Juvenile Encarceration and health

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Juvenile Incarceration and Health Elizabeth S. Barnert, MD, MPH, MS; Raymond Perry, MD, MSHS; Robert E. Morris, MD From the Department of Pediatrics, David Geffen School of Medicine at UCLA (Drs Barnert and Morris), Children’s Discovery & Innovation Institute, Mattel Children’s Hospital UCLA (Dr Barnert), and Juvenile Court Health Services, Los Angeles County Department of Health Services, Los Angeles, Calif (Dr Perry) The authors declare that they have no conflict of interest. Address correspondence to Elizabeth S. Barnert, MD, MPH, MS, Department of Pediatrics, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave B2-447 MDCC, Los Angeles, CA 90095 (e-mail: [email protected]). Received for publication June 2, 2015; accepted September 13, 2015.

ABSTRACT Addressing the health status and needs of incarcerated youth represents an issue at the nexus of juvenile justice reform and health care reform. Incarcerated youth face disproportionately higher morbidity and higher mortality compared to the general adolescent population. Dental health, reproductive health, and mental health needs are particularly high, likely as a result of lower access to care, engagement in high-risk behaviors, and underlying health disparities. Violence exposure and injury also contribute to the health disparities seen in this population. Further, juvenile incarceration itself is an important determinant of health. Juvenile incarceration likely correlates with worse health and social functioning across the life course. Correctional health care facilities allow time for providers to address the unmet physical and mental health needs seen in this population. Yet substantial challenges to care delivery in detention facilities

IMPROVING THE HEALTH of incarcerated youth represents an issue at the intersection of juvenile justice reform and health care reform. Currently, bipartisan support for promoting the health of youth involved in the juvenile justice system is creating a policy window that coincides with public readiness to address the epidemic of juvenile incarceration.1 The juvenile justice system, established in the 1900s to protect, guide, and offer treatment in the “best interest” of the child, has increasingly taken a punitive approach toward delinquent youth. This trend heightened in the 1980s and 1990s, when many punitive statutes were enacted.2,3 Largely in response to the get-tough approach of this era, juvenile justice reformists have increasingly advocated for decriminalization and diversion of nonviolent juvenile offenders to communitybased treatments and other alternatives to incarceration, arguing that institutionalization harms youth and is costly.2,3 Many politicians, law enforcement personnel, legal advocates, and business leaders have begun to make changes on behalf of these vulnerable youth. It is important that pediatricians also embrace the population of justice-involved youth as doing so signifies an opportunity to promote the health of highly vulnerable children. To empower and guide pediatricians in responding to juvenile ACADEMIC PEDIATRICS Published by Elsevier Inc. on behalf of Academic Pediatric 99 Association

exist and quality of care in detention facilities varies widely. Community-based pediatricians can serve a vital role in ensuring continuity of care in the postdetention period and linking youth to services that can potentially prevent juvenile offending. Pediatricians who succeed in understanding and addressing the underlying social contexts of their patients’ lives can have tremendous impact in improving the life trajectories of these vulnerable youth. Opportunities exist in clinical care, research, medical education, policy, and advocacy for pediatricians to lead change and improve the health status of youth involved in the juvenile justice system.

KEYWORDS: adolescent health; juvenile incarceration; juvenile offenders; underserved populations

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incarceration, we address 5 fundamental questions: 1) What type of youth are incarcerated and how does the process work? 2) What are the health needs of incarcerated youth? 3) What are the roles of community and academic pediatricians in preventing incarceration and in caring for justice-involved youths? 4) What is the state of health care in juvenile detention facilities? 5) What are the clinical, research, medical education, policy, and advocacy priorities for promoting the health of youth involved in the juvenile justice system?

INCARCERATED YOUTH AND THE JUVENILE JUSTICE SYSTEM DEMOGRAPHICS With 2 million youth arrested annually in the United States and 60,000 detained, justice-involved youth represent a large, high-risk, vulnerable population largely hidden from public view.4,5 The rate of youth confinement peaked in 1995. It has steadily declined since then, mainly as a result of lower arrest rates and to changes in local and state approaches toward nonviolent youth offenders.6 Nevertheless, the United States still incarcerates a higher proportion of youths than any other developed country.6 Volume 16, Number 2 March 2016

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Significant disparities by race/ethnicity and class exist. African American adolescents are 5 times more likely and Latino and American Indian youth 3 times more likely to be incarcerated compared to white adolescents.4 In 2003, black youth comprised 38% of all detained youth.5 Incarcerated youth often come from highly disadvantaged backgrounds. These youth often have high rates of exposure to adverse childhood experiences (ACEs) and limited financial resources.7 Many live in high-crime neighborhoods. This increases incarceration risk and creates a socioeconomic disparity that is accentuated for black and Hispanic youth.8,9 These inequities perpetuate cycles of mass incarceration seen in many disadvantaged communities.9 Each time a youth is incarcerated, he or she has a higher risk of recidivism. Within 3 years of release, 75% of adolescents are rearrested.6 DETENTION PROCESS Youth enter the juvenile justice system upon arrest or through referrals to the juvenile courts made by parents, schools, or probation officers. In 2012, approximately 5% of juvenile arrests were for violent crimes, including murder, forcible rape, and aggravated assault; 22% were for nonviolent property crimes such as theft or arson; and the majority of other crimes were for low-level, nonviolent offenses such as alcohol or marijuana use.10 Through zerotolerance school policies, infractions such as truancy are more likely to lead to suspension, expulsion, and arrest. This approach is under scrutiny for exacerbating the school-to-prison pipeline, whereby disadvantaged and minority youth are systematically transitioned from the educational system to the criminal justice system.9 Proposed reforms include moving toward decriminalization and diversion for low-level, nonviolent offenders, with an emphasis on community-based supervision and treatment, when appropriate.3 In the current system, after arrest, youth await a court hearing. While awaiting trial, they are placed in detention or, if determined safe by police, may be returned home. A youth who is found guilty will be handled by one of several options: he or she is placed on house arrest; is ordered to serve time in a residential facility, such as a juvenile hall, camp, ranch, or group home; or is diverted to management outside of the court system (eg, to community-based treatment programs). Once released to home, youth remain on probation and under court supervision for a court-specified period of time.11 COSTS OF JUVENILE INCARCERATION US taxpayers spent $5 billion in 2008 to confine youth in the juvenile justice system.12 The average direct cost to states of confining a single young person is estimated at $241 per day. The average length of stay for a youth in confinement typically ranges between 3 and 4 months.13 Following from this, the average cost for confinement is approximately $21,690 to $28,120 per youth per stay. Indirect costs must also be considered. In one report, economists estimate the indirect long-term costs of juvenile incarceration to US taxpayers at $8 to $21 billion per

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year when considering the cost of recidivism (including later involvement in the adult criminal justice system); unemployment and lost future earnings; lost future government tax revenue; additional health care expenditures in Medicare and Medicaid; and cost of sequelae of sexual assaults that may occur during confinement.14 Incarceration among adult men has been shown to reduce hourly wages by 11% and annual earnings by 40%.15 In contrast, the monetary benefit to society of saving a single high-risk 14-year-old from a life of crime is estimated at $2.6 to $5.3 million.16

HEALTH AND JUVENILE INCARCERATION HEALTH AND INCARCERATION ACROSS THE LIFE COURSE Complex relationships exist between juvenile incarceration and health. The racial/ethnic and socioeconomic disparities present in the juvenile justice system may partially explain the worse health status seen among incarcerated youth compared to the general adolescent population.17 Minority youth face significant health inequities that may be exacerbated by the immediate and long-term health consequences of incarceration.19 For example, high rates of unmet mental health needs among minority youth may increase incarceration risk, lead to an exacerbation of symptoms during incarceration, and alter youths’ ability to socially reintegrate after confinement.8,17 Given the relatively high prevalence of incarceration among youth of color, the health of young black and Hispanic boys has become inextricably linked with the cycles of mass incarceration prevalent in many of their communities.9 Incarceration may have some health benefits, mainly because individuals have access to care while in detention and are separated from dangerous environments. However, juvenile incarceration is associated with poor adult health outcomes, including substance use, early mortality, and worse social functioning.19 Recent studies suggest strong causal associations between youth incarceration and adult health outcomes, including worse general health and higher rates of functional limitations.18,20,21 Proposed mechanisms include heightened exposures to infectious diseases, trauma in detention facilities, and social barriers present after detention related to social stigma and social isolation.19 Racial/ethnic disparities in access to health care and the high prevalence of minority youth in the juvenile justice system may reinforce the relationship between juvenile incarceration and health. The school-to-prison pipeline creates disparities in the educational and juvenile justice systems that likely have detrimental effects on health.22 Risks for juvenile incarceration may begin as early as gestation and act across an individual’s entire life.23 Many of these risks relate to experiences of childhood adversity. As many as 93% of youth entering the juvenile justice system report having experienced at least 1 circumstance in their lives that could be considered an ACE.7 Individuals exposed to a high burden of ACEs, namely abuse, neglect, and household dysfunction, may adopt

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compensatory risk-taking behaviors that can worsen their health and lead to trajectories of incarceration.24–26 For example, in utero exposure to alcohol may cause fetal alcohol spectrum disorders (FASD). Compared to a prevalence of approximately 1% in the general population, at least 10% of youth in confinement meet criteria for FASD.27 Poor decision making and vulnerability to peer pressure may make youth with FASD more likely to commit offenses.27 Studies demonstrate that children of incarcerated parents are significantly more likely to offend.28,29 Incarceration of a household member during childhood has direct links not only to increased incarceration risks but to that child’s health outcomes as an adult.30 Thus, exposure to ACEs may contribute to transmitting incarceration risks across generations. HEALTH STATUS AND NEEDS GENERAL PHYSICAL HEALTH NEEDS Incarcerated youth have high rates of unmet physical, developmental, and mental health needs (Table 1), as well as higher mortality rates, compared to the general adolescent population.31–34 Risky health behaviors related to substance use, sexual experiences, and violence all contribute to the poorer health status of incarcerated youth.11,17,35 Priority physical health care needs for incarcerated youth include oral health, trauma-related injury, infectious illnesses, and reproductive health.17 The Office of Juvenile Justice and Delinquency Prevention, a subdivision of the US Department of Justice, surveyed a nationally representative sample of US incarcerated youth about their health care needs. Two-thirds reported having physical health care needs, including dental, vision, or hearing (37%); acute illness (28%); injury (25%); and other problems (29%).36 In another study of youth admitted to a detention facility, 46% of youth had at least 1 diagnosable medical condition requiring medical attention, with respiratory and sexually transmitted infections (STIs) most common.34 Specific data on oral health demonstrated that approximately half of incarcerated youth had untreated tooth decay and 6% had urgent oral health conditions including abscess, jaw fracture, or severe gum disease with bleeding.37 A 1991 survey on health risk behaviors of detained youth found that 70% had been in a fight in the last year, with 25% requiring medical care from injuries.35 Table 1. Health Disparities Affecting Incarcerated Youth  Sexually transmitted infections.  Teenage pregnancy and parenthood.  Chronic conditions affecting ethnic minorities and disadvantaged communities (eg, asthma, type 2 diabetes, sickle cell disease).  ADHD and learning disorders.  Behavioral problems (eg, conduct disorder, anger management).  Posttraumatic stress disorder.  Mood disorders (eg, depression).  Substance abuse.  Suicidality. ADHD indicates attention-deficit/hyperactivity disorder. Adapted from Perry and Morris.11 Reprinted with permission.

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General health complaints are more prevalent among detained youth compared to nondetained adolescents and include headache, abdominal pain, back or joint pain, upper respiratory symptoms, and sleep problems.17,38,39 REPRODUCTIVE HEALTH NEEDS Limited access to health resources in the disadvantaged communities in which many justice-involved youth live contributes to their lack of exposure to sexual health information and reproductive health services. This has likely played a role in the disparate sexual and reproductive health outcomes that are seen in the justice-involved population. Compared to nonincarcerated adolescents, incarcerated youth report high rates of sexual activity and sexually transmitted infections, more lifetime partners, and lower use of condoms and other forms of contraception.17,35,38,40,41 The Centers for Disease Control reported the 2011 prevalence of chlamydia infection among detained girls and boys as 13.5% and 6.7% respectively, compared to rates of 3.3% in the general adolescent female population and 0.7% in the general adolescent male population.42,43 Youth victims of sex trafficking or commercial sexual exploitation have a higher incarceration risk and higher risks of contracting HIV or hepatitis C.31 A 2009 survey of detained youth found that 15% of boys and 9% of girls had children, compared to 2% of teenage boys and 6% of teenage girls in the general population. Additionally, 12% of the incarcerated youth surveyed reported expecting a child (ie, girls said they were pregnant and boys said that someone was pregnant with their child); a third of the surveyed girls reporting having ever been pregnant.36 CHRONIC ILLNESS Chronic illnesses may be ignored or mismanaged before a youth arrives to a correctional health care facility.17,33 Conditions such as asthma, diabetes, seizure disorders, and sickle cell disease are important considerations in detention settings because they are relatively common, often insufficiently managed or undiagnosed, and can have serious consequences if untreated.11 Utilization of community specialists in caring for these complex youth can help assure the best management of chronic diseases after release. MENTAL HEALTH NEEDS Unmet mental health needs include untreated attentiondeficit/hyperactivity disorder, learning disorders, depression, anxiety, conduct disorder, posttraumatic stress disorder, and substance use and abuse.17,31,36,38,41 These conditions, especially conduct disorder and substance abuse, significantly increase incarceration risk and likely contribute to the lower physical health status of this population. Two-thirds of incarcerated boys and three-quarters of incarcerated girls meet criteria for at least 1 psychiatric diagnosis, with substance use, behavior disorders, and depression being the most prevalent.44 Roughly 27% of

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incarcerated youth have a severe mental disorder warranting immediate treatment.44 Approximately half of detained youth receive psychotropic medication while confined.45 Suicidality is common among incarcerated youth. Suicide completion is a concern even within the supervised settings of detention facilities.11,31 Stresses related to incarceration, separation from family and peers, abuse histories, substance use, mental health disorders, and impulsive personality traits contribute to the elevated suicide risk of incarcerated and formerly incarcerated youth.17,31,33,38 One study found that 52% of detained youth reported active suicidal ideation and one-third reported prior suicide attempts.46 Detained youth commit suicide at a rate more than 4 times greater than the general adolescent population.47 Pronounced racial and ethnic differences in mental health diagnoses and access to care for justice-involved youth exist. Non-Hispanic white youth had the highest rates of diagnosed psychiatric disorders and African Americans the lowest.33 Lower rates of service utilization before detention among African American youth compared to youth from other racial groups may contribute to this apparent disparity.17,48 Among detained youth with mental health disorders, minority youth are less likely to receive treatment than their non-Hispanic white counterparts.49 This may exacerbate disparities in mental health outcomes and related incarceration or recidivism patterns affecting minority youth. MORTALITY RISKS Criminal justice involvement correlates with a marked increase in mortality risk.32,50,51 Gang membership and substance use problems have been proposed as mediators for the heightened mortality risk seen in justice-involved youth and may be important foci for addressing disparities in mortality.51 Specifically, for youth with a history of juvenile incarceration, mortality measured 4 times higher than the general adolescent population rate, with homicide accounting for 90% of deaths. The highest mortality rate was observed in African American male youth (887 deaths per 100,000 person-years). The mortality rate among justice-involved girls was 8 times higher than for general-population girls.32

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transmitted infections and pregnancy, and they have higher rates of psychiatric disorders, especially anxiety and mood disorders. A survey of detained youth found that 42% of girls and 22% of boys reported prior physical abuse. Similarly, 35% of girls and 8% of boys reported prior sexual abuse.36 LESBIAN, GAY, BISEXUAL, OR TRANSGENDER YOUTH Lesbian, gay, bisexual, or transgender (LGBT) youth represent a vulnerable, mostly hidden group within correctional facilities.11 LGBT youth face health disparities related to depression, suicidality, substance use, and other mental health problems.52 A 2010 survey found that 11% of detained boys and 27% of detained girls identified as LGBT, with equal distributions across races.53 Most (80%) behaved in a gender-conforming way, at least in part to avoid harassment and because of fear of sexual assault within the detention facility.53,54 Fears of harassment and sexual assault may contribute to higher levels of stress among detained LGBT youth compared to other detainees.11,55 Studies indicate that in fact LGBT youth are significantly more likely to be sexually assaulted; 12.5% of detained LGBT youth reported sexual victimization compared to 1.3% of heterosexual youth.54 The Prison Rape Elimination Act established a zero-tolerance policy toward sexual abuse and harassment in detention facilities, regulates housing and other aspects of detaining LGBT youth, and mandates corrective measures if a facility does not meet national standards.56

SPECIAL POPULATIONS Some smaller subpopulations face distinct health challenges in the juvenile justice system that are important to recognize. These subpopulations include incarcerated girls; lesbian, gay, bisexual, or transgender youth; commercially sexually exploited youth; and youth involved in both the juvenile justice and child welfare systems.

COMMERCIALLY SEXUALLY EXPLOITED CHILDREN The overlapping terms “commercial sexual exploitation of children” and “child sex trafficking” include the exploitation of minors through prostitution, child pornography, and sex tourism.57 Although federal law defines commercially sexually exploited youth as victims of severe human trafficking entitled to legal protections, many are still incarcerated under state criminal laws. A newer trauma-informed approach to victims is emerging, but many juvenile justice systems have yet to enact these changes.58 The Bureau of Justice reports that in 2014 there were 1000 arrests of US minors for prostitution.13 Sexually exploited youth are highly vulnerable to violence-related injuries, sexually transmitted infections, pregnancy, and mental health conditions.59 A crosssectional study of female domestic sex trafficking victims found that 89% had experienced physical violence, 80% had experienced suicidal ideations, 59% had a sexually transmitted infection, and 58% became pregnant while trafficked.60 Juvenile justice facilities, and especially correctional health care providers, can serve a critical role in caring for commercially sexually exploited youth.

GIRLS Girls account for 14% of incarcerated youth; as with incarcerated adult women, female incarcerated detainees often have more documented health needs than boys.4,17,31 Girls have high rates of reproductive health needs, mainly related to prevention and care for sexually

CROSSOVER YOUTH The terms “crossover youth,” “dual jurisdiction,” or “dually involved” refer to youth involved in the child welfare and juvenile justice systems. Foster youth face disproportionately high rates of unmet medical and mental health problems such as developmental delay, emotional

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adjustment problems, substance abuse, and chronic medical problems that may directly increase incarceration risk.61 Studies indicate that 9% to 29% of youth in the child welfare system engage in delinquent behavior.62 Youth living in foster homes or group homes that engage in normal adolescent risktaking behavior may be more likely to have their behavior viewed as delinquent and be referred to law enforcement. HEALTH CARE SERVICES FOR YOUTH IN DETENTION QUALITY OF CARE Federal law requires that health care be provided to all detained youth. Additionally, several state laws mandate specific provisions of care, such as access to urgent care or preventive care.63 The NCCHC provides voluntary accreditation to juvenile detention facilities that meet their health care standards.63 The standards address a variety of systemic expectations for appropriate health care in juvenile detention facilities including access to comprehensive health care services, provider credentials and coverage, recommended health screenings, emergency preparedness, and collaboration with correctional departments. NCCHC accreditation for adult and juvenile correctional facilities is similar to Joint Commission on Accreditation of Healthcare Organizations accreditation for hospitals. Several national provider organizations such as the American Academy of Pediatrics have policy statements promoting comprehensive health care for detained youth.31,41,64 Despite these regulations and guidelines, services vary widely among correctional facilities. For example, despite high rates of STIs that are often asymptomatic (eg, chlamydia), less than one-quarter of juvenile detention facilities screen all youth for STIs.65 The small size of many facilities, staffing challenges, limited availability of nearby specialty medical services, and budgetary constraints are some of the reasons that juvenile facilities may have difficulty meeting the standards set by NCCHC. Furthermore, as more correctional facilities are privatized or made for profit, the full range of health services and organizational operations needed for NCCHC accreditation are less likely to be fulfilled.65 STRUCTURE OF SERVICES Many counties finance correctional health care through local health departments. The health departments deliver care directly or contract with partnering agencies, such as academic medical centers or private correctional health care providers.66 Over recent decades, we have observed that there has been a shift away from partnerships with academic medical centers, possibly as a result of competing priorities within medical centers and training programs. This has reduced medical education opportunities and access to subspecialty care for detained youth. GOALS OF CARE DURING INCARCERATION Goals of care during detention include administering immunizations, diagnosing and treating acute infections and injuries, management of chronic physical and mental illnesses, and meeting reproductive health care needs.

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Health education is a worthwhile goal during the detention period.11 CHALLENGES TO CARE IN DETENTION Challenges in correctional settings include time conflicts related to strict daily schedules; need for correctional officers to escort youth to clinic; barriers related to lack of parental presence including consent issues and incomplete medical histories; reluctance of youth to cooperate with health care staff; lack of emergency care and subspecialty services; and inadequate staffing and difficulty recruiting providers.11 HEALTH CARE COVERAGE Many justice-involved youth, because of low family incomes, are eligible for Medicaid or the Children’s Health Insurance Program (CHIP). However, federal law prohibits federal Medicaid and CHIP funds from covering inmates. As a result of this inmate exclusion, in many states, Medicaid is terminated or suspended during the detention period, such that many youth are uninsured upon release. Although the Affordable Care Act (ACA) expanded Medicaid, it did not address the inmate exclusion.66 Formerly detained youth report lack of access to health insurance as a major barrier in accessing health care, even if they meet eligibility requirements for public insurance.67 Reenrollment procedures vary by county, and delays after termination or suspension of insurance during detention result in significant gaps in care.67 Approximately 88,000 juvenile offenders are released annually in the United States.68 Preparing youth for reentry involves arranging continuing health care coverage, prescriptions, and connections to community-based providers, an underdeveloped role of correctional systems. It is estimated that approximately 80% of detained youth lack a primary health care provider in their home communities.39 Many likely utilize emergency departments instead of primary care.69 A survey of recently detained youth found that most participants did not see a health care provider after detention although 85% reported that they wanted to; lack of insurance and lack of transportation were cited as the major barriers.67 Thus, despite qualifying for health care coverage, a high proportion of released youth are likely not able to follow care plans developed in detention.

OPPORTUNITIES AND FUTURE IMPLICATIONS Although incarcerated youth represent a large, medically vulnerable population, pediatricians have largely been silent in the nationwide movement to address juvenile incarceration. By seizing opportunities in clinical care, research, education, policy, and advocacy, pediatricians can have tremendous impact in improving the trajectories of vulnerable youth (Table 2). CLINICAL CARE CLINICAL OPPORTUNITY 1: CLINICIANS CAN HELP PREVENT JUVENILE INCARCERATION Pediatricians can contribute to preventing juvenile incarceration by identifying and addressing risk behaviors such

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as violent behavior, substance use, and delinquent peer associations. Conducting early screening, offering interventions such as parenting support, and providing referrals to mental health and social service providers helps to reduce downstream incarceration risks. Pediatricians can also monitor and encourage educational attainment, a key protective factor for juvenile offending.70 Youth with known risk factors for offending should be seen more often. Receiving frequent attention and guidance from health care providers instills a positive, future-oriented perspective in youth that helps them overcome trajectories to jail.70 Given the significant barriers that many socially disadvantaged families experience, engaging families of youth at risk for incarceration within the traditional health care setting can be challenging. System-level strategies to engage these youth and families in health care include strengthening safety net clinical networks by offering expanded clinic hours on evenings and weekends, providing on-site mental health care, promoting schoolbased clinics, offering community health worker programs, and ensuring the provision of comprehensive health and mental health care for foster youth. Pediatricians can also build relationships with community organizations to promote health and well-being for

at-risk youth outside of traditional health care settings. Additionally, strengthening partnerships between academic medical centers and juvenile detention systems can enhance clinical services, and foster research, education, and advocacy. CLINICAL OPPORTUNITY 2: PEDIATRICIANS CAN PROMOTE THE HEALTH OF YOUTH IN DETENTION The key strategy for improving the health and health care of youth during detention is to emphasize compliance with established NCCHC standards. The NCCHC is the only well-organized nongovernmental entity overseeing the health of youth in detention. Uptake of these standards is lagging. If not doing so already, pediatric departments within community or academic medical centers can contribute by partnering with youth correctional facilities to offer staffing (which is often needed) and by serving as a dedicated referral site for youth who need specialty medical services while they are detained. CLINICAL OPPORTUNITY 3: COMMUNITY PEDIATRICIANS CAN PROMOTE SUCCESSFUL REENTRY After release, community-based providers serve a vital role in helping youth reintegrate into their communities

Table 2. Priorities for Improving the Health of Youth Involved With the Juvenile Justice System Priority Clinical

Opportunity Opportunity 1: Clinicians can help prevent juvenile incarceration Opportunity 2: Pediatricians can promote the health of youth in detention Opportunity 3: Community pediatricians can promote successful reentry

Research

Medical Education

Policy

Opportunity 1: Defining the role of pediatricians in preventing juvenile incarceration Opportunity 2: Developing evidence-based guidelines for optimal delivery of care for youth in detention Opportunity 3: Exploring the relationship between juvenile incarceration and health across the life course Opportunity 4: Developing strategies and interventions to promote health during community reentry Opportunity 1: Enhance trainees’ exposure to incarcerated youth

Opportunity 2: Offer continuing education opportunities on juvenile incarceration to practicing pediatricians Opportunity 1: Promote policies that aim to prevent juvenile incarceration Opportunity 2: Support policies that promote the health of currently detained youth and enhance success for justiceinvolved youth after detention

Advocacy

NCCHC indicates National Commission on Correctional Health Care.

Description  For children and teens who have never been detained, screen for risk factors for delinquency and offer early interventions whenever possible.  Ensure adherence to NCCHC standards.  For youth who have previously been detained, assist with community reintegration by seeing them regularly, screening for exposures related to incarceration, and providing referrals to community services.

 Provide trainees with clinical exposure to incarcerated youth.  Teach about incarceration as a social determinant of health.  Foster partnerships between academic medical institutions and correctional health care facilities.

 Promote policies that support the development of evidenced-based prevention strategies such as nurse home visiting programs and early education interventions.  Promote policies that support the delivery of high-quality health care to youth in detention and during the reentry period.  Pediatricians and pediatric organizations can become a voice for promoting the health of well-being for youth involved in the juvenile justice system.

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(Table 3). To reduce repeat offending, pediatricians will need to take an active role in facilitating successful reentry. Strong partnerships between juvenile detention systems and community outpatient care facilities are needed. Upon release, youth should have discharge papers that include the detention center clinic phone number, provider name, and fax number. Likewise, community-based providers seeing youth in the postdetention period can request health records from correctional facilities. Providers need not focus on reasons for incarceration but should ascertain the following information: duration of detention; whether acute health issues arose during detention (eg, orthopedic injuries); immunizations and treatments provided in detention; ongoing recommended care; and any continued risks for suicide.11 To truly promote the health of these vulnerable children, however, it is essential that providers exert extra effort to address the underlying factors that contributed to prior incarceration. For example, addressing underlying causes for a youth’s incarceration by providing support and resources to struggling families and addressing school safety may have dramatic effects on promoting health and decreased recidivism. This starts with pediatricians themselves remembering that the ex-offenders are adolescents who are maturing but troubled and who, with support, can make positive changes. We have spent many years working directly with detained youth. These children are hungry for positive interactions with adults, and most respond pleasantly and with appreciation in clinical situations. The majority of delinquent youth realize that they have made bad decisions. By using motivational interviewing, pediatricians can guide youth to make their own constructive decisions to change. RESEARCH Research on juvenile incarceration is an area wide open for discovery. Existing challenges include small sample sizes within detention facilities and obtaining approval from institutional review boards that are reluctant to approve studies involving prisoners. As institutional review boards and researchers gain familiarity with incarcerated populations, research opportunities may become more feasible. Engagement with juvenile courts and detention systems from the beginning of protocol development enhances the likelihood that the research will be approved.

Table 3. Key Points for Pediatricians Caring for Formerly Detained Youth  Request medical records or discharge summaries from detention facility.  Determine if patient needs subspecialty, mental health, or substance abuse treatment referrals.  Ask youth about current risk behaviors.  Continue regular screenings for STIs and mental health issues.  Assist family with academic and social needs (eg, request IEP from school). STI indicates sexually transmitted infection; IEP, individualized education program. Adapted from Perry and Morris.11 Reprinted with permission.

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Additionally, creating research consortiums across correctional settings allows for larger sample sizes and systematic testing of interventions. Many priority research topics exist. RESEARCH OPPORTUNITY 1: DEFINING THE ROLE OF PEDIATRICIANS IN PREVENTING JUVENILE INCARCERATION A key research focus is determining the role of community-based pediatricians and health care systems in preventing juvenile incarceration. This includes addressing underlying social determinants of health. The direct costs of incarceration and health care could be reduced by developing a more effective model to provide appropriate services to youth, especially for black and Hispanic boys at risk for incarceration. Evidence-based interventions that integrate juvenile offending prevention into health homes and other primary care settings are needed. RESEARCH OPPORTUNITY 2: DEVELOPING EVIDENCE-BASED GUIDELINES FOR OPTIMAL DELIVERY OF CARE FOR YOUTH IN DETENTION Correctional health care providers need to critically assess how to efficiently and effectively meet the health needs of detained youth. Adapting and implementing consensus recommendations originally developed for the general adolescent population for youth in corrections, especially for young black and Hispanic boys, is an important research focus. RESEARCH OPPORTUNITY 3: EXPLORING THE RELATIONSHIP BETWEEN JUVENILE INCARCERATION AND HEALTH ACROSS THE LIFE COURSE Exploring hypothesized linkages across the life course between ACEs, juvenile incarceration, and poor health and social outcomes would be worthwhile to help clarify the true costs of incarceration and strategic areas for intervention. Studies that demonstrate the effects of incarceration alone on health, irrespective of race/ethnicity and poverty, are needed. Expanding the limited knowledge concerning short- and long-term impacts of juvenile incarceration on health is a research area that may have great potential benefits for supporting vulnerable youth. RESEARCH OPPORTUNITY 4: DEVELOPING STRATEGIES AND INTERVENTIONS TO PROMOTE HEALTH DURING COMMUNITY REENTRY Pediatricians can also help address system-level issues that impede continuity of care after juvenile detention in order to promote continuity of care for youth in the postdetention period. What are key promoters and barriers to health in this period? A modest reentry literature has explored these questions, but evidence-based guidelines are lacking. MEDICAL EDUCATION Significant opportunities for advances in medical education related to the juvenile justice population exist.

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EDUCATIONAL OPPORTUNITY 1: ENHANCE TRAINEES’ EXPOSURE TO INCARCERATED YOUTH Given the important public health implications of incarceration, medical schools and residency training programs should increase trainees’ exposure to criminal and juvenile detention systems by providing clinical training opportunities inside detention facilities. Medical education about justice-involved youth helps alleviate challenges with recruitment of providers. We have observed that in many medical schools and residency programs, trainees receive little to no education about incarcerated populations. Roughly 1 in 100 adults is behind bars in America at any given moment, so this signifies a gap in training.71 When trainees are exposed to incarcerated youth, the particular medical and psychosocial needs of these youth will be better understood and adequately addressed, whether they are seen within the detention setting or in the community. Because detained youth bring many illnesses, both common and uncommon, juvenile correctional facilities are ideal for training in adolescent medicine. We recommend that training on juvenile incarceration become a curricular requirement for pediatric residency programs. EDUCATIONAL OPPORTUNITY 2: OFFER CONTINUING EDUCATION OPPORTUNITIES ON JUVENILE INCARCERATION TO PRACTICING PEDIATRICIANS Many practicing pediatricians could benefit from learning more about juvenile justice issues. Health care provider organizations can provide continued education opportunities, such as by offering continuing medical education credits to community-based clinicians for learning about the care of justice-involved youth. POLICY The ACA included several provisions beneficial to the health of children and young adults.72 For example, the ACA strengthened Medicaid and the State Health Insurance Program for Children, and established mental health parity and health equity funding. These provisions, if appropriately implemented, are likely to improve the health of incarcerated youth and youth who may be at risk for incarceration. Simultaneously, juvenile justice reform, which seeks to decrease the epidemic of juvenile incarceration, is gaining momentum nationally.2 Within this context, several policy priorities are highly relevant to pediatricians. POLICY OPPORTUNITY 1: PROMOTE POLICIES THAT AIM TO PREVENT JUVENILE INCARCERATION To reduce poor health outcomes associated with incarceration, primary prevention of juvenile detention will be critical. Policies that alleviate child poverty could be beneficial in reducing juvenile incarceration. For example, prenatal and early childhood nurse homevisiting programs demonstrate decreased rates of child abuse perpetration, substance use, and arrest of mothers and their children 15 years after the intervention.73 Early

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education yields similar results. The Perry Preschool Project demonstrated that providing high-quality preschool to low-income African American children correlated with higher high school graduation rates, higher job earnings, and decreased incarceration rates into adulthood.74 POLICY OPPORTUNITY 2: SUPPORT POLICIES THAT PROMOTE THE HEALTH OF CURRENTLY DETAINED YOUTH AND ENHANCE SUCCESS FOR JUSTICE-INVOLVED YOUTH AFTER DETENTION Attention should be paid to improving health of currently detained youth and enforcing appropriate correctional health care standards. Policy priorities to improve the health of youth in the postdetention period include changing current laws regarding the federal restriction of applying Medicaid to inmate populations so that individuals will not have their insurance terminated or suspended while incarcerated and thus will not lack insurance upon release. Additional policies that support continuity of care after release are needed. Although the ACA expanded Medicaid eligibility in many states, additional policies are needed to ensure that youth can access health care coverage once back in their communities. ADVOCACY By understanding justice-involved youth, pediatricians can become empowered to improve the health of these children. Currently, juvenile justice systems are closed systems that receive little sustained attention from the outside community. We have observed that in recent years, although this trend is shifting somewhat, it is not shifting uniformly or fast enough relative to the impact that juvenile incarceration has on individuals and communities. Although incarcerated youth represent a large, highly vulnerable population, when considering their population size and high morbidity, they are underdiscussed at national pediatric conferences, in the pediatric literature, and in most training environments. Pediatricians need to acknowledge that, by and large, incarcerated youth are largely ignored by our profession, then work to change this. Through partnerships with community-based organizations, allied health professionals, and the youth themselves, pediatricians can be a voice in advocating for incarcerated youth. Local and national chapters of professional organizations such as the American Academy of Pediatrics, Academic Pediatric Association, and Society for Adolescent Health and Medicine can serve a vital role in galvanizing pediatricians forward in addressing the health needs of incarcerated youth. When local chapters engage with their respective youth correctional facilities, they can interact directly with the health care providers committed to caring for detained youth. Leadership, working through national chapters, can guide the profession toward developing expertise in caring for justice-involved youth and in promoting delinquency prevention. Five significant advocacy opportunities for pediatricians and pediatric

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institutions that lead the way in promoting the health of incarcerated youth are: 1) juvenile justice and sentencing reform, 2) health care reform, 3) school reform, especially of zero tolerance and other disciplinary practices, 4) research funding from governmental agencies (eg, National Institutes of Health) and private funders, including large foundations, and 5) teaching about juvenile incarceration in medical training programs. Pediatricians, working through professional organizations, can play a powerful role in improving the health of incarcerated youth.

CONCLUSIONS Juvenile incarceration is a threat to pediatric health and public health. Preventing incarceration and addressing the health needs of incarcerated youth are critical goals to protect youth and families from adverse health and social outcomes. Pediatricians need to embrace this vulnerable population. Doing so is vital to addressing the gaping health inequities faced by minority youth and socially disadvantaged communities. Through commitment, concerted action, and enhanced understanding of incarcerated youth, pediatricians can lead the way forward in improving the health of some of the most socially vulnerable youth in our country. With approximately 10,000 youth admissions to the Los Angeles County detention system each year, Los Angeles incarcerates more youth than any other US jurisdiction.75 Latinos and African Americans account for approximately 95% of youth held in LA juvenile detention facilities. The LA Juvenile Court Health Services (JCHS) provides health care for the daily population of nearly 2000 incarcerated youth within 3 juvenile halls and 15 detention camps.76 JCHS is accredited by the National Commission on Correctional Health Care (NCCHC) and demonstrates the various health functions that a large juvenile justice system can serve. JCHS offers:  Nurse intakes and complete physical examinations by pediatricians to all youth.  All necessary immunizations (adolescent and/or catch-up series).  Gonorrhea and chlamydia screening of all youth.  Pregnancy and trichomonas screening for all girls.  Tuberculosis, vision, and hearing screening for all youth.  On-site dental and optometry services.  Pharmacy services.  Close collaboration with mental health and public health professionals.  Discharge summary and copy of updated immunization records upon release.  Referral to county primary care clinics upon release from detention camps.

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ACKNOWLEDGMENTS We thank Drs Robert Ross and Paul J. Chung for his contributions to the conceptual development of this article. Dr Barnert was supported by the Children’s Discovery & Innovation Institute, Mattel Children’s Hospital UCLA.

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