
- Participants: The participants were 200 male prisoners with ADHD aged 16–25 years who met the diagnostic criteria for ADHD. Exclusion criteria included moderate or severe learning disability; serious risk of violence to researchers; current major depression, psychosis, mania or hypomania, or a past history of bipolar disorder or schizophrenia; and drug-seeking behaviour that was of sufficient severity to affect the titration protocol.
- Intervention: The intervention was over-encapsulated OROS-methylphenidate (18 mg) or placebo capsules. Trial medication was titrated weekly for 5 weeks against symptom reduction and adverse effects to a final dose of one to four capsules per day, followed by a stable dose for 3 weeks.
- Main outcome measures: The primary outcome was ADHD symptoms at 8 weeks using the investigator rated Conners’ Adult ADHD Rating Scale-Observer. There were 13 secondary outcomes, including
- measures of emotional dysregulation, general psychopathology, reports of behaviour by prison staff and engagement with educational activities.
- Results: For the primary outcome, the estimated improvement between the OROS-methylphenidate and placebo arms was 0.57 points on the Conners’ Adult ADHD Rating Scale-Observer (95% confidence interval –2.41 to 3.56) at 8 weeks, with a standardised effect size of 0.06. The difference was not statistically significant and was smaller than the difference the trial was powered to detect. Responder rate, defined as a 20% reduction in the Conners’ Adult ADHD Rating Scale-Observer score, was 48.3% for the OROS-methylphenidate arm and 47.9% for the placebo arm. None of the 13 secondary outcomes that could be formally compared between the trial arms showed a significant effect and no mediators of change in behaviour were identified.
- Limitations: Low adherence to trial medication and low medication dose might have affected the results.
- Conclusion: OROS-methylphenidate was not found to have an effect, compared with placebo, on the primary and secondary outcomes investigated. The findings indicate that ADHD symptoms do not respond to a standard treatment for ADHD following titration to low doses in young adults in prison. The findings do not support the routine treatment with OROS-methylphenidate of young adult prisoners meeting diagnostic criteria for ADHD.
- Future research: Investigations of adequate, maintained dosing, non-pharmacological interventions and community studies are suggested.
- Trial registration: This trial is registered as ISRCTN16827947 and EudraCT 2015-004271-78.
- Funding: This project was funded by the Efficacy and Mechanism Evaluation (EME) programme, a MRC and National Institute for Health and Care Research (NIHR) partnership. Janssen-Cilag Ltd supplied OROS-MPH (Concerta-XL). This will be published in full in Efficacy and Mechanism Evaluation; Vol. 9, No. 6. See the NIHR Journals Library website for further project information