Juvenile Detention and Incarcerated Youth and Young Adults

Matthew C. Aalsma

Cynthia L. Robbins

Katherine S. L. Lau

Katherine Schwartz

When children reach adolescence and young adulthood, it becomes more likely that they will be involved in the justice system. In the US, youth offenders under the age of 18 are subject to the juvenile justice system, a process that is separate and distinct from that of adult criminals. For over 100 years, the juvenile justice system has been charged with protecting the community from delinquent youth through supervision and incarceration, but the system must also aid in the rehabilitation of these youth. Over time, society may vacillate toward either end of this continuum—law enforcement versus rehabilitation—but the political climate since the late nineties has increasingly favored limiting the incarceration of youth. Contributions to this societal shift may include recent research findings that highlight procedural injustice within the system, the unique characteristics and needs of youth offenders, and the health costs of incarceration to both individual youth and their communities. For example, much research has affirmed that youth of color are disproportionately involved in both the juvenile and adult criminal justice systems.¹ Through increased health screening efforts, it is evident that justice system-involved youth face both physical and mental health issues at higher rates than their nondelinquent peers.² As such, juvenile justice policy reform efforts continue.

Young adult offenders between the ages of 18 and 26 are not typically afforded the protections, however limited, associated with the juvenile justice system. In contrast, they are subject to the adult criminal justice system, where their experiences and needs are rarely separated from those of older adult offenders. Research on the health of young adult offenders as a distinct group is limited, though their physical and mental health issues may be similar to the needs of older adolescent offenders. Though the majority of youth offenders are no longer involved in the justice system after reaching adulthood, there is evidence that the criminal behavior of young adults is frequently a continuation of adolescent delinquency.³ Researchers further suggest that young adult offenders are more similar to juvenile offenders than adults in both their physical and mental development as well as their criminal activity.⁴ These findings are reflected in policy recommendations to extend the jurisdiction of the juvenile justice system to include young adults.⁵

EPIDEMIOLOGY OF JUSTICE SYSTEM INVOLVEMENT

Approximately 1.47 million juveniles <18 years were arrested in the US in 2011,⁶ with nearly 1.4 million delinquency cases processed in juvenile courts in 2010.⁷ Of these youth offenders, just under 300,000 (21%) were placed in detention (short-term, local secure placement prior to court) and over 98,000 (7%) were sentenced to a term in juvenile prison (longer-term incarceration at a state facility).⁷ Further, it is estimated that more than 200,000 arrested juveniles faced prosecution in the adult criminal justice system.⁸ In terms of young adults, more than 2.52 million individuals between the ages of 18 and 24 were arrested in 2013. This age range represents nearly a third of arrests, though they make up only 10% of the general population.⁹

Recidivism

The repetition of criminal behavior, recidivism, is a common outcome among detained adolescents; as many as 40% to 70% of adolescents recidivate within 1 year of release from detention.¹⁰ Within the detained adolescent and young adult (AYA) populations, recidivism rates tend to be higher among males, minorities, youth younger at their first offense, those with prior criminal history, youth in unstable families, those with high rates of substance abuse, and those with a history of early childhood misbehavior or conduct problems.¹¹,¹²

Disproportionate Minority Contact

Minority youth and adults are overrepresented in the justice system, which is defined as disproportionate minority contact. Over 60% of juvenile justice-involved youth are minority youth, though they make up only a third of the general population.¹ Not only are minority youth disproportionately represented within the juvenile justice system, they also tend to receive harsher sentences, including placement in adult prisons, and are more likely to be removed from their home environments than White youth.¹³ Racial disparities are also prevalent throughout every stage of the adult criminal justice system.¹⁴

Mortality

Detained and incarcerated youth and young adults have increased rates of mortality in comparison to the general public. In a longitudinal study of detained youth, 15% of whom were tried in adult court, Teplin and colleagues found the mortality rate of detained youth to be four times that of the general population for males and eight times for females.¹⁵ Most of these deaths result from gunshot wounds post-release.⁹ Black, male, young adults are at greatest risk for violent death.¹⁵ In a study of serious offenders with felony
charges, 31% of whom were institutionalized, Chassin and colleagues found 3% of their sample died, which is similar to other studies of detained populations.¹⁶

Summary

It is likely that most providers will encounter patients involved in the justice system, especially providers who see minority youth and young adults. These individuals face much more troubled futures than the general population. Knowledge of high recidivism and mortality rates can have a direct effect on improving health by identifying factors that could lead to reinvolvement and screening for nonaccidental trauma risks, such as access to firearms. Advocacy is another way to intervene on behalf of young people; providers are in a unique role to advocate for youth as they are most knowledgeable about healthy adolescent development and conditions, such as substance abuse disorder, which are associated with continued delinquent behavior.

HEALTH ISSUES OF YOUNG PEOPLE IN THE JUSTICE SYSTEM

Youth and young adults involved in the justice system exhibit significant acute and chronic medical problems, whether precursors to, causes of, or direct and indirect effects of their system involvement. As examples, problems resulting from dog bites or drug use can be related to the reason for an individual’s involvement in the system; other medical problems, such as poor dentition, may manifest frequently among AYA offenders because this population is largely medically underserved. Young people in custody are more likely than the general population to suffer diseases such as asthma, sexually transmitted infections (STIs), substance abuse, and other chronic conditions.¹⁴

Detention Conditions

The range of common health problems experienced by AYAs in the justice system presents unique challenges to health care providers, especially when their illnesses may arise as a direct result of confinement. Complaints related to stress and adaption to a new environment, such as somatic pain, are to be expected. Gastrointestinal complaints may result from a set menu of food that differs significantly from pre-detention diet (e.g., menus high in lactose). Communicable diseases are also a concern for youth in custody, since detained youth are often housed together in conditions that facilitate disease spread (e.g., crowded quarters, communal eating, and bathing) and because some diseases, such as tuberculosis, occur at high rates in correctional facilities.

The 2010 Juvenile Residential Facility Census collected information from 2,519 facilities in the US. The census is performed biennially. The 2010 census found crowding remains a common problem in facilities: 20% of facilities were either at or above capacity in 2010 and 3% of publically operated facilities were above bed capacity. Mechanical restraints and isolation (defined as locking a youth in a room for more than 4 hours) are used, respectively, in 41% and 47% of detention centers, and just over 20% of all facilities. Crowding and use of mechanical restraints and/or isolation can exacerbate health conditions. In addition, this census collected information on acute health events in custody. One-third of facilities utilized emergency room visits (most commonly for sports-related injuries and illness). While deaths were rare, 11 were reported in 2010 (five were suicides and four from illness or natural causes).¹⁷

Mental Health and Substance Use

Young people involved in the justice system suffer from mental health and substance use disorders at higher rates than the general population.¹⁴,¹⁸ Among youth, studies have consistently found that, outside of externalizing problems (e.g., conduct disorder, attention-deficit hyperactivity disorder), psychiatric disorders of the internalizing spectrum, such as major depression, anxiety, and posttraumatic stress disorder, are prevalent.¹⁹ Unfortunately, most detention centers are not equipped to address the mental health needs of young people, and studies have found that even 5 years after release, at least 45% of male and 30% of female detainees experience one or more psychiatric disorders with associated impairment.²⁰ Substance use is also quite common among adolescents in the justice system, with approximately half of detained youth meeting the criteria for a substance use disorder and roughly 10% having a comorbid mental health and substance use disorder.²¹

Physical Health

Few national studies have described detainee health issues or how detention conditions specifically affect AYA in juvenile or adult facilities. The Survey of Youth in Residential Placement (SYRP)²² and the National Commission on Correctional Health Care (NCCHC)²³ have both revealed higher rates of health problems among youth in detention when compared to the general population. The data regarding general health issues are reviewed in the following sections.

Preexisting Health Needs

The health needs of some youth in detention are related to neglected preexisting health conditions, which are common among this vulnerable population. For example, among a large sample of youth in an Alabama detention center, slightly more than 16% of youth had been hospitalized at some point before incarceration, and 10% presented with a significant medical problem that would require follow-up after release from detention. Again, physical health problems among detained youth are often a consequence of poor access to care before custody. No more than one-third of participating youth could identify a regular source of medical care, with only 20% of these youth identifying a private physician as their source of care.²⁴ A longitudinal study of almost 50,000 detained adolescents over more than a decade documented that almost half (46%) had an identifiable medical problem during their detention stay, more than 3,300 were admitted to the detention center infirmary, and 500 were transferred to a hospital for admission.²⁵

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