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Behind bars: Caring for incarcerated youths rewarding despite challenges :

March 2, 2016

Dr. ReamsDr. ReamsWhen Patricia N. Reams, M.D., M.P.H., FAAP, accepted a position as chief physician at the Virginia Department of Juvenile Justice, she admittedly had little idea what she was getting into.

Quickly, she learned her incarcerated patients had a lot in common with those she cared for previously.

“I’ve never had a child try to do anything that would harm me,” she said. “They looked at me like a co-conspirator to take care of them. It became very, very rewarding.”

The kids she treated during her 15 years in juvenile justice were mostly from poor communities and lacked access to quality health care. Mental illness, dental problems and sexually transmitted infections are “ridiculously overwhelming,” she said.

Incarcerated youths also have higher rates of substance abuse and are more likely to have had traumatic experiences, injuries including traumatic brain injury, and tuberculosis, according to a 2011 AAP policy statement Health Care for Youth in the Juvenile Justice System (

“There’s so many gaps in their care that we can actually fill,” said Paula K. Braverman, M.D., FAAP, past chair of the AAP Committee on Adolescence, lead author of the statement and medical director at an Ohio juvenile detention facility.

Dr. BravermanDr. Braverman“Every day, we have such an opportunity to make a difference in the lives of these youth in terms of their medical care. They are so appreciative,” she said.

By treating underlying conditions, particularly anxiety and depression, pediatricians impact a youth’s behavior, said Robert E. Morris, M.D., FAAP, former health care director for the Division of Juvenile Justice at the California Department of Corrections and Rehabilitation.

“There’s no question in order to function well, youth need to be both physically and mentally healthy, and dental health is very much connected to physical health,” he added.

Resources, quality of care varies 

About 1 million youth arrests were made in 2014, and more than 54,000 juvenile offenders are held in roughly 2,000 residential juvenile facilities at any one time, according to the U.S. Department of Justice. Dr. Reams has visited numerous correctional facilities as an accreditation surveyor for the National Commission on Correctional Health Care (NCCHC), an organization that works to improve health care in correctional facilities. NCCHC accreditation is voluntary but requires facilities to meet certain standards. Dr. Reams, past chair of the NCCHC board, also is the AAP representative to the commission.

Despite high rates of unmet medical needs, confined children rarely are treated by pediatricians, Dr. Reams said. Internists and family physicians are the norm.

“I visited one facility where the doctor didn’t know children have different normal blood pressure than adults,” she recalled.

Resources also are lacking. Federal law prohibits use of federal funds to care for detained youths, leaving states and local jurisdictions to foot the bill for health care, Dr. Braverman said. Many facilities partner with their county and state health departments or local hospitals to close gaps in care, she said.

Dr. MorrisDr. MorrisSmaller communities tend to struggle the most, said Dr. Morris, who led the NCCHC task force that recently updated the commission’s standards of juvenile health care.

Although the accreditation standards can be applied to any size juvenile facility, many rural facilities don’t consider accreditation because it’s often felt to be complex and expensive, he said. According to NCCHC, only about 3% of juvenile correctional facilities in the U.S. are accredited.

Nutrition is another challenge, Dr. Reams said. Juvenile correctional facilities qualify for the National School Lunch and School Breakfast programs, which provide low-cost or free nutritional meals to low-income children. Many of the accredited facilities consult with dietitians; however, it’s common for confined youths to be overfed with federal surplus foods, she said. When pork was very cheap, one facility served the meat at 19 out of 21 weekly meals.

“These kids are more likely to gain weight especially if they don’t have enough exercise built into the program,” Dr. Reams said.

Even for those confined at a facility with quality health care, continuity of care upon release is a challenge, heightened by the often two- to three-month time required to re-enroll in Medicaid in many states.

Continuity is especially concerning for youths who need psychotropic medications, Dr. Morris said. One option is to provide the caretaker with a month’s supply of medication and give the parole officer a prescription for two additional months; however, that requires budgetary buy-in and a clinician to monitor the youth while waiting for his or her mental health clinic appointment, he said.

In the end, that’s cost-effective because you don’t have kids who re-offend because of their untreated mental health condition, he said.

Need for more involvement, advocacy 

In addition to calling for high-quality, comprehensive health care, more needs to be done for youths in minority and lower socioeconomic families who have disproportionate representation in juvenile corrections, said Dr. Braverman.

“We can do our part when kids are in the correctional facility, but ultimately improving their health care means improving social determinants of health,” she said.

Dr. PerryDr. PerryMany youths who end up in corrections want to do the right thing, said Raymond Perry, M.D., M.S.H.S., former medical director of the Los Angeles (LA) juvenile detention center. Recalling his discussions with youths in the system, he said, “They were dealing with a lot of challenges at home and in their neighborhoods that made it hard to do the right thing. They made decisions to help them with social struggles, and sometimes those things got them in trouble with the law.”

The teens frequently wanted guidance to help make the right decisions in the future, he said. Pediatricians often are trusted for their guidance, but they need to be willing to work in the juvenile system, Dr. Perry said.

Dr. Reams recommends that pediatricians check out the juvenile facilities in their own communities and offer their assistance.

“If you can get just one kid onto a path of being a good citizen, you’ve done a lot,” Dr. Reams said.

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