Trauma responses are normal reactions to abnormal or violent events, yet many health care providers treat the challenging behavioral manifestations of trauma with judgment or misunderstanding. As providers who care for vulnerable children, it is our obligation to understand and interrogate our roles within systems that perpetuate the overcriminalization of developmentally appropriate responses to trauma and abuse, which create the trauma-to-prison pipeline. By understanding this pipeline and its impact, we as health care providers can better support our trauma-exposed patients and advocate for systemic change to dismantle and disrupt it.

Exposure to trauma and abuse can impact the reactivity of the prefrontal cortex’s “fear circuitry,” perpetuating a prolonged or sudden stress response even if a tangible danger is not present.1  Fear responses can be difficult to manage, particularly in youth, and can lead to substance use, emotional outbursts, self-harm, truancy, or other challenging behaviors to cope with underlying activation.2  Unfortunately, many institutions, including health care, augment the negative impacts of trauma by pathologizing these behaviors rather than recognizing and treating them for what they are: manifestations of trauma. Here we discuss 2 well-described pathways that health care providers should recognize, in which existing systems increase the likelihood for traumatized children to be incarcerated and exposed to additional harm.

The first pathway is the school-to-prison pipeline: policies and practices that increase the likelihood of a child becoming disengaged from school and involved in carceral systems. Disciplinary “zero tolerance” policies were initially introduced to the school system in the 1990s to address violence but were subsequently expanded to address other behavioral problems.3  Zero tolerance policies can result in suspension, expulsion, police investigation, or arrest. This places children, particularly Black, Indigenous, and people of color, through discriminatory application of these policies, at a greater risk for poor educational and health outcomes.3  As described above, children with unaddressed trauma are more likely to be perceived as disruptive, particularly in situations in which stress is triggered. The school setting itself, in which youth lack control over many aspects of their day, can exacerbate previous traumas, particularly when signs of traumatic stress crises are not recognized by adults. This pushes children with trauma histories, who might benefit from additional educational and counseling services, away from educational environments and into carceral systems that do not adequately address their underlying needs.

A second pathway is the foster care–to-prison pipeline,4,5  in which more than half of youth in foster care experience an arrest, conviction, or overnight stay in a correctional facility by age 17.6  Children within this system face complex and cumulative trauma, much of which precedes initial removal from the home. In addition to the maltreatment precipitating their entry into foster care, the system itself can be traumatic (eg, removal from their homes, placement instability, minimal social supports, and risk of further abuse), leading to complex behavioral needs that are difficult to address without caregiver education and support. Because caregivers in foster families and congregate settings (eg, group homes) may be less familiar with children’s unique trauma manifestations, they may be more likely to use harsher disciplinary tactics, including calls for police involvement. In addition, a limited understanding of trauma symptomology, paired with difficulties with record keeping, may lead to misdiagnosis or greater attempts to control behavior through psychotropic medications, which may be less effective in facilitating long-term resolution of trauma compared with other evidence-based therapies.7  Particularly for those who identify as Black, Indigenous, or people of color; youth who are lesbian, gay, bisexual, transgender, and queer; and youth with disabilities who are disproportionately institutionalized,4  continually disciplining or medicating behaviors without therapeutically addressing underlying traumatic stress can perpetuate cycles of abuse, trauma, and incarceration. Thus, a multifaceted approach is needed to educate and support youth, their caregivers, and the systems that support them.

As health care providers, we must use an ecological approach to understand and dismantle the trauma-to-prison pipeline (Fig 1). At the individual level, we should identify our own biases that may perpetuate pathologizing and discriminatory practices toward youth who have experienced trauma. We should empower youth with the knowledge that their reactions to trauma are normal responses to abnormal experiences while encouraging them to take an active role in symptom management. We can also cultivate more supportive environments by equipping families with the education and skills necessary to respond to traumatic stress crises with patience and empathy rather than judgment. At the community level, we should advocate for a trauma-informed approach, including standardized, holistic trauma screening to identify children who would benefit from referrals to mental and behavioral health services or evidence-based trauma treatment.7  In addition, we can collaborate with school nurses, social workers, and other colleagues3  to shift from suspensions, expulsions, and policing in schools to more restorative and individualized approaches focused on health and wellness. At the systems level, we can advocate for policies that incentivize trauma-informed crisis management training for all staff involved in education, child welfare, and other systems that interface with youth. Finally, we must call for investment in community safety models that extend beyond police involvement, shifting our approach from punitive to therapeutic. By changing the narrative from “what’s wrong with you” to “what happened to you,” we can enable a culture of healing to mitigate the public health impacts of trauma in our communities.

We must also examine how health care systems unintentionally contribute to these pipelines by pathologizing trauma responses, sending the message that trauma-exposed youth (especially marginalized youth) are broken, delinquent, or ill. In contrast, a more trauma-informed system builds on messages that affirm, rather than try to erase, variations in children's moods and behaviors that result from trauma. We must contextualize our patient’s behaviors within the structures they interact with that may perpetuate harm and provide opportunities for mutual understanding, accountability, and healing. By critically interrogating the links between trauma and incarceration while fostering a trauma-informed environment of safety, mutuality, and empowerment, we can be leaders in dismantling these pipelines and providing the quality care that children deserve.

We express our appreciation for the National Clinician Scholars Program at both Yale and the University of Pennsylvania for their generous fellowship funding. We also acknowledge the youth within our communities who inspired this work and our commitment toward creating a more equitable future for all children.

Drs Sinko, He, and Tolliver conceptualized the manuscript, drafted the initial manuscript, and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: Funded by the University of Pennsylvania National Clinician Scholars Program (Drs Sinko and He). Dr Tolliver’s time is funded by the Yale National Clinician Scholars Program and by Clinical and Translational Science Awards grant TL1 TR001864 from the National Center for Advancing Translational Science, a component of the National Institutes of Health. The contents of this article are solely the responsibility of the authors and do not necessarily represent the official view of the National Institutes of Health. Funded by the National Institutes of Health (NIH).

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.