MENTAL HEALTH AND
MEDICATION ISSUES IN
YOUTH IN THE JUVENILE
JUSTICE SYSTEM
Christopher R. Thompson, M.D.
Medical Director, Juvenile Justice Mental Health Program
Los Angeles County Department of Mental Health
Assistant Clinical Professor
Child & Adolescent Division
UCLA Department of Psychiatry
[email protected]
[email protected]
OBJECTIVES
• Review prevalence of mental disorders in
the juvenile justice population
• Discuss the use of psychotropic
medications in the juvenile justice and
foster care (i.e., CPS, DCFS) populations
• Review the Los Angeles County
Psychotropic Medication Authorization
(PMA) review process
RISK FACTORS FOR JUVENILE
OFFENDING
• Early onset of behavior problems/aggression
• ADHD/Disruptive Behavior Disorders (DBDs)
• Substance use disorders (SUDs)/acute
intoxication
• Gang affiliation
• Diversity of offenses (? related to “Criminal
Versatility” component of PCL-R/PCL:YV)
• Psychopathy (?)
PREVALENCE OF MENTAL
DISORDERS IN JJ SYSTEM (1)
•
•
•
•
•
•
•
•
•
Conduct Disorder
ADHD
Substance Abuse
Personality Disorders
Mental Retardation
Learning Disorders
Mood Disorders
Anxiety Disorders
Psychoses & Autism
50 – 90%
19 – 46%
25 – 50%
02 – 17%
07 – 15%
17 – 53%
32 – 78%
06 – 41%
01 – 06%
Otto R, Greenstein J, Johnson M, Friedman R. (1992). Prevalence of mental disorders among
youth in the juvenile justice system. In J. Cocozza (Ed.), Responding to the mental health needs
of youth in the juvenile system (pp. 7-48). Seattle: National Coalition for the Mentally Ill in the
Criminal Justice System.
PREVALENCE OF MENTAL
DISORDERS IN JJ SYSTEM (2)
•
•
•
•
•
•
•
•
Any DSM-III-R D/O
Conduct Disorder
ADHD
SUDs
Major Dep. Episode
Dysthymia
Manic Episode
Psychosis
69%
39%
18%
50%
18%
14%
2%
1%
Teplin LA, et al. (2002). Psychiatric disorders in youth in juvenile detention. Arch Gen Psychiatry
59(12): 1133-43.
PREVALENCE OF MENTAL
DISORDERS IN JJ SYSTEM (3)
• All rates higher than general population
• “Big three”:
– Conduct Disorder
– ADHD
– Substance Abuse/Dependence
• Cognitive difficulties:
– Learning Disorders (17-53%)
– Mental Retardation (7-15%)
– lower intelligence levels (see next slide)
PREVALENCE OF MENTAL
DISORDERS IN JJ SYSTEM (4)
• Other risk factors for delinquency and (for some)
mental illness:
– pre-natal exposure to drugs or alcohol
– attachment problems
– exposure to trauma
– dysfunctional and chaotic families and
neighborhoods
– overcrowded schools with limited resources
– lower intelligence
LIFETIME CRIMINALITY AMONG
BOYS WITH ADHD
• Followed boys from age 6-12 → age 38
• ADHD boys more likely to be:
– arrested (47% vs. 24%)
– convicted (42% vs. 14%)
– incarcerated (15% vs. 1%)
•  Rates of felonies/aggressive offenses
• ADHD w/o CD=↑ risk of adult criminality
Mannuzza S, et al. (2008). Lifetime criminality among boys with attention deficit hyperactivity
disorder: a prospective follow-up study into adulthood using official arrest records. Psychiatry
Res 160(3), 237-46.
AGE OF INITIATION OF STIMULANT
TREATMENT AND DEVELOPMENT OF
SUBSTANCE USE DISORDERS (SUDS)
• 176 MPH-treated Caucasian male children aged 6-12
w/ ADHD but w/o CD
• Followed up in late adolescence (mean age=18.4
years) and adulthood (mean age=25.3 years)
• Subjects with late initiation of stimulant treatment
(i.e., at age 8 or later) had higher rates of non-EtOH
SUDs and Antisocial Personality Disorder (ASPD) in
adulthood
• Subjects with early initiation of stimulant treatment
did not differ from controls w/r/t rates of SUDs or
ASPD
Mannuzza S, et al. (2008). Age of methylphenidate treatment initiation in children with ADHD and
later substance abuse: prospective follow-up into adulthood. Am J Psychiatry 165(5): 604-9.
SCREENING & ASSESSMENT OF
YOUTH IN THE JJ SYSTEM (1)
• Massachusetts Youth Screening Instrument2nd Version (MAYSI-2):
– layperson can administer
• Comprehensive MH Evaluation:
– for youth screening “positive” on MAYSI-2
• Psychiatric Evaluation:
– for youth who may benefit from psychotropic medications
SCREENING & ASSESSMENT OF
YOUTH IN THE JJ SYSTEM (2)
• Collateral Information:
– from parents/schools
• Rating Scales:
– SNAP-IV, CDI, CRAFFT (for SUDs), T-ASI (for SUDs)
• Psychoeducational Testing:
– K-BIT (IQ), WRAT (achievement testing)
• Los Angeles Risk and Resiliency Check-Up
(LARRC):
– assesses risk of recidivism
TREATMENT ISSUES
• Treating Disruptive Behavior Disorders (and SUDs)
– likely reduce recidivism/delinquency/criminality
• Meds can be misused/diverted stimulants, Seroquel
(quetiapine), Wellbutrin (bupropion)
– youth in juvenile detention settings (OR=2.76) or with
SUDs ([email protected]) (Schepis 2008)
• Meds can have side effects, some significant
• To treat or not to treat? That is the question.
– provide effective treatment with minimal side effects
– minimize risk of abuse/diversion
CONFIRMING ADHD DX IN JJ
POPULATION (1)
• “Informal” collateral (parents, teachers, custody):
–
–
–
–
What is the history?
How is youth functioning in school?
Can s/he follow instructions?
Does s/he need to be told to do things several times?
• “Formal” rating scales:
– Conners, SNAP-IV, etc.
CONFIRMING ADHD DX IN JJ
POPULATION (2)
• Psycho-educational/neuropsychological testing:
– rare to have been done in community or JJ settings
• Computerized testing:
– Continuous Performance Task (CPT) (e.g., TOVA, Conner’s
CPT II)
– looks at errors of commission/omission
– also rare in JJ setting
ATTENTION-DEFICIT/HYPERACTIVITY
DISORDER (ADHD)
• Base rate in population around 6-8%, 4-5x
higher in JJ and DCFS populations
• 2.5x higher rate in boys
• General domains include hyperactivity,
impulsivity, and ↓attention/concentration
• Children/adolescents with ADHD,
Inattentive Type are likely to be diagnosed
later
STIMULANTS AND STRATTERA (1)
•
•
•
•
Adderall XR (mixed d,l-amphetamine salts)
Concerta (long-acting methylphenidate (Ritalin))
Focalin XR (long-acting dexmethylphenidate)
Dexedrine spansules (long acting damphetamine)
• Strattera (atomoxetine): NE re-uptake inhibitor
• Variety of other short- and medium-acting
stimulants
STIMULANTS (2)
Targeted Disorders/Symptoms: ADHD, Narcolepsy, extreme
psychomotor retardation in depression
Evidence for use: excellent, scores (if not hundreds) of RCTs
supporting use of stimulants in treatment of ADHD,
Effects and “pros”: improve attention/concentration, decrease
hyperactivity/impulsivity; most effective treatment (effect sizes
1.0-1.3 for stimulants vs. 0.6-0.7 for atomoxetine), quick onset
of action, excellent safety profile, Limited side effects
including no significant long-term side effects (? ↓ adult height
w/ post-hoc analysis of MTA data)
Side effects and “cons”: ↓ appetite, insomnia, ?growth
retardation, GI upset; very rarely psychosis or sudden cardiac
death (1 in 10 million or so for latter); possible ↑ in SI for
atomoxetine
PEDIATRIC BIPOLAR DISORDER (PBD)
(1)
• Very controversial topic in C&A Psychiatry
• Essentially two camps: those who see it
everywhere and those who see it nowhere
• Lots of overlap of ADHD, PTSD, BD, and Fetal
Alcohol Syndrome (FAS) symptoms
• The former group claim PBD is qualitatively
different than adult BD (e.g., little periodicity
(i.e., always manic/hypomanic), irritable (rather
than grandiose) mood more common, etc.)
PEDIATRIC BIPOLAR DISORDER (PBD)
(2)
• As of now, little longitudinal data to support view that
PBD is qualitatively different that adult BD
• Several studies in progress which are following
children dxed with PBD longitudinally and seeing if
they develop adult BD
• Most consistent differentiators b/t PBD and other
disorders have been:
– Grandiosity
– Decreased need for sleep (not just insomnia)
– Hypersexuality (though also may happen with sexual
abuse)
PRE-NATAL ETOH AND DRUG
EXPOSURE (1)
• Obviously very common in JJ and DCFS
populations
• Varying degrees/types of exposure
• Can lead to neurological/psychiatric problems
either:
– From direct effects of substance on CNS
– Medical complications due to substance use
(e.g., placental abruption and premature delivery
2^ cocaine/MA use, intra-cerebral hemorrhage due to
cocaine/MA use) which affect CNS (usually anoxia))
• Most well characterized syndrome is Fetal
Alcohol Syndrome (FAS)
PRE-NATAL ETOH AND DRUG
EXPOSURE (2)
• FAS incidence around 2 in 1000 in general pop.
– Facial features: a flattened midface, thin upper lip,
indistinct/absent philtrum and short eye slits
– Growth retardation: lower birth weight, disproportional
weight not due to nutrition, height and/or weight below
the 5th percentile.
– Neurodevelopmental abnormalities: impaired fine
motor skills, learning disabilities, behavior disorders
or a mental illness (the latter of which is found in
approximately 50% of those with FAS)
FACIAL ANOMALIES IN FAS AT
DIFFERENT AGES
25
PRE-NATAL ETOH AND DRUG
EXPOSURE (3):
BEHAVIORAL DIFFICULTIES
• socially inappropriate behavior, as if inebriated
• inability to figure out solutions spontaneously
• inability to control sexual impulses, esp. in social
situations
• inability to apply consequences of past actions
• difficulty with abstract concepts of time and
money
• difficulty processing information
PRE-NATAL ETOH AND DRUG
EXPOSURE (4):
BEHAVIORAL DIFFICULTIES
• difficulty storing and/or retrieving information
• needs frequent cues and requires policing by
others
• needs to talk to self out loud; needs feedback
• fine motor skills more affected than gross motor
• Moody, “roller-coaster” emotions
• apparent lack of remorse; needs external
motivators
• inability to weigh pros and cons reasonably
when making decisions
PRE-NATAL ETOH AND DRUG
EXPOSURE (5):
BEHAVIORAL DIFFICULTIES
• FAS children frequently diagnosed with ADHD,
Conduct Disorder, Bipolar Disorder, etc.
• Co-morbid psychiatric conditions often present
• Medications and behavioral interventions not
particularly effective for FAS
• Alcohol-Related Neurodevelopmental Disorder
(ARND) is a separate, less well-defined entity in
which behavioral manifestations of FAS present,
but no facial anomalies or growth retardation
SECOND-GENERATION
ANTIPSYCHOTICS (SGAS) (1)
•
•
•
•
•
•
•
•
Risperdal (risperidone)
Seroquel (quetiapine)
Abilify (aripiprazole)
Zyprexa (olanzapine)
Geodon (ziprasidone)
Clozaril (clozapine)
Invega (paliperidone)
Fanapt (iloperidone)
SECOND-GENERATION
ANTIPSYCHOTICS (SGAS) (2)
Targeted Disorders/Symptoms: psychotic disorders, bipolar
d/o, baseline irritability, anger, impulsivity, or aggression
Evidence for use: fair for psychosis and bipolar disorder in
children, limited for aggression in children
Effects: ↓ psychotic sxs, stabilize mood, improve
irritability/aggression
Side effects: depends on agent used; generally sedation, ↑
wt., jitteriness/akathisia, sexual SEs; more rarely (but not
uncommonly) diabetes, ↑ cholesterol/lipids,
Parkinsonism, tardive dyskinesia (TD)
SECOND-GENERATION
ANTIPSYCHOTICS (SGAS) (3)
Pros: probably effective in variety of disorders and for
aggression (“shotgun approach”), limited abuse potential
Cons: expensive, significant SEs (including potential longterm SEs), moderate time to onset of action (possibly
weeks), ongoing lab monitoring required (e.g., glucose,
lipids)
PSYCHOTROPIC MEDICATION
CONSENT (1)
• Guardian/Parent (usually not foster parent)
– explain indications/risks/benefits/alternatives
– oral vs. written consent (more variable and r/t
jurisdictional/organizational policy)
• Delinquency Court:
– upon detention minor becomes “ward of court”
– judge/magistrate/commissioner/referee can
authorize medication
• routine vs. emergency (somewhat loose definition of
latter in Los Angeles County)
PSYCHOTROPIC MEDICATION
CONSENT (2): L.A. COUNTY
• Independent review of all psychotropic meds Rxed
to youth in JJ detention settings (wards) and under
DCFS supervision (dependents):
– done by child psychiatrist or senior pharmacist in Juvenile
Court Mental Health Services (JCMHS) of LACDMH
• Reviewer makes recs to judge/commissioner
• Court approval lasts for six months
• Other CA counties may use independent contractors
(rather than County employees) for same purpose
(state law now requires some independent review)
PSYCHOTROPIC MEDICATION
CONSENT (3): L.A. COUNTY
• 8,000 - 12,000 psychotropic medication
authorization forms (PMAFs) from the dependency
and the delinquency systems come through
LACDMH JCMHS every year.
• JCMHS makes a recommendation to the court
whether the PMA should be approved or denied or
whether it should be approved with modifications.
• JCMHS does not provide or withhold consent. The
judicial officer is responsible for providing consent.
PSYCHOTROPIC MEDICATION
CONSENT (4): L.A. COUNTY
• DMH has formal practice parameters for the use of
psychotropic medications in children and
adolescents.
• DMH convenes a practice parameters workgroup
quarterly.
• The workgroup consists of DMH and community
psychiatrists and pharmacists and representatives
from both USC and UCLA.
• Review of the PMAFs is based on DMH practice
parameters and American Academy of Child and
Adolescent Psychiatry practice parameters.
PSYCHOTROPIC MEDICATION
CONSENT (5): L.A. COUNTY
• Demographic Data
• Age
• Weight
• Height
• Gender
• Ethnicity
• Placement type
PSYCHOTROPIC MEDICATION
CONSENT (6): L.A. COUNTY
• Narrative: description of symptoms, duration and
severity of symptoms, response to medications, past
medication history
• Diagnosis: as it relates to symptoms
• Non-medication treatments: for example, behavioral
therapy, milieu, psychodynamic therapy
PSYCHOTROPIC MEDICATION
CONSENT (7): L.A. COUNTY
• Medical Conditions
• Cardiac disorder
• Seizure disorder
• Others
• Non-psychotropic medications
PSYCHOTROPIC MEDICATION
CONSENT (8): L.A. COUNTY
• Psychotropic Medications
• Type of medications
• Number of medications and interactions
• Maximum daily dosage of medications
• New or continuing medications
• Past medication history
• Plan (e.g., length of treatment, titration schedule)
PSYCHOTROPIC MEDICATION
CONSENT (9): L.A. COUNTY
• Labs
• Are appropriate lab tests being
done/monitored/ordered?
• How recent is lab data and how frequently are
labs being checked?
PSYCHOTROPIC MEDICATION
CONSENT (11): L.A. COUNTY
• Initial Review Decision:
• Yes - Attach review page and send to court
• No - Attempt to contact physician for clarification,
pull history, look in DMH Information System (IS),
alert judicial officer if necessary
• ?s - Attempt to contact physician for clarification,
may recommend consent for 30 days to allow
time for follow-up, alert judicial officer if necessary
PSYCHOTHERAPEUTIC
INTERVENTIONS IN DETAINED
JUVENILES
• Crisis Counseling/Supportive Therapy
• Motivational Interviewing/Enhancement (MI/MET)
• Cognitive-Behavioral Therapy (CBT):
– including TF-CBT and C-BITS (both for trauma)
• Parent Management Training (PMT):
– when caregivers/parents available
• Girls…Moving On:
– designed to reduce recidivism in female detainees
• Should we target MH symptoms or recidivism
risk first/primarily?
PSYCHOTHERAPEUTIC
INTERVENTIONS PRIOR TO
DETENTION (OR ON RELEASE)
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•
•
•
•
Parent Management Training (PMT)
Functional Family Therapy (FFT)
Multidimensional Family Therapy (MDFT)
Multisystemic Therapy (MST)
Integrated Family CBT (IFCBT): pilot data
showed promising results
• Juvenile Drug/Mental Health Courts:
generally “diversion”; mixed results
TAKE HOME POINTS
• Youth in delinquency and dependency
systems have ↑ rates of mental disorders
compared w/ community youth
• Psychotropic medications can be a very
useful/necessary treatment for youth in these
systems
• In L.A. County (and other jurisdictions),
prescribing of psychotropic medications to
these youth is closely monitored
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