Journal of Correctional Health Care - April 2023 - 98

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TAMBURELLO ET AL.
a court order to start administering medications if there is
an imminent danger to the youth or others.
There is no established national age in the United
States when a youth can independently consent to treatment.
Interested readers are referred to Kerwin et al.'s
(2015) work to list the state regulations regarding
decision-making rights for drug and mental health treatment
of youth in both inpatient and outpatient settings,
though we recommend verification of current laws and
regulations in the specific jurisdiction. Correctional facilities
for youth are generally considered outpatient treatment.
Even when minor consent is allowed by state law
or regulation, given the complicated nature of this population,
we recommended that efforts (with more effort for
younger people) be made to obtain consent from the authorized
legal guardian.
Even when not able to legally consent for treatment,
the patient's assent is useful to obtain. It is valuable to
consider their understanding and acceptance of the treatment.
Whenever clinically appropriate, their preferences
should be included.
Depending on local laws, signed informed consent is
generally needed for those who have not yet reached
the age of majority. We recommend that facilities contact
parents or the youth's authorized medical decision makers
to notify them whenever medication is changed. Psychiatrists
should be prepared to answer reasonable questions
from patients and authorized adults in a phone call or family
meeting.
Adherence and Adverse Effects of Medication
In residential settings, medication adherence is typically
monitored via medication administration records or the
electronic health record. A pattern of refusal or inconsistent
adherence should be promptly addressed during
follow-up visits with the prescriber. Input from the clinical
team, other relevant staff, and the youth's family
may be helpful to understand the circumstances and rationale
for refusals or missed doses.
Other considerations include concerns about stigma,
cultural views of medication, peer pressure, and lack of
family support. Often many of these concerns may be
addressed by sensitive and supportive listening and targeted
psychoeducation to address knowledge gaps of
the patient or their family members.
Side effects are a common reason for medication nonadherence.
Youth especially may suffer medical, psychological,
and social harm from complications such as
metabolic changes, gynecomastia, dystonia, and tardive
dyskinesia. Weight gain in juvenile justice settings is promoted
by the sedentary nature of congregate settings,
limited opportunities for regular exercise, and ready access
to snacks and high-calorie meals. Psychiatrists
should pay close attention to medications that present
higher risk for weight gain such as mirtazapine, divalproex
sodium, and second-generation antipsychotics.
Other common concerns include, but are not limited
to, kidney and thyroid complications from lithium, polycystic
ovary disease from divalproex sodium, and
Stevens-Johnson syndrome from carbamazepine and
lamotrigine (Texas Health and Human Services Commission,
2019).
Misuse and Diversion of Prescribed Medications
As in adult corrections (McKee et al., 2014; Tamburello
et al., 2022), misuse and diversion of medications, even
noncontrolled medications, is a concern in juvenile facilities.
Up to 80% of youth who enter the justice system
have a history of substance use in the community, with
up to 40% meeting criteria for a substance use disorder
(SUD; Harzke et al., 2011, 2012). Some may want to reproduce
the feeling they were used to experiencing from
illegal substances, even if the effects are less satisfying.
Bartering of diverted medicine encourages antisocial
behaviors in the facility and may prevent medications
from being taken by those who need them. Furthermore,
vulnerable youth, particularly those with lower cognitive
abilities, a prior history of trauma, low self-esteem, and
those identifying as LGBTQ, may be coerced into relinquishing
their medications. Even more concerning, failing
to take medication as prescribed, along with
hoarding, may be a prelude to a suicide attempt.
Misuse and diversion of medication is a major safety
concern for both patient and peers. Methods include
cheeking (the patient puts a pill in the mouth but only pretends
to swallow it), palming (the patient pretends to put a
pill in the mouth but hides it in the hand), hiding the pill
in an empty tooth socket, or regurgitating the medication
later. A multidisciplinary approach involving psychiatric,
nursing, and other staff is needed to minimize the problem.
Staff may address cheeking with mouth checks;
palming may be avoided by giving the medication in a
paper cup and inspecting the hands after administration.
Whenmisuse is detected, it is appropriate to reassess the
need for the medication. Depending on the clinical circumstances,
ordering the medication as crushed (and sprinkled
into water or juice) may help manage the risk. Although
crushing medication is a common practice in juvenile justice
facilities, there are no formal studies of this. Before ordering
a medication this way, prescribers should consult
the latest version of the ''do not crush'' list (Institute for
Safe Medication Practices, 2020) When hoarding is suspected,
further clinical assessment is appropriate and any
necessary risk management procedures enacted.
Attention-Deficit/Hyperactivity Disorder
ADHD is one of the most common psychiatric disorders
of childhood and adolescence (Beaudry et al., 2021;

Journal of Correctional Health Care - April 2023

Table of Contents for the Digital Edition of Journal of Correctional Health Care - April 2023

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