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TAMBURELLO ET AL.
8 mg), and hydroxyzine (25 to 100 mg). Anticholinergic
side effects such as dry mouth, constipation, and daytime
somnolence may be problematic (Ekambaram & Owens,
2021).
Case studies for the melatonin receptor agonist ramelteon
show some efficacy in adolescents, but no controlled
studies have been attempted in this group (Kawabe et al.,
2014). Melatonin has empirical evidence in the pediatric
population, mainly derived from studies involving children
with special needs. Melatonin is not FDA regulated,
and formulations may significantly vary in terms of quality.
Using a low dose (0.5 to 1 mg) of melatonin 4 to 5
hours before bedtime may help sleep-onset circadian
phase-shift problems. A larger hypnotic dose (3 to
5 mg) closer to bedtime may decrease sleep onset latency.
Controlled-release melatonin formulations may be used
for sleep maintenance (Ekambaram & Owens, 2021).
Some medications may be worth considering when insomnia
is comorbid with other conditions in adolescents.
Low-dose amitriptyline (10 to 25 mg), for example, may
be a helpful agent in cases of concurrent nocturnal enuresis.
The alpha-2 agonists clonidine and guanfacine both
have extended-release formulations FDA approved for
ADHD. Immediate release formulations of clonidine or
guanfacine could reasonably be used to treat ADHD
symptoms with co-occurring delayed sleep latency. Of
concern, though, a study of extended-release guanfacine
reported worsened sleep in participants (Rugino, 2018).
When depression is comorbid, mirtazapine has a high
degree of sedation at lower doses (though higher doses
may be required for antidepressant effects in adolescents;
Haapasalo-Pesu et al., 2004). Given mirtazapine's propensity
to promote weight gain, sleep apnea and obesity
would be relative contraindications. Trazodone has been
used as a sleep-inducing agent as standard practice in
adult psychiatry for decades ( Jaffer et al., 2017).
Although generally well tolerated with a recommended
pediatric dose of 25 to 50 mg, more side effects (e.g., hypertension,
arrhythmias, serotonin syndrome, and priapism)
are seen with higher doses. Given a lack of studies
in adolescents and considering the side effect profile, trazodone
should be used with caution with this group, especially
in males.
Most antipsychotics decrease sleep onset latency, increase
sleep continuity, and in high doses suppress
rapid eye movement sleep. Due to their serious side effect
profile, though, antipsychotics should not be used as
stand-alone sleep agents. Furthermore, quetiapine is frequently
specifically requested by youth in juvenile justice
settings. It has a well-known abuse potential and commonly
has been taken off the formulary in adult correctional
facilities (Tamburello et al., 2012).
In juvenile justice settings, the timing of evening pill
call may vary from 4 to 9 pm. Psychiatrists should advocate
for an evening pill call that better approximates a reasonable
bedtime for patients. When the evening pill call is
very early, the use of any sleep aid may be unreasonable.
Youth may sometimes present already prescribed
high-risk medication for sleep without a clear psychiatric
indication (e.g., quetiapine). Some youth, especially
those with CD or SUDs, may be highly resistant to clinically
appropriate efforts to reduce or eliminate such
medications, and may threaten or engage in disruptive
or assaultive behaviors in response. Involving therapists
or security personnel in these conversations can facilitate
a safe and productive discussion.
Depressive Disorders
Although common in these settings (Beaudry et al., 2021),
there are no published studies of treatment of depressive
disorders for justice-involved youth. Antidepressants are
commonly prescribed to children and adolescents even
in the community, but available evidence on safety and efficacy
of these agents is inconclusive. Zhou et al.'s (2020)
meta-analysis on the treatment of depressive disorders in
youth suggested that fluoxetine (either alone or in combination
with cognitive behavioral therapy) had the strongest
support based on available research.
Bipolar Disorder and Disruptive Mood
Dysregulation Disorder
When adolescents present with mood and behavioral dysregulation,
accurate diagnosis is one of the most important
and difficult challenges for psychiatrists in the
community, and even more so in juvenile justice settings.
Pediatric bipolar disorder is controversial related to its
prevalence, diagnosis, and treatment (Goldstein et al.,
2017; McClellan et al., 2007). Many justice-involved
youths present with severe behavioral dysregulation, getting
too angry or agitated, too quickly, for too long, with
trivial precipitants or disproportionate provocation from
peers or staff setting limits. Concluding that these patients
have bipolar disorder may be satisfying for families
and psychiatrists but may unnecessarily expose the patient
to stigma and long-term, high-risk medications.
Bipolar disorder should not be diagnosed solely based
on disruptive behavior, a depressive episode, or a family
history of bipolar disorder. The differential for unstable
mood in youth is broad and should include adjustment
disorders, substance-induced mood or psychotic symptoms,
major depressive disorder, trauma-related disorders,
CD, ODD, ADHD, and (rarely) general medical
conditions (e.g., central nervous system infections, malignancy,
stroke, hyperthyroidism, hypothyroidism,
Cushing's syndrome; National Institute for Health and
Care Excellence, 2020).
To address overdiagnosis of bipolar disorder in youths,
the APA (2013) included DMDD in the DSM-5. The core
features of DMDD are temper outbursts (manifested by
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