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and adolescents (Evans et al., 2015; Malmgren et al., 1999;
Raskind et al., 1999; Sikorski, 1991) are inconsistent, 10%
of youth in correctional facilities are estimated to have a
specific learning disability, and are more likely to recidivate
(Chin, 2017). Collaboration with the educational system
is of the essence in identifying youths with LD/ID.
Many times, children with severe LD/ID are identified
early on, but those with higher abilities (particularly verbal
abilities) may be overlooked by the system and have
their symptoms characterized as primarily behavioral.
Information such as family history, developmental history,
educational records, IQ, and academic achievement
testing is helpful to diagnose LD/ID (American Academy
of Child and Adolescent Psychiatry, 1998). Once identified,
addressing these problems to improve language
skills and learning capacity will aid in academic achievement,
which would be expected to protect against recidivism
(Linares-Orama, 2005).
There are no pharmacological interventions specifically
for LD/ID, but once a diagnosis is established, it
can clarify other comorbid disorders that may benefit
from treatment (American Academy of Child and Adolescent
Psychiatry, 1998), such as impulsive aggression.
Treatment should preferentially be targeted toward approved
indications, when possible, with consideration
for the level of impairment caused by the symptoms.
Autistic Spectrum Disorders
Surveys report high rates of youth with developmental
disabilities, including autistic spectrum disorders (ASD)
in the juvenile justice system (Cheely et al., 2012; Rutten
et al., 2017). Rutten et al. (2017) found that the prevalence
of delinquency in the ASD population varied
from 5% to 26%, and ASD was found in 2% to 18% of
the forensic populations studied. ASD in justice-involved
youth may be signaled by disruptive behavior triggered
by factors such as environmental changes or complex social
interactions with peers or staff.
Treatment of ASD in juvenile facilities is no different
than treatment in the community. Volkmar et al. (2014)
suggested that although there are no specific medications
to treat the core features of ASD, medications should be
chosen to address symptoms that cause distress or impair
functioning. Aripiprazole and risperidone have received
FDA approval for the treatment of irritability associated
with ASD (LeClerc & Easley, 2015). Interested readers
are referred to LeClerc and Easley's (2015) review of
off-label medications for features of ASD, including social
behavior, repetitive behaviors, hyperactivity and inattention,
and cognition.
Oppositional-Defiant and Conduct Disorder
Oppositional defiant disorder (ODD) is characterized by
a persisting pattern of angry or irritable mood, argumentative
or defiant behavior, or vindictiveness (American
Psychiatric Association [APA], 2013). Youths with
ODD may have trouble controlling their temper and are
generally disobedient. ODD is often comorbid with
ADHD, CD, anxiety disorders, and mood disorders.
Behavioral therapy for the youth and family members improves
symptoms of ODD and psychotropic medications
are not recommended as first-line treatment for ODD.
However, treatment of comorbid psychiatric disorders
with medications often improves ODD symptoms (Steiner
& Remsing, 2007). For example, when ODD and ADHD
overlap, medications to treat ADHD (including psychostimulants
and atomoxetine) may also reduce symptoms of
ODD (Turgay, 2009). Early diagnosis and intervention
may prevent the development of ODD into CD, SUD,
and adult antisocial behavior (Steiner & Remsing, 2007).
Research for the pharmacological treatment of CD is
limited, and no studies of CD have included justiceinvolved
youth (Hambly et al., 2016). Those with ODD
and CD with severe aggression may respond well to risperidone,
with or without psychostimulants (Turgay,
2009). Mood stabilizing medications, alpha-2 agonists,
and antidepressants may also have a role as second-line
agents in the treatment of ODD and its comorbidities
(Turgay, 2009).
Evidence also indicates that psychostimulants, alpha-2
agonists, and atomoxetine can be beneficial for disruptive
and aggressive behaviors in addition to core ADHD
symptoms, though psychostimulants generally provide
more benefit (Pringsheim et al., 2015). A small, randomized,
placebo-controlled study of outpatient youths suggested
that risperidone reduced aggression in CD
(Findling et al., 2000). A larger recent study, though subjects
were 18 years or older, found that when CD was
comorbid with schizophrenia, the anti-aggressive effects
of haloperidol, olanzapine, and especially clozapine were
augmented. The benefits observed were independent of
antipsychotic effects (Krakowski et al., 2021).
In 2015, a multidisciplinary group from Canada published
consensus guidelines on medications to treat disruptive
and aggressive behavior in (not necessarily
justice-involved) youths with ADHD, ODD, or CD.
This suggested that only risperidone has moderate evidence
to support its use for aggression in these contexts.
The group specifically recommended against using quetiapine,
haloperidol, lithium, or carbamazepine because
of the poor quality of evidence and their major adverse
effects (Gorman et al., 2015).
The UK's National Institute for Care and Clinical
Excellence discourages medication for the routine management
of behavior problems for ODD or CD. When
necessary, medications for ADHD should be used first,
though risperidone may be considered for short-term
management of severe aggressive behavior (National
Institute for Health and Care Excellence, 2017).
Journal of Correctional Health Care - April 2023

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