Journal of Correctional Health Care - April 2023 - 99

PRESCRIBING PSYCHOTROPIC MEDICATIONS
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Volkmar et al., 1999). ADHD is a risk factor for legal entanglements,
violent offending, and recidivism (Eme,
2008; Retz et al., 2021; Ro¨sler et al., 2004). Therefore,
it is particularly important to identify and treat ADHD
in settings with justice-involved youth.
SUDs are not mutually exclusive with ADHD and may
complicate assessment; many youths engage in substance
use to minimize symptoms associated with ADHD (Bukstein,
2009; Zaso et al., 2020). Untreated ADHD is a significant
risk factor for SUD in adolescence (Zulauf et al.,
2014), and treatment of ADHD may be protective against
later development of SUD, though this effect is dependent
on adherence (Zulauf et al., 2014).
There are nonpharmacological interventions to help
youth with ADHD, but medications should be considered
when the symptoms are severe enough to cause functional
impairment (Volkmar et al., 1999). Once a youth
has been placed in a residential facility, this alone is usually
sufficient to conclude that there is a severe impairment
in functioning.
Stimulants (e.g., amphetamines and methylphenidate
in their various formulations) remain first-line treatment
for ADHD. Nonstimulant and FDA-approved options include
alpha-adrenergic agents (e.g., extended-release
clonidine, guanfacine) and norepinephrine reuptake inhibitors
(e.g., atomoxetine, viloxazine). Although we are
unaware of ADHD studies specific to justice-involved
youth, a large body of evidence, including numerous
double-blind randomized controlled trials, support the
use of amphetamines, methylphenidate, and atomoxetine
for the core symptoms of ADHD (Cortese et al., 2018).
Off-label options include antidepressants such as
bupropion, serotonin-norepinephrine reuptake inhibitors
(SNRIs), and tricyclics (TCAs). Research is limited for
antidepressants, and safety concerns should constrain
the use of TCAs (Volkmar et al., 1999). Prescribing
alpha-2 agonists, especially clonidine, merits caution
given their risks of respiratory and central nervous system
depression, bradycardia, and hypotension. In a metaanalysis
of pediatric poisonings from alpha-2 agonists,
clonidine exposures were the most common, and were
the only ones that resulted in cardiac arrest and death
(Wang et al., 2014).
Practitioners may be concerned about misuse and diversion
of controlled stimulant medications. In this population,
especially, such concerns must be weighed against the risk
of disruptive behavior in the facility or in the community,
and the dangers of future and worsening involvement in
the criminal justice system. Appropriate stimulant formulations
should be chosen to improve adherence and minimize
the risk of misuse and diversion. Monitoring the patient's
behavior for appropriate amelioration of symptoms
should be the guide when prescribing. Formulations of
stimulant medications that minimize the need for repeated
dosing will reduce opportunities for diversion.
The general population ofAmerican youth shows significant
vitamin andmineral deficiencies (Darnton-Hill, 2019;
Popper, 2014) and some researchers askwhether these deficiencies
are causative or contributing agents in mental
health problems (Villagomez&Ramtekkar, 2014). Several
studies have supported supplementation with vitamin D
(Gan et al., 2019), iron (when low ferritin is detected;
Wang et al., 2017), omega-3 fatty acids (Banaschewski
et al., 2018), and magnesium to reduce ADHD symptoms
in youth (Effatpanah et al., 2019). Iron and vitamin D also
have evidence as augmentation strategies with stimulants
(Mohammadpour et al., 2018; Wang et al., 2017).
In juvenile corrections, special laboratory tests such as
omega-3 fatty acid levels tend to be unavailable, yet D vitamins
levels, serum magnesium, and serum ferritin typically
are. Psychiatrists may consider evidence-based
nutritional approaches, especially in treatment-resistant
patients or when patients or families are reluctant regarding
psychotropic medications.
ADHD may be associated with various psychiatric
comorbidities, though it may also mimic mood or anxiety
disorders. For example, youth with ADHD may display
irritability and other mood symptoms that may improve
with the treatment of their primary ADHD symptoms.
A suggested approach is to first treat the ADHD symptoms,
as stimulants are fast acting and enable the prescriber
to rule out other disorders.
However, if treating with a stimulant worsens mood
symptoms, prompt discontinuation of the stimulant and
treatment with another type of stimulant (amphetamine
vs. methylphenidate) or a nonstimulant ADHD medication
is an appropriate strategy. Coprescription of a stimulant
with other types of medications (e.g., antidepressants,
mood stabilizers, atypical antipsychotics) may be needed
to fully resolve a patient's symptoms. Sometimes, though,
reassessment of the diagnosis may be needed to avoid ineffective
polypharmacy.
Learning and Intellectual Disorders
Undiagnosed learning and intellectual disorders (LD/ID)
can lead to school desertion and involvement in antisocial
and criminal behaviors (Mayer, 2001). Children at risk
for academic failure in elementary school often have unidentified
special educational needs and are subsequently
at increased risk for later violent behaviors (Hawkins
et al., 2000). Limited social awareness and poor interpersonal
skills in these individuals are posited to render people
with LD/ID vulnerable to involvement in the justice
system (Chin, 2017).
Many youths in juvenile facilities have previously unrecognized
LD/ID, possibly related to the lack ofconsistent
definitions for these disorders across systems (Mallett,
2014; Morris &Morris, 2006). Although longitudinal studies
on the association ofLD/ID with criminality in children
Journal of Correctional Health Care - April 2023

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