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Psychopharmacology and Juvenile Sex Offenders
by Paul Copeland D.O.
Child/Adolescent Psychiatrist & Asst. Clinical Professor, U.C.D.
[In recent discussions with Dr. Paul Copeland, I have been greatly
impressed with his broad understanding and organized/methodical
approach to applying psychopharmacological treatment interventions
to the recovery process in treating juvenile sex offenders. His
interest in new technologies and eagerness to add to the greater
body of knowledge makes him invaluable to the field in its growth
and success. It is marvelous to have a dedicated professional and
strong proponent for combining team effort toward both community
safety and the recovery process as a colleague. He demonstrates
in his writing and service to our client population that he understands
the difficulties and complex variety of issues necessary to assess
and adequately address treatment with strategies well-adapted to
appropriate applications in mental health care and establishing
bridges with predominantly identified JSO symptomatology. I have
obtained permission to reprint a portion of his useful outline defining
how he reaches decisions in applying medication and combinations
of medication currently discussed in the psychiatric field to address
complicated impairments in adaptive functioning and alleviating
impediments to treatment progress. - Randy Shores, Publisher of
Perspectives]
Characteristics of Juvenile Sex Offenders
• Heterogeneous mix.
• Differ according to victim and offense type and other variables.
• Types of behaviors, histories of child maltreatment, sexual
knowledge and experience, academic and cognitive functioning and
mental health issues.
• Adequacy, competency, adaptive functioning, regard for rules
and authority and socialization.
Dysthymia and Depression
• Phase: Often sets in after initial denial system is disturbed
and shame and guilt set in.
• May have been present, subclinically, for years related to
longstanding self-esteem impairment from family of origin issues.
Program progress can elicit the emergence of vegetative symptoms
such as sleep, appetite, energy, memory and concentration problems
which are persistent and perhaps traceable to family history.
• Decisions to medicate must be determined by the team whether
or not appropriate when experiences of depressive symptomotology,
grief, shame and guilt are determined to be healthy, natural responses.
• Treatment for dysthymia and depression can be cognitive therapy,
antidepressants or both.
Antidepressants: Tricyclics
• Amitriptyline, imipramine, desipramine and other amines.
• Dosage range 25-300 mg.
• Usually given all at bedtime (HS).
• EKGs and blood work are necessary.
• Many side effects including possible sudden death.
Antidepressants: SSRIs
• Prozac, Celexa, Zoloft, Luvox, Paxil.
• Dosage range 10 mg (Prozac) to 300 mg (Luvox)
• Usually given single daily dose.
• No lab work necessary.
• Fewer side effects than TCA’s.
• Works on serotonergic system
Antidepressants: Other
• Wellbutrin 37.5-300 mg. Given twice daily. No lab work necessary.
Seizures can occur (1%). Also good for ADHD and perhaps addictive
compulsive behavior (Zyban). Non SSRI.
• Effexor 37.5-300 mg. Usually given twice daily. No lab work
and usually safe. Nor-epi and SSRI.
• Remeron 15-45 mg. All at night. Very sedating. Safe. No lab
work needed. Nor-epi and SSRI. Lower doses are more sedating.
• Trazodone 50-600 mg. All at night. Sedating and safe in women.
Priapism can occur in male. Good in combination with SSRIs. Non
SSRI.
Anxiety and Obsessionality
• Preservation, fixation, perpetual fantasy which is excitatory
and dysfunctional can
often be a part of the JSO profile. Often these thought processes
are related to the potential for rage and may, in some instances,
affect potential for acting out, thus assisting in prognosticating.
• Psychiatric diagnoses which reflect this include anxiety
disorders, obsessive-compulsive disorder, obsessive-compulsive features
and personality disorders.
Treatment for Anxiety and Obsessionality
• Drugs of choice for anxiety are now the SSRIs: Zoloft, Luvox,
Celexa.
• There is no place for the benzodiazepines in the treatment
of offenders. Such medications include Xanax, Valium, Ativan and
the like. They tend to be disinhibitory and can also cause paradoxical
rage. They are also addictive.
• Drugs of choice for OCD include the SSRIs, especially Luvox.
• Anafranil, a tricyclic with chloride ion stuck onto it, is
also quite useful but is considered a "dirty drug" because
of its many metabolites and side effects.
• Atypical antipsychotics like Risperdal, Zyprexa and the like
seem to be useful. These act upon the dopamine system.
• A combination of medications used together seem to be particularly
useful in the perseverative, obsessional, irritable, moody and anxious
sex offender.
• This includes Wellbutrin (an antidepressant with anti-impulsive
capabilities) and Tenex or clonidine (alpha agonist that works centrally).
• Another combination of medications that has been useful includes
an atypical antipsychotic, an SSRI and an alpha agonist. This has
been an effective approach targeting aggression, emotional regulation
and down-regulating the central nervous system.
Impulse Control Disorders
• Many JSOs have a primary dysfunction in delaying gratification,
inhibiting socially inappropriate thoughts which lead to criminal
actions and in tempering a narcissistic and entitled view of his
or her place in the world. Many personality disorders reveal this
pathology. Such disorders include the narcissistic, borderline and
antisocial personality. Medications are usually not indicated in
the treatment of PDs.
• The etiology for this problem in drive disregulation is often
quite complex and if there is a clear problem in regulation of central
nervous system arousal, medication may be quite useful. This can
be seen in Depression, Bipolar disorder, Reactive Attachment Disorder
and Pseudocharacterological behavior which has its etiologic roots
in trauma causing Post Traumatic Stress Disorder.
Impulse Control Problems: Treatment
• Depression: Medication as discussed.
• Bipolar Disorder: The Mood Stabilizers are quite effective.
These include Lithium, Depakote, Tegretol and now Neurontin.
Mood Stabilizers
• Lithium: 600-1800 mg. Lab work needed. Usually twice daily
dosing. Some side effects.
• Depakote: 500-4000 mg. Lab work needed. Taken 2-3 times per
day. Few side effects.
• Tegretol: 400-1600 mg. Lab work needed. Some side effects.
• Neurontin: 300-4000 mg. No lab work needed. Sedating.
• All are anticonvulsants.
Reactive Attachment Disorder
• Often under diagnosed. Related to grossly pathogenic care
at an early age. Two types: Socially inhibited and the socially
uninhibited. Often a profound lack of empathy because of absent
bonding at an early age.
• Sometimes low dose atypical antipsychotics are marginally
useful.
Post Traumatic Stress Disorder
This diagnosis can be found in this population. Etiologically related
to disturbed, usually violent care, often goes hand-in-hand with
RAD. These individuals can often appear to be "characterologic"
and may have Conduct Disordered or Borderline- like features. Polypharmacy
may be required.
Disruptive Disorders and ADHD
• Disruptive disorders such as Conduct Disorder and oppositional
Defiant Disorder are frequently seen in this population. Medication
are not really useful with these diagnoses. Natural consequences.
• ADHD is often seen in the JSO population and can be easily
treated. Central stimulants are the drugs of choice for ADHD. These
are Ritalin in all its forms these days, dexedrine and Adderall.
Central Stimulants
• Ritalin: Many forms: Ritalin, Ritalin SR, Metadate, Concerta.
Dosage is based upon weight.
• Dexedrine: Fast and long-acting forms. Strong appetite suppressant.
Significant rebound.
• Adderall. Mixed salts. Four kinds of amphetamine. Just released
new long-acting Adderall XR.
The Developmentally Delayed Juvenile Sex Offender
• All the same issues are present in the developmentally delayed
offender that are present in the nondelayed offender.
• Impaired cognitive functioning limits expressive capability
and insight oriented therapy
• Pharmacologically, I would treat them the same. The psychiatric
diagnoses are more difficult to make because of limited expressive
capability often and in general our profound lack of clinical acumen
in dealing with the psychiatrically impaired, developmentally delayed
individual.
Conclusions
Accurate assessment is the cornerstone of effective treatment. Adequately
screening and treating for comorbidities, such as Mood Disorders,
Impulse Control Disorders, ADHD, RAD, PTSD and seeing through pseudocharacterological
presentations, will offer this population the best opportunity for
the successful resolution of their etiologically complex medico-legal
dilemma.
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