Psychiatric and medical health care policies in juvenile detention facilities

Health of Convicted Persons in the Third Generation of the Longitudinal Cambridge Study in Delinquent Development

Research suggests that convicted persons are more likely than non-convicted persons to suffer poor health. However, few longitudinal studies have investigated associations between health and offending across generations. Using the Cambridge Study in Delinquent Development, this article prospectively investigates the relationship between health and offending across generations and between genders. At the average age of 25, third generation convicted males and females reported a higher incidence of serious drug use than non-convicted persons. Convicted males reported a higher incidence of mental illness and self-harm, whereas convicted females reported a lower incidence of physical illness, mental illness, self-harm and hospitalizations when compared to non-convicted females. Convicted males reported a higher incidence of industrial accidents, sports injuries and fight injuries, but a lower incidence of road accidents, whereas convicted females were more likely to report road accidents. Like their fathers, convicted males show worse health compared to non-convicted individuals.

Juvenile justice systems of care: results of a national survey of community supervision agencies and behavioral health providers on services provision and cross-system interactions

BACKGROUND

Youth involved in the juvenile justice (JJ) system have high needs for behavioral health services, especially related to substance use and mental disorders. This study aimed to understand the extent to which elements in the cascade model of behavioral health services for JJ-involved youth are provided to youth by Community Supervision (CS) and/or Behavioral Health (BH) providers. In order to understand interactions across CS and BH systems, this study used a multistage probabilistic survey design to sample CS agencies and their primary BH service providers of substance use and mental health treatment in the United States. Parallel surveys were administered to both CS and BH providers regarding: characteristics of youth served, BH services available, whether services were provided directly and/or by referral, use of evidence-based practices (EBPs), and methods of collaboration, referral, and information exchange across CS and BH providers.

RESULTS

The findings from weighted national estimates demonstrate that youth referred from CS to the BH programs represent a more severe sub-group of youth under CS supervision. There are established cross-system relationships for assessment and referral for substance use and mental health treatment, but less so for prevention services. Most CS programs refer youth to BH providers for these services, which typically utilize more highly trained staff to provide EBPs to a majority of the youth served. More intensive substance use and mental health treatment, aftercare, and recovery support services were limited in availability.

CONCLUSIONS

The findings suggest that although many elements in a cascade model of BH services for JJ-involved youth have been implemented within local systems of care through collaboration between CS and BH providers, there are several underdeveloped areas and potential for attrition across the service cascade. Greater attention to providing services to youth with higher levels of severity, aftercare services, and recovery support is warranted within a multi-systemic framework.

Behavioral Health Service Utilization Among Detained Adolescents: A Meta-Analysis of Prevalence and Potential Moderators

PURPOSE

Utilization of behavioral health treatment services among adolescents who have been detained or incarcerated within the juvenile justice system is poorly understood, with estimated utilization rates varying widely across studies. This meta-analysis was conducted to review and synthesize the literature on the prevalence of service utilization among this population.

METHODS

Data from 27 studies of 28 distinct samples were abstracted and coded. A meta-analysis was conducted to calculate individual prevalence estimates of behavioral health service utilization, which were combined using random effects models. A moderator analysis was also conducted.

RESULTS

Prevalence effect sizes (pr) for service utilization were low, with effect sizes pr = 33.1% for mental health services, pr = 27.95% for substance use-related services, and pr = 45.32% for unspecified services. The moderator analysis showed significant heterogeneity in prevalence of behavioral health service utilization.

CONCLUSIONS

The findings suggest limited service utilization by adolescents who had been detained or incarcerated, whether assessed before, during, or after confinement. Future research should focus on assessing the quality of, and youth access to, behavioral health services within and outside of juvenile justice facilities. Improved programs to ensure consistent treatment for previously detained or incarcerated adolescents are warranted.

Preventive Care Use Among Justice-Involved and Non-Justice-Involved Youth

BACKGROUND AND OBJECTIVES

Youth involved in the juvenile justice system (ie, arrested youth) are at risk for health problems. Although increasing preventive care use by justice-involved youth (JIY) is 1 approach to improving their well-being, little is known about their access to and use of care. The objective of this study was to determine how rates of well-child (WC) and emergency department visits, as well as public insurance enrollment continuity, differed between youth involved in the justice system and youth who have never been in the system. We hypothesized that JIY would exhibit less frequent WC and more frequent emergency service use than non-justice-involved youth (NJIY).

METHODS

This was a retrospective cohort study of administrative medical and criminal records of all youth (ages 12-18) enrolled in Medicaid in Marion County, Indiana, between January 1, 2004, and December 31, 2011.

RESULTS

The sample included 88 647 youth; 20 668 (23%) were involved in the justice system. JIY had lower use rates of WC visits and higher use rates of emergency services in comparison with NJIY. JIY had more and longer gaps in Medicaid coverage compared with NJIY. For all youth sampled, both preventive and emergency services use varied significantly by Medicaid enrollment continuity.

CONCLUSIONS

JIY experience more and longer gaps in Medicaid coverage, and rely more on emergency services than NJIY. Medicaid enrollment continuity was associated with differences in WC and emergency service use among JIY, with policy implications for improving preventive care for these vulnerable youth.

Psychopathology and Borderline Personality Pathology Associated with Lifetime Self-Injurious Behavior in Adolescent Psychiatric Inpatients and Detainees

OBJECTIVE

Self-injurious behavior (SIB) is a widespread phenomenon among adolescent psychiatric inpatients. It is also reported among delinquent adolescents detained in correctional facilities. While previous studies have addressed different functions of SIB within offender populations, here we investigate particular patterns of borderline personality pathology and psychopathology underlying SIB in both adolescent psychiatric inpatients and detainees.

METHOD

Adolescent psychiatric inpatients and detainees were recruited consecutively. Participants completed self-reports on SIB, suicidal thoughts and behavior, borderline personality pathology, and general psychopathology. Predictors of lifetime SIB by group were analyzed.

RESULTS

Psychiatric inpatients (n = 77) and detainees (n = 50) did not differ with respect to lifetime SIB (57.14 % versus 54.00 %), whereas SIB within the past year did (67.53 % versus 14 %; χ2₍₁₎ = 6.158, p = .013). Psychiatric inpatients reported greater emotional problems (t₍₁₂₅₎ = 5.109, p < .0001) and greater borderline personality pathology. Those with lifetime SIB were characterized by greater emotional problems and borderline personality pathology, independent of their group. Results from regression analyses suggest no group-specific predictors of lifetime SIB.

CONCLUSIONS

Although psychiatric inpatients endorse greater psychopathological distress, lifetime SIB among adolescent psychiatric inpatients and detainees is associated with similar patterns of psychopathology and borderline personality pathology.

Judges' Perceptions of Screening, Assessment, Prevention, and Treatment for Substance Use, Mental Health, and HIV among Juveniles on Community Supervision: Results of a National Survey

Juvenile Justice-Translational Research on Interventions for Adolescents in the Legal System (JJ-TRIALS) National Survey was funded in part to describe the current status of screening, assessment, prevention and treatment for substance use, mental health, and HIV for youth on community supervision within the US juvenile justice system. Surveys were administered to community supervision agencies and their primary behavioral healthcare providers, as well as the juvenile or family court judge with the largest caseload of youth on community supervision. This article presents the findings from the judges' survey. Survey results indicated juvenile and family court judges were open to innovations for improving the court's performance, rated their relationships with collaborators highly, and appreciated the impact of screening, assessment, prevention, and treatment on judicial practices.

Mortality of Youth Offenders Along a Continuum of Justice System Involvement

INTRODUCTION

Black male youth are at high risk of homicide and criminal justice involvement. This study aimed to determine how early mortality among youth offenders varies based on race; gender; and the continuum of justice system involvement: arrest, detention, incarceration, and transfer to adult courts.

METHODS

Criminal and death records of 49,479 youth offenders (ages 10-18 years at first arrest) in Marion County, Indiana, from January 1, 1999, to December 31, 2011, were examined. Statistical analyses were completed in November 2014.

RESULTS

From 1999 to 2011 (aggregate exposure, 386,709 person-years), 518 youth offender deaths occurred. The most common cause of death was homicide (48.2%). The mortality rate of youth offenders was nearly 1.5 times greater than that among community youth (standardized mortality ratio, 1.48). The youth offender mortality rate varied depending on the severity of justice system involvement. Arrested youth had the lowest rate of mortality (90/100,000), followed by detained youth (165/100,000); incarcerated youth (216/100,000); and youth transferred to adult court (313/100,000). A proportional hazards model demonstrated that older age, male gender, and more severe justice system involvement 5 years post-arrest predicted shorter time to mortality.

CONCLUSIONS

Youth offenders face greater risk for early death than community youth. Among these, black male youth face higher risk of early mortality than their white male counterparts. However, regardless of race/ethnicity, mortality rates for youth offenders increase as youth involvement in the justice system becomes more protracted and severe. Thus, justice system involvement is a significant factor to target for intervention.

Juvenile Justice, Mental Health, and the Transition to Adulthood: A Review of Service System Involvement and Unmet Needs in the U.S

Although adolescents are the primary focus of juvenile justice, a significant number of young people involved with this system are considered transition age youth (i.e., 16-25 years of age). The aim of this review is to summarize the specific needs of transition age youth with mental health conditions involved with the juvenile justice system, identify the multiple service systems relevant to this group, and offer recommendations for policies and practice. A comprehensive search strategy was used to identify and synthesize the literature. Findings highlight the paucity of research specific to transition age youth. Thus, we also summarized relevant research on justice-involved adolescents, with a focus evaluating its potential relevance in the context of the unique milestones of the transition age, including finishing one's education, setting and working towards vocational goals, and transitioning from ones' family of origin to more independent living situations. Existing programs and initiatives relevant to transition age youth with mental health conditions are highlighted, and nine specific recommendations for policy and practice are offered.

Academic Achievement Among Juvenile Detainees

The literature has long pointed to heightened frequencies of learning disabilities (LD) within the population of law offenders; however, a systematic appraisal of these observations, careful estimation of these frequencies, and investigation of their correlates and causes have been lacking. Here we present data collected from all youth (1,337 unique admissions, mean age 14.81, 20.3% females) placed in detention in Connecticut (January 1, 2010-July 1, 2011). All youth completed a computerized educational screener designed to test a range of performance in reading (word and text levels) and mathematics. A subsample (n = 410) received the Wide Range Achievement Test, in addition to the educational screener. Quantitative (scale-based) and qualitative (grade-equivalence-based) indicators were then analyzed for both assessments. Results established the range of LD in this sample from 13% to 40%, averaging 24.9%. This work provides a systematic exploration of the type and severity of word and text reading and mathematics skill deficiencies among juvenile detainees and builds the foundation for subsequent efforts that may link these deficiencies to both more formal, structured, and variable definitions and classifications of LD, and to other types of disabilities (e.g., intellectual disability) and developmental disorders (e.g., ADHD) that need to be conducted in future research.

Behavioral Health Care Needs, Detention-Based Care, and Criminal Recidivism at Community Reentry From Juvenile Detention: A Multisite Survival Curve Analysis

OBJECTIVES

We examined the provision of behavioral health services to youths detained in Indiana between 2008 and 2012 and the impact of services on recidivism.

METHOD

We obtained information about behavioral health needs, behavioral health treatment received, and recidivism within 12 months after release for 8363 adolescents (aged 12-18 years; 79.4% male). We conducted survival analyses to determine whether behavioral health services significantly affected time to recidivating.

RESULTS

Approximately 19.1% of youths had positive mental health screens, and 25.3% of all youths recidivated within 12 months after release. Of youths with positive screens, 29.2% saw a mental health clinician, 16.1% received behavioral health services during detention, and 30.0% received referrals for postdetention services. Survival analyses showed that being male, Black, and younger, and having higher scores on the substance use or irritability subscales of the screen predicted shorter time to recidivism. Receiving a behavior precaution, behavioral health services in detention, or an assessment in the community also predicted shorter time to recidivating.

CONCLUSIONS

Findings support previous research showing that behavioral health problems are related to recidivism and that Black males are disproportionately rearrested after detention.

A statewide collaboration to initiate mental health screening and assess services for detained youths in Indiana

OBJECTIVES

We describe a statewide effort to implement detention-based mental health screening and assess follow-up services offered to detained youths in Indiana.

METHODS

A total of 25,265 detention stays (15,461 unique youths) occurred between January 1, 2008, and December 31, 2011, across 16 detention centers participating in the Indiana Juvenile Mental Health Screening Project. We collected screening results and reports of detention-based follow-up mental health services and referrals from justice system records.

RESULTS

Approximately 21% of youths screened positive for mental health issues requiring follow-up. A positive screen significantly predicted that youths would receive a follow-up mental health service or referral while detained or upon detention center discharge, compared with youths who did not screen positive (61% vs 39%). Logistic regression models indicated that a positive screen was associated with (1) contact with a mental health clinician within 24 hours of detention center intake and (2) a mental health referral upon discharge. White youths were more likely than minorities to receive both follow-up services.

CONCLUSIONS

Future statewide efforts to improve the mental health of detained youths should incorporate standards for providing appropriate follow-up services in detention centers.

Treating psychiatric emergencies in incarcerated minors in the emergency department: what is the cost and what is their disposition?

BACKGROUND

Although mental health disorders are common among incarcerated minors, psychiatric urgencies and emergencies often cannot be treated in juvenile detention facilities, necessitating emergency department (ED) transfers. The cost of this ED care has not been well studied.

OBJECTIVE

This study aimed to provide information on disposition and cost related to ED visits by juvenile hall patients transported for urgent psychiatric evaluation.

METHODS

A retrospective cross-sectional descriptive study of patients presenting to 1 ED from juvenile detention centers for consideration of psychiatric holds was conducted. Eligible patients were identified by a search of the International Classification of Diseases, Ninth Revision, discharge diagnosis codes and chart review. We collected information on patient demographics and disposition and calculated costs of ED visits, screening laboratories performed, inpatient stays on a medical ward, sitter and parole officer salaries, and ambulance transfers.

RESULTS

One hundred eight patients accounting for 196 visits were transported from juvenile hall for urgent psychiatric evaluation. Of the 196 visits, 131 (67%) resulted in an involuntary psychiatric hold. More than half of the patients on hold (75 patients) were admitted to a medical ward for boarding because of lack of psychiatric inpatient beds. Included charges for the 196 visits during the 18-month period totaled US $1,357,884, with most of the costs due to boarding on the medical ward.

CONCLUSIONS

We describe the magnitude and cost associated with addressing psychiatric emergencies in a juvenile correctional system relying on transport of patients to an ED for acute psychiatric evaluation and treatment. Further research is needed to determine if costs could be decreased by increasing psychiatric resources in juvenile detention centers.

Psychological distress in an incarcerated juvenile population

BACKGROUND/PURPOSE

This study sought to examine the prevalence and correlates of psychological distress among incarcerated youth in Taiwan using the 5-item Brief Symptom Rating Scale (BSRS-5).

METHODS

This cross-sectional census survey study was conducted in 2007 among all the juveniles incarcerated in 23 correctional institutions (n = 1505) in Taiwan using a self-administered anonymous questionnaire. Of the total 1505 participants, 1363 completed the questionnaire (91% response rate). We excluded 494 participants as they were aged either over 17 years or under 12 years. Psychological distress was measured among the final 869 participants using the BSRS-5. Psychological distress was defined as a total score of at least 6 out of 20. Those identified as having psychological distress were then pooled into a case group and compared with control participants without psychological distress.

RESULTS

The prevalence of psychological distress was 44.1%. Among the case group, sleep disturbance (36.8%) had the highest prevalence of severe or very severe symptoms, followed by depression (34.7%), and hostility (27.9%). Multivariate logistic regression analysis revealed that correlates of psychological distress included the following: being female; having a poor self-rated health status; having joined a gang; having experienced life disturbances prior to the current imprisonment; and having ever had a smoking habit.

CONCLUSION

Significant sex differences were found for both the overall BSRS-5, as well as for each individual item of the BSRS-5. Treatment programs and interventions should be carefully tailored to address the mental health needs of juvenile inmates in a sex-specific manner using a multifaceted approach.

The girls' health screen pilot study: a screening instrument for girls in the juvenile detention system

The purpose of this study was to assess the validity of the Girls' Health Screen as a screening instrument compared to a standard history and physical examination among females entering juvenile detention. Chi-square analyses were performed to evaluate the association between the results of the self-administered screen and the history and physical examination performed by a provider. The screen was administered to 119 females. A number of acute issues were elicited that were also statistically correlated with the history and physical exam making it a valid screen for urgent issues at the time of detention.

Mental health screening and STI among detained youth

Our objective was to understand the relationship between mental health screening results, health disparity, and STI risk among detained adolescents. In this 24-month cross-sectional study of 1,181 detainees (age 13-18 years), we examined associations between race, gender, mental health screening results (as measured by the Massachusetts Youth Screening Instrument-2nd Edition) and sexually transmitted infection rates (STI; chlamydia, gonorrhea, and trichomonas). Consistent with previous research, females and black youth were disproportionately affected by STI. Race and gender differences were also noted in mental health screening. The odds of having an STI increased by 23% (OR = 1.23, 95% CI = 1.06, 1.37) with each one-unit increase in the alcohol/drug subscale score for females. Gender-specific STI interventions for detained youth are warranted. For young women with substance abuse, specific interventions are necessary and may help reduce health disparity in this vulnerable population.

Childhood poverty and the social safety net

Childhood poverty in the USA remains an issue that concerns the child, the family, the community, each state, and the nation. It also is a topic that pediatricians must become cognizant of because of the impact it has on the children we care for daily. It goes beyond the specific income threshold that sets the federal poverty level; rather it impacts on the ability of families to acquire life's basic needs to allow their children the opportunity to reach their full potential. These basic needs include adequate nutrition to grow and develop in an optimal fashion and a secure and stable home in a safe neighborhood, which allows for play, exploration, and physical activity. It must also include access to health insurance coverage as well as a physician, health center, and health system to meet their medical needs. In addition, we must provide early education opportunities to nurture the social and emotional health of our children and prepare each child for school. The school environment must promote academic achievement and the broader community must foster opportunities to minimize violence and reduce the need for incarceration. The integration of such provisions represents a broadening and redefinition of the Social Safety Net that incorporates both public and private sector efforts to maximize the life potential of each child.

Ethical issues in psychopharmacology of children and adolescents

PURPOSE OF REVIEW

This summary of the literature published over recent years focuses on the ethical aspects of interventions with psychotropic medication in child and adolescent psychiatry. Ethical issues of pharmacotherapy concern aspects of research, safety, indicated use, enhancement, information and evidence-based practice.

RECENT FINDINGS

The literature on pharmacological interventions suggests changes in prescribing patterns for some substance classes owing to regulatory authorities' warnings. For most of the commonly used medications in children and adolescents no sound database about efficacy and safety is available and knowledge about adverse events and long-term safety remains poor. This is due to a general lack of clinical trials in this population. Legislative efforts have tried to improve safety and labelling of medicines for children. Ethical issues of enhancement in minors have been increasingly discussed over recent years.

SUMMARY

The ethical aspects of psychopharmacotherapy in minors are still rarely discussed in the literature. Practical questions of research and treatment ethics such as a need for information for children and parents are pointed out; conflicts of evocation and access to care for special populations in need are identified in a field lacking adequate ethical and clinical research.

Caring for incarcerated youth

PURPOSE OF REVIEW

Incarcerated youth are an unusually high-risk cohort with numerous unmet medical and psychiatric needs. Frequently seen medical conditions including sexually transmitted diseases, pregnancy, and psychiatric illness are reviewed along with recommended standards of care for this population.

RECENT FINDINGS

The recent realization that two-thirds of juvenile detainees have a psychiatric disorder has sparked renewed interest in screening and treating these high-risk adolescents. The push for increased identification and treatment has been prompted by the hypothesis that treating illness reduces recidivism and therefore improves individual and community public health. Although many facilities perform psychiatric and medical health screening within 24 hours of detention, there are many lacking areas. Examples include limited sexually transmitted disease, HIV and pregnancy testing; given the high rates of asymptomatic sexually transmitted disease infection, universal screening is essential. Also, interpretation of psychiatric screening tools by untrained individuals and utilization of results to incriminate juveniles are other problem areas.

SUMMARY

Incarcerated adolescents' time in detention represents a rare opportunity to provide care to this underserved population. Full implementation of recommended screening and assessment protocols could greatly enhance individual as well as community health.