Journal of Correctional Health Care - April 2023 - 101

PRESCRIBING PSYCHOTROPIC MEDICATIONS
101
Impulse-Control Disorders and Self-Injury
Impulsive acts of self-mutilation, self-harm, nonsuicidal
self-injury, deliberate self-harm, behavioral outbursts,
and assaultive behaviors toward peers and staff commonly
occur in juvenile justice settings. Potential contributors
to these problems include developmental and
intellectual disabilities, early childhood traumatic events,
attachment disorders, emerging maladaptive personality
traits, psychiatric disorders, and a variety of other psychological,
familial, peer, and cultural factors. Although
intermittent explosive disorder remains in the APA's
Diagnostic and Statistical Manual of Mental Disorders
(APA, 2013), this diagnosis has received little attention
in the medical literature. We recommend that psychiatrists
consider first other diagnoses like adjustment
disorder, major depressive disorder, bipolar disorder, disruptive
mood dysregulation disorder (DMDD), personality
disorders, and SUDs.
Incarcerated adolescents have higher rates of suicide attempts
and use more violent methods than adolescents in
the general population (Penn et al., 2003). Self-injuring
youths report more severe affective symptoms than their
counterparts. Nonlethal self-injury may present as a learned
or contagion effect in juvenile detention and correctional
settings. Facing substantial environmental changes, some
justice-involved youths may feign suicidality.
Self-mutilative behaviors such as actual, attempted, or
reported ingestion of chemicals or foreign objects, superficial
cutting, or other actual or threated self-injury may
be attempts to avoid incarceration or to be placed into a
perceived less restrictive environment (e.g., a medical
or psychiatric hospital) or a less secure setting to enable
elopement (Penn & Thomas, 2005). Nevertheless, all
self-injury should be taken seriously.
Currently, dialectical behavior therapy for adolescents
is the only well-established treatment for self-harming
adolescents at high risk for suicide (Clarke et al.,
2019). Although many medication classes, doses, and
combinations (e.g., atypical antipsychotics, lithium and
other mood stabilizers, antidepressants, alpha-2 agonists)
are used off-label to treat impulse control disorders, there
is little evidence to support their use in this population,
and no trials have been done specifically for adolescents
who self-harm (Hawton et al., 2012).
Research suggests that antidepressants can sometimes
be counterproductive. In the Treatment for Adolescents
with Depression Study for this purpose, suicidal acts
were more common in patients taking fluoxetine alone
(14.7%), with the lower rates in those getting cognitive
behavioral therapy (6.3%) or the combination (8.4%;
March et al., 2007).
Some literature supports the use of the opioid antagonist
naltrexone for self-injurious behaviors in adults with
borderline personality disorder, intellectual disabilities,
and autism and other developmental disabilities (Symons
et al., 2004). One case report indicated that naltrexone reduced
head-banging behavior in a 3-year-old (White &
Schultz, 2000), and small open-label trials suggest benefit
for self-injury in severe neurodevelopmental disorders
(Sabus et al., 2019). Due to the lack of controlled studies
in justice-involved youth, we cannot yet recommend naltrexone
for this indication.
Insomnia and Other Sleep Disorders
Sleep-related complaints are quite common in juvenile
justice settings. Although the rate of insomnia is estimated
at 11% of the overall adolescent population
(de Zambotti et al., 2018), in children with special
needs the rate may be as high as 75% (Ekambaram &
Owens, 2021). Environmental factors in juvenile justice
settings contribute to sleep problems: noise, variable temperatures,
poor ventilation, limited daylight exposure, excessive
nighttime light exposure, and limited daytime
opportunities for physical activity. Structured early bed
and waking times are inconsistent with typical adolescent
circadian rhythm cycles.
Facilities should avoid referring complaints of poor
sleep without other mental health symptoms directly to
the psychiatrist. Rather, psychosocial interventions provided
by ancillary staff is a more appropriate first step.
When evaluating a complaint of insomnia, it is helpful
in residential settings to ask nighttime staff to document
observed sleep patterns for the patient for 3 to 5 nights.
Current guidelines for adolescent insomnia recommend
behavioral interventions like cognitive behavioral therapy
and sleep hygiene as first-line treatment (Lunsford-Avery
et al., 2021; Williams Buckley et al., 2020). In our experience,
youth injuvenilejustice settings prefer medications
for sleep. Nevertheless, given the lack of evidence for benefits
of sleep-inducing medication in adolescence, it is reasonable
for facilities to develop a practice of avoiding
pharmacological interventions for insomnia. Controlled
sedating medications like benzodiazepines and orexin receptor
antagonists are almost never clinically appropriate
for insomnia in justice-involved youth, particularly considering
the risks of misuse, dependence, and diversion.
There may be cases where pharmacotherapy is appropriate,
especially when there is a documented pattern of
poor sleep and associated impairment in functioning
that is not responsive to nonpharmacological strategies.
When the psychiatrist feels the benefits of using sleep
medications outweigh the risks, a time-limited prescription
(e.g., 1 to 2 weeks) of a lower-risk medication, followed
by a reassessment of the risks and benefits of the
medication, may be considered.
Appropriately dosed antihistamines are a relatively
safe and reasonable choice for short-term treatment of insomnia.
Options include low-dose doxepin (3 to 6 mg),
diphenhydramine (25 to 50 mg), cyproheptadine (4 to
Journal of Correctional Health Care - April 2023

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