mental health and medication issues in youth in the juvenile justice system christopher r. thompson,...

MENTAL HEALTH AND MEDICATION ISSUES IN

YOUTH IN THE JUVENILE JUSTICE SYSTEM

Christopher R. Thompson, M.D.Medical Director, Juvenile Justice Mental Health Program

Los Angeles County Department of Mental Health

Assistant Clinical ProfessorChild & Adolescent Division

UCLA Department of [email protected]@mednet.ucla.edu

mailto:[email protected]

mailto:[email protected]

OBJECTIVES

• Review prevalence of mental disorders in the juvenile justice population

• Discuss the use of psychotropic medications in the juvenile justice and foster care (i.e., CPS, DCFS) populations

• Review the Los Angeles County Psychotropic Medication Authorization (PMA) review process

RISK FACTORS FOR JUVENILE OFFENDING

• Early onset of behavior problems/aggression• ADHD/Disruptive Behavior Disorders (DBDs)• Substance use disorders (SUDs)/acute

intoxication• Gang affiliation• Diversity of offenses (? related to “Criminal

Versatility” component of PCL-R/PCL:YV) • Psychopathy (?)

PREVALENCE OF MENTAL DISORDERS IN JJ SYSTEM (1)

• Conduct Disorder 50 – 90%• ADHD 19 – 46%• Substance Abuse 25 – 50%• Personality Disorders02 – 17%• Mental Retardation 07 – 15%• Learning Disorders 17 – 53%• Mood Disorders 32 – 78%• Anxiety Disorders 06 – 41%• Psychoses & Autism 01 – 06%

Otto R, Greenstein J, Johnson M, Friedman R. (1992). Prevalence of mental disorders among youth in the juvenile justice system. In J. Cocozza (Ed.), Responding to the mental health needs of youth in the juvenile system (pp. 7-48). Seattle: National Coalition for the Mentally Ill in the Criminal Justice System.


• Any DSM-III-R D/O 69%• Conduct Disorder 39%• ADHD 18%• SUDs 50%• Major Dep. Episode 18%• Dysthymia 14%• Manic Episode 2%• Psychosis 1%

Teplin LA, et al. (2002). Psychiatric disorders in youth in juvenile detention. Arch Gen Psychiatry 59(12): 1133-43.


• All rates higher than general population• “Big three”:

– Conduct Disorder – ADHD – Substance Abuse/Dependence

• Cognitive difficulties: – Learning Disorders (17-53%)– Mental Retardation (7-15%) – lower intelligence levels (see next slide)


• Other risk factors for delinquency and (for some) mental illness:

– pre-natal exposure to drugs or alcohol

– attachment problems

– exposure to trauma

– dysfunctional and chaotic families and neighborhoods

– overcrowded schools with limited resources

– lower intelligence

LIFETIME CRIMINALITY AMONG BOYS WITH ADHD

• Followed boys from age 6-12 → age 38

• ADHD boys more likely to be: – arrested (47% vs. 24%)– convicted (42% vs. 14%)– incarcerated (15% vs. 1%)

• Rates of felonies/aggressive offenses

• ADHD w/o CD=↑ risk of adult criminality

Mannuzza S, et al. (2008). Lifetime criminality among boys with attention deficit hyperactivity disorder: a prospective follow-up study into adulthood using official arrest records. Psychiatry Res 160(3), 237-46.

AGE OF INITIATION OF STIMULANT TREATMENT AND DEVELOPMENT OF SUBSTANCE USE DISORDERS (SUDS)

• 176 MPH-treated Caucasian male children aged 6-12 w/ ADHD but w/o CD

• Followed up in late adolescence (mean age=18.4 years) and adulthood (mean age=25.3 years)

• Subjects with late initiation of stimulant treatment (i.e., at age 8 or later) had higher rates of non-EtOH SUDs and Antisocial Personality Disorder (ASPD) in adulthood

• Subjects with early initiation of stimulant treatment did not differ from controls w/r/t rates of SUDs or ASPD

Mannuzza S, et al. (2008). Age of methylphenidate treatment initiation in children with ADHD and later substance abuse: prospective follow-up into adulthood. Am J Psychiatry 165(5): 604-9.

SCREENING & ASSESSMENT OF YOUTH IN THE JJ SYSTEM (1)

• Massachusetts Youth Screening Instrument-2nd Version (MAYSI-2): – layperson can administer

• Comprehensive MH Evaluation: – for youth screening “positive” on MAYSI-2

• Psychiatric Evaluation: – for youth who may benefit from psychotropic medications

SCREENING & ASSESSMENT OF YOUTH IN THE JJ SYSTEM (2)

• Collateral Information: – from parents/schools

• Rating Scales: – SNAP-IV, CDI, CRAFFT (for SUDs), T-ASI (for SUDs)

• Psychoeducational Testing: – K-BIT (IQ), WRAT (achievement testing)

• Los Angeles Risk and Resiliency Check-Up (LARRC): – assesses risk of recidivism

TREATMENT ISSUES

• Treating Disruptive Behavior Disorders (and SUDs) – likely reduce recidivism/delinquency/criminality

• Meds can be misused/diverted stimulants, Seroquel (quetiapine), Wellbutrin (bupropion)– youth in juvenile detention settings (OR=2.76) or with

SUDs (OR=@17) (Schepis 2008)

• Meds can have side effects, some significant

• To treat or not to treat? That is the question.– provide effective treatment with minimal side effects

– minimize risk of abuse/diversion

CONFIRMING ADHD DX IN JJ POPULATION (1)

• “Informal” collateral (parents, teachers, custody):– What is the history?

– How is youth functioning in school?

– Can s/he follow instructions?

– Does s/he need to be told to do things several times?

• “Formal” rating scales: – Conners, SNAP-IV, etc.

CONFIRMING ADHD DX IN JJ POPULATION (2)

• Psycho-educational/neuropsychological testing:– rare to have been done in community or JJ settings

• Computerized testing: – Continuous Performance Task (CPT) (e.g., TOVA, Conner’s

CPT II)

– looks at errors of commission/omission

– also rare in JJ setting

ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD)

• Base rate in population around 6-8%, 4-5x higher in JJ and DCFS populations

• 2.5x higher rate in boys

• General domains include hyperactivity, impulsivity, and ↓attention/concentration

• Children/adolescents with ADHD, Inattentive Type are likely to be diagnosed later

STIMULANTS AND STRATTERA (1)

• Adderall XR (mixed d,l-amphetamine salts) • Concerta (long-acting methylphenidate (Ritalin))• Focalin XR (long-acting dexmethylphenidate)• Dexedrine spansules (long acting d-

amphetamine)• Strattera (atomoxetine): NE re-uptake inhibitor• Variety of other short- and medium-acting

stimulants

STIMULANTS (2)

Targeted Disorders/Symptoms: ADHD, Narcolepsy, extreme psychomotor retardation in depression

Evidence for use: excellent, scores (if not hundreds) of RCTs supporting use of stimulants in treatment of ADHD,

Effects and “pros”: improve attention/concentration, decrease hyperactivity/impulsivity; most effective treatment (effect sizes 1.0-1.3 for stimulants vs. 0.6-0.7 for atomoxetine), quick onset of action, excellent safety profile, Limited side effects including no significant long-term side effects (? ↓ adult height w/ post-hoc analysis of MTA data)

Side effects and “cons”: ↓ appetite, insomnia, ?growth retardation, GI upset; very rarely psychosis or sudden cardiac death (1 in 10 million or so for latter); possible ↑ in SI for atomoxetine

PEDIATRIC BIPOLAR DISORDER (PBD) (1)

• Very controversial topic in C&A Psychiatry• Essentially two camps: those who see it

everywhere and those who see it nowhere• Lots of overlap of ADHD, PTSD, BD, and Fetal

Alcohol Syndrome (FAS) symptoms• The former group claim PBD is qualitatively

different than adult BD (e.g., little periodicity (i.e., always manic/hypomanic), irritable (rather than grandiose) mood more common, etc.)

PEDIATRIC BIPOLAR DISORDER (PBD) (2)

• As of now, little longitudinal data to support view that PBD is qualitatively different that adult BD

• Several studies in progress which are following children dxed with PBD longitudinally and seeing if they develop adult BD

• Most consistent differentiators b/t PBD and other disorders have been:– Grandiosity– Decreased need for sleep (not just insomnia)– Hypersexuality (though also may happen with sexual

abuse)

PRE-NATAL ETOH AND DRUG EXPOSURE (1)

• Obviously very common in JJ and DCFS populations

• Varying degrees/types of exposure• Can lead to neurological/psychiatric problems

either:– From direct effects of substance on CNS– Medical complications due to substance use

(e.g., placental abruption and premature delivery 2^ cocaine/MA use, intra-cerebral hemorrhage due to cocaine/MA use) which affect CNS (usually anoxia))

• Most well characterized syndrome is Fetal Alcohol Syndrome (FAS)

PRE-NATAL ETOH AND DRUG EXPOSURE (2)

• FAS incidence around 2 in 1000 in general pop.

– Facial features: a flattened midface, thin upper lip, indistinct/absent philtrum and short eye slits

– Growth retardation: lower birth weight, disproportional weight not due to nutrition, height and/or weight below the 5th percentile.

– Neurodevelopmental abnormalities: impaired fine motor skills, learning disabilities, behavior disorders or a mental illness (the latter of which is found in approximately 50% of those with FAS)

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FACIAL ANOMALIES IN FAS AT DIFFERENT AGES

PRE-NATAL ETOH AND DRUG EXPOSURE (3):

BEHAVIORAL DIFFICULTIES

• socially inappropriate behavior, as if inebriated • inability to figure out solutions spontaneously • inability to control sexual impulses, esp. in social

situations • inability to apply consequences of past actions • difficulty with abstract concepts of time and

money • difficulty processing information


BEHAVIORAL DIFFICULTIES

• difficulty storing and/or retrieving information • needs frequent cues and requires policing by

others • needs to talk to self out loud; needs feedback • fine motor skills more affected than gross motor • Moody, “roller-coaster” emotions• apparent lack of remorse; needs external

motivators • inability to weigh pros and cons reasonably

when making decisions


BEHAVIORAL DIFFICULTIES• FAS children frequently diagnosed with ADHD,

Conduct Disorder, Bipolar Disorder, etc.• Co-morbid psychiatric conditions often present• Medications and behavioral interventions not

particularly effective for FAS• Alcohol-Related Neurodevelopmental Disorder

(ARND) is a separate, less well-defined entity in which behavioral manifestations of FAS present, but no facial anomalies or growth retardation

SECOND-GENERATION ANTIPSYCHOTICS (SGAS) (1)

• Risperdal (risperidone)• Seroquel (quetiapine)• Abilify (aripiprazole)• Zyprexa (olanzapine)• Geodon (ziprasidone)• Clozaril (clozapine)• Invega (paliperidone)• Fanapt (iloperidone)


Targeted Disorders/Symptoms: psychotic disorders, bipolar d/o, baseline irritability, anger, impulsivity, or aggression

Evidence for use: fair for psychosis and bipolar disorder in children, limited for aggression in children

Effects: ↓ psychotic sxs, stabilize mood, improve irritability/aggression

Side effects: depends on agent used; generally sedation, ↑ wt., jitteriness/akathisia, sexual SEs; more rarely (but not uncommonly) diabetes, ↑ cholesterol/lipids, Parkinsonism, tardive dyskinesia (TD)


Pros: probably effective in variety of disorders and for aggression (“shotgun approach”), limited abuse potential

Cons: expensive, significant SEs (including potential long-term SEs), moderate time to onset of action (possibly weeks), ongoing lab monitoring required (e.g., glucose, lipids)

PSYCHOTROPIC MEDICATION CONSENT (1)

• Guardian/Parent (usually not foster parent)

– explain indications/risks/benefits/alternatives

– oral vs. written consent (more variable and r/t jurisdictional/organizational policy)

• Delinquency Court:

– upon detention minor becomes “ward of court”

– judge/magistrate/commissioner/referee can authorize medication

• routine vs. emergency (somewhat loose definition of latter in Los Angeles County)

PSYCHOTROPIC MEDICATION CONSENT (2): L.A. COUNTY

• Independent review of all psychotropic meds Rxed to youth in JJ detention settings (wards) and under DCFS supervision (dependents):– done by child psychiatrist or senior pharmacist in Juvenile

Court Mental Health Services (JCMHS) of LACDMH

• Reviewer makes recs to judge/commissioner

• Court approval lasts for six months

• Other CA counties may use independent contractors (rather than County employees) for same purpose (state law now requires some independent review)


• 8,000 - 12,000 psychotropic medication authorization forms (PMAFs) from the dependency and the delinquency systems come through LACDMH JCMHS every year.

• JCMHS makes a recommendation to the court whether the PMA should be approved or denied or whether it should be approved with modifications.

• JCMHS does not provide or withhold consent. The judicial officer is responsible for providing consent.


• DMH has formal practice parameters for the use of psychotropic medications in children and adolescents.

• DMH convenes a practice parameters workgroup quarterly.

• The workgroup consists of DMH and community psychiatrists and pharmacists and representatives from both USC and UCLA.

• Review of the PMAFs is based on DMH practice parameters and American Academy of Child and Adolescent Psychiatry practice parameters.


• Demographic Data

• Age

• Weight

• Height

• Gender

• Ethnicity

• Placement type


• Narrative: description of symptoms, duration and severity of symptoms, response to medications, past medication history

• Diagnosis: as it relates to symptoms

• Non-medication treatments: for example, behavioral therapy, milieu, psychodynamic therapy


• Medical Conditions

• Cardiac disorder

• Seizure disorder

• Others

• Non-psychotropic medications


• Psychotropic Medications

• Type of medications

• Number of medications and interactions

• Maximum daily dosage of medications

• New or continuing medications

• Past medication history

• Plan (e.g., length of treatment, titration schedule)


• Labs

• Are appropriate lab tests being done/monitored/ordered?

• How recent is lab data and how frequently are labs being checked?


• Initial Review Decision:

• Yes - Attach review page and send to court

• No - Attempt to contact physician for clarification, pull history, look in DMH Information System (IS), alert judicial officer if necessary

• ?s - Attempt to contact physician for clarification, may recommend consent for 30 days to allow time for follow-up, alert judicial officer if necessary

PSYCHOTHERAPEUTIC INTERVENTIONS IN DETAINED

JUVENILES

• Crisis Counseling/Supportive Therapy

• Motivational Interviewing/Enhancement (MI/MET)

• Cognitive-Behavioral Therapy (CBT):– including TF-CBT and C-BITS (both for trauma)

• Parent Management Training (PMT):– when caregivers/parents available

• Girls…Moving On: – designed to reduce recidivism in female detainees

• Should we target MH symptoms or recidivism risk first/primarily?

PSYCHOTHERAPEUTIC INTERVENTIONS PRIOR TO

DETENTION (OR ON RELEASE)

• Parent Management Training (PMT)• Functional Family Therapy (FFT)• Multidimensional Family Therapy (MDFT)• Multisystemic Therapy (MST)• Integrated Family CBT (IFCBT): pilot data

showed promising results• Juvenile Drug/Mental Health Courts: generally

“diversion”; mixed results

TAKE HOME POINTS

• Youth in delinquency and dependency systems have ↑ rates of mental disorders compared w/ community youth

• Psychotropic medications can be a very useful/necessary treatment for youth in these systems

• In L.A. County (and other jurisdictions), prescribing of psychotropic medications to these youth is closely monitored

mental health and medication issues in youth in the juvenile justice system christopher r. thompson,...

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