Journal of Correctional Health Care - April 2023 - 96

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TAMBURELLO ET AL.
beyond (Umpierre, 2014). Juvenile justice facilities are
institutions under the Civil Rights of Institutionalized
Persons Act, under which the Department of Justice has
prosecuted complaints of inadequate health care in
these settings (Civil Rights of Institutionalized Persons
Act, 1980; Umpierre, 2014).
Other federal laws are also relevant to health care for
justice-involved youth. The Prison Rape Elimination
Act of 2003, for example, guarantees screening as well
as emergency and ongoing medical and mental health services
for victims of sexual assault in juvenile facilities
(Prison Rape Elimination Act, 2003; United States
Department of Justice, 2012). Additional protections
and rights related to health care may be granted by
jurisdiction-specific state laws and regulations (Umpierre,
2014).
Differences in Prescribing Psychotropic
Medications in Juvenile Justice Settings
Youth in juvenile justice settings are physically, emotionally,
and neurodevelopmentally different from adults
(Penn & Thomas, 2005). Besides substantial heterogeneity
in chronological age, there are wide differences in
physical, social, and intellectual development. Interpersonal
skills and problem-solving capacities vary considerably.
Although some youth may have a pervasive
developmental disorder or intellectual disability, serious
mental illness is unusual in this population (Beaudry
et al., 2021; Mallett, 2014).
In most community settings, psychiatrists can expect
evaluations of children and adolescents to happen during
regular hours and with active family involvement, yet
justice-involved youths more often arrive after hours or
on weekends, and family members and past records are
not immediately available, making information collection
and continuity of care challenging. Communicating
with family members may be difficult because of work
schedules, childcare demands, lack of reliable phone service,
or limited means of transportation. Patients may be
reticent to speak with staff (whom they perceive as part of
the criminal justice system), and some families may refuse
to engage in treatment planning or provide informed
consent for medication.
Because many psychotropic medications lack Food
and Drug Administration (FDA) approval specifically
for children or adolescents, off-label prescribing is common
(Syed et al., 2021). Failure to disclose off-label prescribing
to the patient or the authorized adult creates a
substantial medicolegal risk. Many youths arrive to justice
settings on a variety of psychotropic medications,
sometimes with unanticipated doses and combinations
(i.e., polypharmacy). Many also have a history of treatment
nonadherence and may have misused psychotropic
(e.g., psychostimulant) medications.
Justice-involved youth require screening not often required
in adult facilities for certain diseases (e.g., scoliosis),
but they typically present with a much lower chronic
medical disease burden. Some youth though may have serious
medical comorbidities such as obesity, diabetes
mellitus, asthma, sickle cell disease, hemophilia, or pregnancy,
thus necessitating timely and coordinated treatment
approaches between psychiatry, general medical
providers, and specialist consultants (Committee on Adolescence
et al., 2011).
Assessment
The topic of assessment in juvenile correctional facilities
has been explored in detail elsewhere, and the interested
reader is referred to these resources (Desai et al., 2006;
Penn & Thomas, 2005). Commonly, youth arrive already
prescribed medication and it is customary and usually appropriate
to continue medications pending a formal psychiatric
assessment. Otherwise, psychotropic medications
should be used only after a comprehensive psychiatric
evaluation and after obtaining valid informed consent.
Psychiatrists will often evaluate youth presenting with
specific self-reported complaints such as insomnia or depression.
They may also be referred by staff because of
suicide attempts, deliberate self-harm, assaults, or other
disruptive behaviors.
Adequate time and resources are needed to perform a
mental health assessment with special attention to cultural,
family, gender, and other relevant factors (Whitley
et al., 2022). The psychiatrist should reassess the need for
previously prescribed psychotropic medications based on
current and historical symptoms, level of functioning,
and current treatment needs. In short-term settings, a
youth's legal disposition and placement should be clarified
or resolved before any psychiatric medication is initiated
or changed. Side effects, medication refusals,
unavailable (i.e., nonformulary) medication, or emergent
medical issues may prompt the need for rapid assessment
and response.
Many youths arrive on large doses of multiple medications
(Lyons et al., 2013). In these circumstances, psychiatrists
should vigilantly consider side effects and
complications. Sometimes adjudicated youth have recently
had medication changes made by outside psychiatric
prescribers who may have been unaware that recent
substance use or medication nonadherence may have better
explained treatment-refractory symptoms.
These patients may be poor sources of information,
and with less help from responsible adults than in community
settings, it can be challenging to elucidate their
history. Primary caregivers, especially the parents or
guardians of children under 18, should be contacted regarding
treatment history, current medication regimen,
and consent. This can be particularly challenging for
Journal of Correctional Health Care - April 2023

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