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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 Professor Child & Adolescent Division

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  1. 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 Professor Child & Adolescent Division UCLA Department of Psychiatry cthompson@dmh.lacounty.gov chthompson@mednet.ucla.edu

  2. 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

  3. 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 (?)

  4. PREVALENCE OF MENTAL DISORDERS IN JJ SYSTEM (1) • Conduct Disorder 50 – 90% • ADHD 19 – 46% • Substance Abuse 25 – 50% • Personality Disorders 02 – 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.

  5. PREVALENCE OF MENTAL DISORDERS IN JJ SYSTEM (2) 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.

  6. PREVALENCE OF MENTAL DISORDERS IN JJ SYSTEM (3) • 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)

  7. PREVALENCE OF MENTAL DISORDERS IN JJ SYSTEM (4) 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

  8. 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.

  9. 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.

  10. 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

  11. 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

  12. 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

  13. 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.

  14. 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

  15. 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

  16. 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

  17. 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

  18. 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.)

  19. 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)

  20. 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)

  21. 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)


  23. 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

  24. PRE-NATAL ETOH AND DRUG EXPOSURE (4):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

  25. PRE-NATAL ETOH AND DRUG EXPOSURE (5):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

  26. SECOND-GENERATION ANTIPSYCHOTICS (SGAS) (1) Risperdal (risperidone) Seroquel (quetiapine) Abilify (aripiprazole) Zyprexa (olanzapine) Geodon (ziprasidone) Clozaril (clozapine) Invega (paliperidone) Fanapt (iloperidone)

  27. SECOND-GENERATION ANTIPSYCHOTICS (SGAS) (2) 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)

  28. SECOND-GENERATION ANTIPSYCHOTICS (SGAS) (3) 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)

  29. 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)

  30. 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)

  31. PSYCHOTROPIC MEDICATION CONSENT (3): L.A. COUNTY 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.

  32. PSYCHOTROPIC MEDICATION CONSENT (4): L.A. COUNTY 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.

  33. PSYCHOTROPIC MEDICATION CONSENT (5): L.A. COUNTY Demographic Data Age Weight Height Gender Ethnicity Placement type

  34. PSYCHOTROPIC MEDICATION CONSENT (6): L.A. COUNTY 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

  35. PSYCHOTROPIC MEDICATION CONSENT (7): L.A. COUNTY Medical Conditions Cardiac disorder Seizure disorder Others Non-psychotropic medications

  36. PSYCHOTROPIC MEDICATION CONSENT (8): L.A. COUNTY 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)

  37. PSYCHOTROPIC MEDICATION CONSENT (9): L.A. COUNTY Labs Are appropriate lab tests being done/monitored/ordered? How recent is lab data and how frequently are labs being checked?

  38. PSYCHOTROPIC MEDICATION CONSENT (11): L.A. COUNTY 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

  39. 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?

  40. 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

  41. 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

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