Journal of Correctional Health Care - April 2023 - 103

PRESCRIBING PSYCHOTROPIC MEDICATIONS
103
either verbal rages or physical aggression) and unrelenting
irritability or anger. Currently, the literature is lacking
in terms of treatment options for DMDD. There are no
practice guidelines or reviews summarizing the treatment
of DMDD. Off-label medication options for DMDD include
selective serotonin reuptake inhibitors (SSRIs) and
SNRIs, mood stabilizers, psychostimulants, antipsychotics,
and alpha-2 agonists (Tourian et al., 2015).
Although there are randomized placebo-controlled clinical
trials evaluating medications for mood stabilization in
youths with bipolar disorder (Stepanova & Findling, 2017;
Yatham et al., 2018), most have small sample sizes, none
are in correctional settings, and none are related to the
pharmacological treatment of pediatric bipolar disorder
with comorbid CD or SUDs.
A diagnosis of bipolar illness typically implies the
need for a traditional mood stabilizer (e.g., lithium over
the age of 7, lamotrigine over age 10, divalproex sodium,
or carbamazepine) or a second-generation antipsychotic
(e.g., aripiprazole over age 10 for mania or mixed episodes,
quetiapine over age 10 for mania, olanzapine
over age 10 for mania or mixed episodes, olanzapine
and fluoxetine for bipolar depression, risperidone over
age 13 for mania or mixed episodes, lurasidone over
age 10 for bipolar depression, or asenapine over age 10
for mania or mixed episodes; Texas Health and Human
Services Commission, 2019).
If the diagnosis is uncertain and depression symptoms
predominate, the psychiatrist may consider a trial of
lower-risk antidepressant monotherapy, closely monitoring
for manic switching or rapid cycling. Antipsychotic
agents may be preferred in patients with significant psychotic
symptoms.
Trauma- and Stressor-Related Disorders
Exposure to trauma, including physical abuse, sexual
abuse, or witnessing violence in the home, school, or
community, is remarkably high-up to 90%-in justiceinvolved
youth (Branson et al., 2017). Research strongly
suggests a correlation between trauma and juvenile justice
involvement, likely mediated by dangerous coping
like substance use, running away, and gang involvement.
As in adult facilities, young people may also suffer physical
or sexual trauma while in placement (Branson et al.,
2017; Tamburello et al., 2022).
Traumatic experiences have a direct impact on the
environment of juvenile justice systems as previously
traumatized children and adolescents may respond aggressively
to perceived threats (Ford et al., 2012; Margolin
& Vickerman, 2007). Depending on the study, from
11% to 32% of justice-involved youth will meet criteria
for PTSD (Underwood & Washington, 2016). Disinhibition,
hypervigilance, or hypersexuality may be signs of
sexual, emotional, or physical abuse in these patients.
To our knowledge, there are no medication studies for
PTSD specifically in juvenile justice settings, nor FDAapproved
treatments for PTSD in children and adolescents.
Some studies have returned positive results for
citalopram and fluoxetine for pediatric PTSD (Cohen &
the AACAPWork Group on Quality Issues, 2010), but evidence
is inadequate to support the use of SSRIs for this
indication (Strawn & Keeshin, 2019). Although some
studies and guidelines suggest benefit in adults (Tamburello
et al., 2022), no relevant studies are available for
paroxetine, venlafaxine, or mirtazapine in youth (Strawn
& Keeshin, 2019). If the psychiatrist decides to use an antidepressant
off-label for PTSD for a young patient, they
must be aware of the black box warnings for overactivation
and suicide risk in children and adolescents, and
must include this information in the informed consent
process.
Open or retrospective studies have suggested benefit for
children with PTSD from clonidine, guanfacine, propranolol,
prazosin, risperidone, divalproex sodium, and carbamazepine,
though antiadrenergic agents are relatively more
likely to be well tolerated (Strawn & Keeshin, 2019).
After carefully assessing the risks and benefits, it may be
reasonable to consider off-label options in the case of
comorbid (on-label) indications such as ADHD, bipolar
disorder, schizophrenia, or epilepsy (Cohen & the
AACAP Work Group on Quality Issues, 2010; Strawn &
Keeshin, 2019).
As in adults, long-term medication is neither evidence
based nor indicated for adjustment disorders, though
short-term symptomatic treatment may be appropriate in
the case of an acute traumatic event (Tamburello et al.,
2022). Quality treatment for PTSD in any age group
includes psychotherapeutic approaches; medication alone
is inadequate (Cohen & the AACAP Work Group on
Quality Issues, 2010).
Substance Use Disorders
After CD, SUDs are the most common mental health
problems in youth in secure facilities (Harzke et al.,
2012). Youth in custody report high rates of lifetime
use of alcohol (74%) and illegal drugs (85%; Committee
on Adolescence et al., 2011). More than 16% of arrests of
children and adolescents are specifically related to substance
use (OJJDP, 2019a). These problems often correlate
with other psychiatric disorders and may lead to
further drug use and delinquency, risky sexual behaviors,
and other medical problems (Belenko et al., 2017).
Given the high rate of morbidity and mortality in the
community, opioid use has received greater attention
lately, including the treatment of opioid use disorder
(OUD) with medications (MOUD) such as buprenorphine,
methadone, or naltrexone, even during incarceration.
Buprenorphine is FDA approved for ages 16 and over
Journal of Correctional Health Care - April 2023

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