Youth Correctional Facility

[EEGNeurofeedback]

Has anyone worked for a youth correctional facility? How did you like it? I am considering this move.

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[Caldwell-Luc]

Has anyone worked for a youth correctional facility? How did you like it? I am considering this move.

This sounds interesting. Of course psychiatry is not my field. But, I am interested to know what the position entails.

 

[wolfvgang22]

Has anyone worked for a youth correctional facility? How did you like it? I am considering this move.

A lot of it depends on the state and facilities you are working in. I have worked with youth within the correctional system in my conservative state at a couple of different facilities for a full year during child fellowship. It is medication management, not doing psychotherapy. I have observed:

• Often youth don't really have parents, or their parents are also locked up, or they have their own legal and psychiatric issues. And they aren't at the youth's facility much. So there is very limited family support and interaction.
• Conduct Disorder is the #1 diagnosis. Nearly every patient will lie to you, on purpose. Take normal patients, then multiply the lies by 5.
• Substance Abuse is #2. Patients will lie to get anything they sort of think they can divert and abuse, even Prozac, even Melatonin. They will cooperate with each other to try to manipulate you.
• Many of these youth do have severe ADHD, but the issue of diversion and misuse of medications in this population of patients makes treatment challenging. Yes, they check for cheeking. These kids can be very sneaky and resourceful.
• 99% of the youth I saw are not misunderstood kids who made one or two mistakes. They are here after burglarizing five houses on multiple occasions, stealing cars, routinely dealing hard drugs, multiple assaults, or even killing someone. These are youth with facial tattoos. They sometimes aspire to "age out" to adult facilities.
• Keep in mind some parents, who have not seen their child in months, will file a grievance when you don't prescribe their child Adderall despite his recent history of methamphetamine abuse and cheeking.
  
• There is a limited formulary in the correctional system, even compared to medicaid in my state. Example: I couldn't prescribe Seroquel, not even with prior authorization.
• Many kids came to me on Risperidone, mostly for aggressive and oppositional behavior related to Conduct Disorder rather than other psychiatric issues.
• I was initially surprised to find that Schizophrenia and Bipolar I Disorder were not more prevalent in this population than outside the facilities.
• There seems to be a much higher proportion of intellectually disabled or borderline intellectual functioning youth in the correctional system. Many are barely literate.
• My state had a severe shortage of psychotherapists available, so there is a several month waiting list for youth to see a therapist.
• Most facilities in my state are located outside of the city, or in small towns.
• I think one of the reasons I did so much of this work as fellow is due to their severe need for any psychiatrist to work in these facilities.

So, I didn't think it was for me, given all the other opportunities out there. It was too frustrating. But other places and systems may be different, and you're not me. There was no call, so that's good I guess.
I feel bad for not liking it more. I keep thinking:
"I needed clothes and you clothed me, I was sick and you looked after me, I was in prison and you came to visit me." - Jesus Christ, Matthew 25:36

 

[Caldwell-Luc]

Thank you for your informative and detailed response. I always thought that this would be a tough/very challenging position to be in. It sounds like a provider really has to fit in.

 

[d2305]

Lots of borderline and antisocial PD. At least they usually take what you prescribe them as the nurse looks in their mouth after they take it.

 

[vistaril]

Has anyone worked for a youth correctional facility? How did you like it? I am considering this move.

imo, it is hard to imagine a role that is a better example of what is wrong with our approach to mental health care. Almost certainly in this role you are going to be seeing adolescents for brief med mgt visits(or intakes that are the setup to such), won't be doing any therapy, will be throwing medications(every class probably) at pathology that isn't going to respond all that well to these medications. Just a cluster from start to finish. Given the role, you'd probably accomplish just as much on the job everyday if you just sat in the break room playing video games. At least the kids then wouldn't get diabetes.

I have little interest in this population, but I'm going to go out on a limb and guess that little johnny didn't assault his sister, rob the store, and sell oxycontin because his Seroquel dose wasn't high enough. Just a hunch.

 

[erg923]

Lots of borderline and antisocial PD. At least they usually take what you prescribe them as the nurse looks in their mouth after they take it.

What medication does one prescribe for young, burgeoning Antisocial PD? Same question in relation to borderline...

 

[hamstergang]

Almost certainly in this role you ... will be throwing medications(every class probably) at pathology that isn't going to respond all that well to these medications.

You know that as a doctor, you're allowed to not prescribe a medication if you don't think it will help. One is not doomed to make mistakes just because others may have in the same setting.

 

[vistaril]

What medication does one prescribe for young, burgeoning Antisocial PD? Same question in relation to borderline...

What I see mostly prescribed is Zyprexa or Seroquel + Depakote. Almost always depakote. But I'm sure there are some variations across institutions.

 

[vistaril]

You know that as a doctor, you're allowed to not prescribe a medication if you don't think it will help. One is not doomed to make mistakes just because others may have in the same setting.

well yeah that's why I choose not to work in those settings(in the role I am imagining). But good luck trying to maintain the position you were hired for very long(essentially intakes followed by brief med mgt visits) if you don't prescribe many meds.

 

[erg923]

What I see mostly prescribed is Zyprexa or Seroquel + Depakote. Almost always depakote. But I'm sure there are some variations across institutions.

why

 

[vistaril]

why

why are they prescribed or why are there variations across institutions?

They're prescribed for reasons you could probably guess- there is pressure to 'do something'(even if there is no evidence it works) and throwing money into the med mgt visits and pharmacy is easy to do at least. So you're covered on two fronts- you're 'doing something' and it's also not that
hard to put a contract in place to do it(ie call up MHM, they send you an agency psych or psych np to write meds for these troubled kids, and voila you have a 'mental health program' as part of your correction center). MHM gets their cut, the psych or psych np gets their wages without too many neurons having to go off in their head, and the correction officials are satisfied because they are doing something, or at least giving the appearance. Win all the way around....well except for the taxpayers and kids/inmates.

To the second question- anytime something doesn't have great evidence a lot of different approaches(well in this case really not all that different) tend to be adopted here and there.

 

[erg923]

I guess was speaking more academically. Knowing what we know (or what we think we know) about the development of these disorders, why are these medications viewed as appopriate and effective treatment agents? And i really hope someone doesnt say "mood regulation", lest I tear my hair out.

 

[vistaril]

I guess was speaking more academically. Knowing what we know (or what we think we know) about the development of these disorders, why are these medications viewed as appopriate and effective treatment agents?

well the answer to that question is I don't think they are.

 

[Shikima]

I guess was speaking more academically. Knowing what we know (or what we think we know) about the development of these disorders, why are these medications viewed as appopriate and effective treatment agents? And i really hope someone doesnt say "mood regulation", lest I tear my hair out.

I can say that I've used similar medications to improve impulse control.

 

[wolfvgang22]

why are they prescribed or why are there variations across institutions?

They're prescribed for reasons you could probably guess- there is pressure to 'do something'(even if there is no evidence it works) and throwing money into the med mgt visits and pharmacy is easy to do at least. So you're covered on two fronts- you're 'doing something' and it's also not that
hard to put a contract in place to do it(ie call up MHM, they send you an agency psych or psych np to write meds for these troubled kids, and voila you have a 'mental health program' as part of your correction center). MHM gets their cut, the psych or psych np gets their wages without too many neurons having to go off in their head, and the correction officials are satisfied because they are doing something, or at least giving the appearance. Win all the way around....well except for the taxpayers and kids/inmates.

To the second question- anytime something doesn't have great evidence a lot of different approaches(well in this case really not all that different) tend to be adopted here and there.

Thanks Vistaril, great comments. I 100% agree.

I can say that I've used similar medications to improve impulse control.

We use antipsychotics and mood stabilizers off-label. They are not approved by the FDA as safe and effective for use in children for impulse control. To my knowledge there is no FDA approved medication for the treatment of "impulse control" or "aggression" in children or adolescents. Yeah, they may work to treat the immediate symptom of aggression, but it doesn't treat the underlying personality and behavioral problems wrought by a child's developmental environment. And then they develop diabetes, tardive dyskinesia, and so on which costs our society money down the line.

I think one day history is going to look back at how we treat children and adolescents in psychiatry today in a similar way to how we look at the mass institutionalization of mentally ill patients in past years. We can do better.

 

[erg923]

Thanks Vistaril, great comments. I 100% agree.


We use antipsychotics and mood stabilizers off-label. They are not approved by the FDA as safe and effective for use in children for impulse control. To my knowledge there is no FDA approved medication for the treatment of "impulse control" or "aggression" in children or adolescents. Yeah, they may work to treat the immediate symptom of aggression, but it doesn't treat the underlying personality and behavioral problems wrought by a child's developmental environment. And then they develop diabetes, tardive dyskinesia, and so on which costs our society money down the line.

I think one day history is going to look back at how we treat children and adolescents in psychiatry today in a similar way to how we look at the mass institutionalization of mentally ill patients in past years. We can do better.

I was pushing the issue because there was a thread awhile back where many were insistent that we did NOT use psychaitric medications to control behavior.

Uh, Paaaaa-lease...

 

[d2305]

They also take away their Medicade once they're incarcerated.

 

[Brainlock]

nm