Journal of Correctional Health Care - April 2023 - 95

PRESCRIBING PSYCHOTROPIC MEDICATIONS
95
Child and adolescent psychiatrists are few in number and
unevenly distributed in the United States, making it logistically
difficult to meet the needs of this system of care,
even if all parties were willing (Thomas & Holzer,
1999). Due to both availability and budget constraints,
these facilities often employ providers who are not specialized
in child and adolescent psychiatry (Penn &
Thomas, 2005).
This review and analysis regarding prescribing psychotropic
medication in juvenile justice settings will
speak to the target audience of child and adolescent psychiatrists
yet is broadly applicable to other professionals
with prescribing privileges. The terms provider, prescriber,
and psychiatrist in this document can be taken
to mean any such clinician.
To our knowledge, this is the first document to organize
in one place the sparse research related to the prescribing
of psychotropic medications for justice-involved youth.
The intent is to provide guidance on best practices for psychiatrists
and other professionals prescribing to children
and adolescents with court involvement who are housed
in jails, prisons, juvenile detention facilities, state juvenile
facilities, halfway houses, residential facilities, and other
relevant settings. It is meant to be a resource for prescribers
but should not be interpreted as a practice guideline. It
does not represent a standard of care and does not represent
all possible clinical approaches.
Terminology and Processes Involving
Justice-Involved Youth
In this article, when used to describe individuals, the term
juvenile is avoided to respect the National Commission
on Correctional Health Care (NCCHC) position statement
on the use of humanizing language in correctional
health care (NCCHC, 2021).
Crimes that are only relevant to youth (like school truancy,
running away from home, and curfew violation) in
proceedings are called status offenses. Adjudication is the
process, like a trial, in which a hearing is held to determine
if a youth is delinquent, whichmeans that they committed a
crime. Children and adolescents awaiting adjudication may
be kept in youth detention facilities, and iffound delinquent
for a crime that is not a status offense ( Juvenile Justice
Delinquency and Prevention Act, 1974), may be subject
to placement, which is akin to incarceration.
Some youths charged with violent or serious offenses
may be held in (adult) jail. Others may be held in juvenile
facilities while they undergo certification or legal transfer
proceedings (i.e., waiver or bindover) and are tried and
sentenced as adults to state or federal prison. Some
youth may serve ''blended'' sentences (i.e., beginning
in a state juvenile facility and subsequently transferred
to adult state prison) for serious charges like murder,
other capital offenses, or violent assaults on staff.
Placement may range from treatment in nonsecure
group homes and residential programs to secure juvenile
correctional facilities. Youths may also be mandated into
treatment in the community through conditions of probation.
In some jurisdictions, they may avoid a finding of
delinquency by successfully completing terms of probation.
Most justice-involved children and adolescents receive
community-based treatment and supervision rather
than residential placement. Residential placement, even
when used, is typically brief. In 2017, the median number
of days youths were retained and awaiting adjudication
was 23, whereas those committed to residential treatment
spent a median of 114 days there (OJJDP, 2017).
Although certain adolescents may be transferred to
adult facilities if sentenced as an adult, the juvenile system
is not typically a preface to adult incarceration.
Most justice-involved youth will not go on to become
justice-involved adults. Extensive research validates
Moffitt's hypothesis that criminal behavior peaks in adolescence
and a small portion of individuals will continue
to offend over the course of their lifetime, but for most
antisociality is transient and resolves in adulthood (Moffitt,
1993, 2018). Only 10% of youths who commit a serious
crime will persist in illegal activities at the same
high rate over the course of 3 years, regardless of the seriousness
of their original offense or the intensity of court
interventions (Sickmund & Puzzanchera, 2014).
Mental health services are a critical component of the
treatment provided to justice-involved youth.
Prevalence of Psychiatric Disorders
Psychiatric disorders are exceedingly common in justiceinvolved
youth. In a long-term study of youths in first
contact with the justice system, 75% met criteria for a
mood, anxiety, or behavioral disorder (Burke et al.,
2015). A comprehensive review of electronic medical records
in the Texas state juvenile correctional system
found that 98% of youth in these facilities were diagnosed
with at least one psychiatric disorder (Harzke
et al., 2012). A 2021 meta-analysis compiling data on
the prevalence of psychiatric disorders in justiceinvolved
youth found rates of 61.7% for conduct disorder
(CD), 17.3% for attention-deficit/hyperactivity disorder
(ADHD), 10.1% for major depressive disorder, 8% for
post-traumatic stress disorder (PTSD), and 2.7% for a
psychotic disorder (Beaudry et al., 2021).
Legal Basis for Mental Health Care
Although we are unaware of case law that explicitly addresses
health care for justice-involved youth, the constitutional
basis for the rights of incarcerated adults to
medical and mental health care, including Estelle v. Gamble
(1976) and its progeny, has been considered applicable
to children and adolescents in residential settings and
Journal of Correctional Health Care - April 2023

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