In the article “Health Care Use and Health Behaviors Among Young Adults with History of Parental Incarceration,” Heard-Garris et al1 use the nationally representative longitudinal survey “Add Health” to demonstrate strong associations between parental incarceration before age 18 years and higher rates of forgone health care and unhealthy behaviors in early adulthood (ages 25–32 years). This work is valuable given the scope of parental incarceration and the social vulnerabilities of many justice-involved families. Overall, >2.7 million US children (1 in 28; roughly 1 per school classroom or dozens per general pediatrician’s average panel) have a parent who is currently incarcerated.2 For African American children, the proportion is 1 in 9.2 On any given day, approximately one-half of federal and state prisoners are parents of children <18 years of age.3 Moreover, parental incarceration is disproportionately high among poor children, and for immigrant children, concomitant parent status concerns may dramatically heighten risks.2
Given the limitations of the data set, there is a lack of clarity on the precise mechanisms linking parents’ incarceration with their children’s worsening long-term health and higher rates of forgone care. The authors speculate that mechanisms may relate to disruptions in a child’s family unit. These disruptions may result in both direct psychological damage and indirect damage through the overburdening of other caregivers, financial stress, and the learned mistrust of systems (including health systems) that foster a lifelong pattern of higher-risk behaviors and weaker engagement in care. These pathways, although plausible, need to be examined. What also needs to be examined is how parental incarceration may both overlap with and be distinct from other types of family separation, including parent death, parent divorce, child protective services involvement, parent deportation, or inhumane border policies.
Findings that reveal differential effects of maternal versus paternal incarceration are novel and intriguing. Some of the observed differences, as the authors postulate, may be related to a lack of statistical power in the maternal incarceration group. However, other differences, such as the observed strong association between maternal incarceration and higher rates of exchanging sex for money during adulthood, reveal that some effects may be unique to mothers. Although the mechanisms for these differences are unclear, they suggest that parental incarceration may impact youth differently depending on parent sex.
Given the observed associations, what should be done next? First, pediatric clinicians should screen for parental incarceration either separately or as part of a typical adverse childhood experience screener. Moreover, simply asking about parental incarceration may signal that the clinician is open to questions and requests for referrals, such as for mental health therapy, for children or caregivers who are having difficulty coping. Second, several tools exist that may aid clinicians in caring for children of incarcerated parents. For example, the creators of Sesame Street developed the Muppet character Alex to help children understand why daddy or mommy go away for a long time; the Sesame Street Web site also contains a tool kit for clinicians.4 Pediatricians can also refer families to social support services and resources such as the nonprofit Essie Justice Group, an organization that networks and supports women with incarcerated loved ones.5
Policy strategies entail minimizing the negative impact of parental separation and, as stated by the study authors, promoting steps toward deincarceration. Approaches such as the Formerly Incarcerated Reenter Society Transformed Safely Transitioning Every Person Act, which was passed in the US House of Representatives in May 2018, call for federal prisoners to be placed within 500 miles of their families.6 Although legislation such as this might decrease the negative impact of family separation by keeping families geographically closer, clearly, much more needs to be done. Deincarceration, which is aimed at diverting less serious offenses away from confinement and, when appropriate, into nonjustice sectors (eg, health services for charges related to substance use or mental illness), is perhaps the most important step. Community-based sentencing alternatives can allow for parental rehabilitation and accountability while keeping families together; for example, parents can attend court-ordered drug treatment and vocational programs while living at home.7
In many respects, when a parent is incarcerated, the entire family serves the sentence. The field of pediatrics must adapt accordingly, with much greater responsibility and urgency than it has to this point. Mitigating the negative impacts of parental incarceration (both by supporting the youth and their families and by direct advocacy to reverse mass incarceration and its negative effects) can reduce health disparities and improve health outcomes for vulnerable youth who, without help, may become vulnerable adults who underutilize needed care. The study in this month’s issue is an important reminder that parental incarceration and broader issues of family separation are pediatric problems that require pediatric solutions.
Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.
FUNDING: Supported by a National Institutes of Health KL2 grant (UL1TR000124) and the University of California, Los Angeles Children’s Discovery and Innovation Institute. Funded by the National Institutes of Health (NIH).
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2017-4314.
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.