Juvenile confinement exacerbates adversity burden: A neurobiological impetus for decarceration

Every year, about 700,000 youth arrests occur in the United States, creating significant neurodevelopmental strain; this is especially concerning as most of these youth have early life adversity exposures that may alter brain development. Males, Black, and Latinx youth, and individuals from low socioeconomic status households have disproportionate contact with the juvenile justice system (JJS). Youth confined in the JJS are frequently exposed to threat and abuse, in addition to separation from family and other social supports. Youths’ educational and exploratory behaviors and activities are substantially restricted, and youth are confined to sterile environments that often lack sufficient enrichment resources. In addition to their demonstrated ineffectiveness in preventing future delinquent behaviors, high recidivism rates, and costs, juvenile conditions of confinement likely exacerbate youths’ adversity burden and neurodevelopmentally harm youth during the temporally sensitive window of adolescence. Developmentally appropriate methods that capitalize on adolescents’ unique rehabilitative potential should be instated through interventions that minimize confinement. Such changes would require joint advocacy from the pediatric and behavioral health care communities. “The distinct nature of children, their initial dependent, and developmental state, their unique human potential as well as their vulnerability, all demand the need for more, rather than less, legal and other protection from all forms of violence (United Nations Committee on the Rights of the Child, 2007).”

Prevalence, Comorbidity, and Continuity of Psychiatric Disorders in a 15-Year Longitudinal Study of Youths Involved in the Juvenile Justice System

Importance

Previous studies have found that one-half to three-quarters of youths detained in juvenile justice facilities have 1 or more psychiatric disorders. Little is known about the course of their disorders as they age.

Objective

To examine the prevalence, comorbidity, and continuity of 13 psychiatric disorders among youths detained in a juvenile justice facility during the 15 years after detention up to a median age of 31 years, with a focus on sex and racial/ethnic differences.

Design, Setting, and Participants

The Northwestern Juvenile Project is a longitudinal cohort study of health needs and outcomes of 1829 randomly selected youths in a temporary juvenile detention center in Cook County, Illinois. Youths aged 10 to 18 years were interviewed in detention from November 20, 1995, through June 14, 1998. Participants were reinterviewed up to 12 times during the 15-year study period through February 2015, for a total of 16 372 interviews. The sample was stratified by sex, race/ethnicity (Black, Hispanic, and non-Hispanic White), age (10-13 years or 14-18 years), and legal status (processed in juvenile or adult court). Data analysis was conducted from February 2014, when data preparation began, to March 2020.

Exposures

Detention in a juvenile justice facility.

Main Outcomes and Measures

Psychiatric disorders, assessed by the Diagnostic Interview Schedule for Children, version 2.3 at the baseline interviews. Follow-up interviews were conducted using the Diagnostic Interview Schedule for Children, version IV; the Diagnostic Interview Schedule, version IV; and the World Mental Health Composite International Diagnostic Interview (beginning at the 6-year follow-up interview).

Results

The study included 1829 youths sampled at baseline (1172 males and 657 females; mean [SD] age, 14.9 [1.4] years). Although prevalence and comorbidity of psychiatric disorders decreased as the 1829 participants aged, 52.3% of males and 30.9% of females had at least 1 or more psychiatric disorders 15 years postdetention. Among participants with a disorder at baseline, 64.3% of males and 34.8% of females had a disorder 15 years later. Compared with females, males had 3.37 times the odds of persisting with a psychiatric disorder 15 years after baseline (95% CI, 1.79-6.35). Compared with Black participants and Hispanic participants, non-Hispanic White participants had 1.6 times the odds of behavioral disorders (odds ratio, 1.56; 95% CI, 1.27-1.91 and odds ratio, 1.59; 95% CI, 1.23-2.05, respectively) and greater than 1.3 times the odds of substance use disorders (odds ratio, 1.90; 95% CI, 1.55-2.33 and odds ratio, 1.39; 95% CI, 1.11-1.73, respectively) throughout the follow-up period. Behavioral disorders and substance use disorders were the most prevalent 15 years after detention.

Conclusions and Relevance

This study's findings suggest that persistent psychiatric disorders may complicate the transition from adolescence to adulthood, which is already challenging for youths involved in the juvenile justice system, many of whom are from racial/ethnic minority groups and low-income backgrounds. The pediatric health community should advocate for early identification and treatment of disorders among youths in the justice system.

Indiana's Section 1115 Medicaid Waiver And Interagency Coordination Improve Enrollment For Justice-Involved Adults

Timely access to Medicaid coverage offers many potential benefits to justice-involved adults reentering the community. In 2015 Indiana's Section 1115 Medicaid waiver (the Healthy Indiana Plan [HIP]) expanded eligibility for low-income adults. To expedite coverage for justice-involved adults, Indiana subsequently improved interagency coordination in two ways. First, the Indiana Department of Correction began initiating Medicaid applications for those in custody. Second, Medicaid began temporarily suspending coverage for people while they were incarcerated instead of discontinuing it. Prison release data from the Indiana Department of Correction linked to Medicaid enrollment data indicate that before HIP was implemented, approximately 9 percent of justice-involved adults received Medicaid coverage within 120 days of release. After HIP implementation, coverage rates increased by 9 percentage points. After both interagency coordination policies were implemented, an additional 29-percentage-point increase in coverage occurred. Furthermore, coverage effective within seven days of release increased by 14 percentage points after the interagency coordination policies went into effect. These findings support the notion that policies and procedures encouraging interagency coordination are beneficial in increasing timely access to Medicaid coverage for justice-involved people.

Eliminating Gaps in Medicaid Coverage During Reentry After Incarceration

This commentary explores the health and social challenges associated with gaps in Medicaid health insurance coverage for adults and youths exiting the US criminal justice system, and highlights some potential solutions.Because a high proportion of recently incarcerated people come from low-income backgrounds and experience a high burden of disease, the Medicaid program plays an important role in ensuring access to care for this population. However, the Medicaid Inmate Exclusion Policy, or "inmate exclusion," leads to Medicaid being terminated or suspended upon incarceration, often resulting in gaps in Medicaid coverage at release. These coverage gaps interact with individual-level and population-level factors to influence key health and social outcomes associated with recidivism.Ensuring Medicaid coverage upon release is an important, feasible component of structural change to alleviate health inequities and reduce recidivism. High-yield opportunities to ensure continuous coverage exist at the time of Medicaid suspension or termination and during incarceration prior to release.

Parent and Provider Perspectives on Recently Incarcerated Youths' Access to Healthcare During Community Reentry

Incarcerated youth have numerous healthcare needs, yet access to healthcare following community reentry is limited. Healthcare and juvenile justice providers, along with parents, strongly influence access to care for youth undergoing reentry. However, their perspectives are often missing from the literature. We examined parent and provider perspectives on youths' access to healthcare during community reentry. We conducted 72 longitudinal interviews with parents of youth undergoing reentry (n= 34 parents) and cross-sectional interviews with health and juvenile justice providers (n=20 providers). We performed inductive analysis of interview transcripts to identify the major themes related to access to healthcare during reentry. Respondents identified key leverage points that influence access to healthcare along the spectrum of individual, community, and policy-level factors. Parent and provider perspectives demonstrated substantial overlap, strongly concurring on the essential role of parents in linking youth to care and the external factors that limit parents' ability to connect youth to care. However, providers discussed parents not buying-in to treatment plans as a barrier to care, and parents uniquely described feeling powerless when their children were not motivated to receive care. Parents and providers agreed on priority solutions for improving care access during reentry. Immediate solutions centered on: 1) increasing reliability and continuity of providers, 2) providing free or low-cost transportation to healthcare visits, and 3) eliminating gaps in Medicaid coverage post-incarceration. Findings also signal the broader need to pursue strategies that increase family engagement in healthcare during reentry. In doing so, health and juvenile justice providers can partner with parents to overcome barriers to healthcare for youth during reentry.