Youth impacted by the US juvenile and adult criminal justice systems are an important, largely overlooked pediatric population at grave risk of devastating consequences from the coronavirus disease (COVID-19) pandemic. Correctional facilities have high likelihood of COVID-19 outbreak, portending disproportionate risk and challenges to 3 groups of US children: (1) the 44 000 incarcerated youth,1  (2) the 2.7 million children whose parents are incarcerated,2  and (3) the hundreds of thousands of children whose parents work in correctional settings.3  As multiple correctional facilities become US epicenters for COVID-19, incarcerated youth and youth in contact with adults living or working in corrections have heightened medical risk of contracting COVID-19. Additionally, the susceptibility of jails, prisons, and detention centers to COVID-19 challenges the wellbeing of all children impacted directly or indirectly by the justice system. The COVID-19 correctional health crisis has advocacy and clinical implications for pediatric health professionals, including for providers in community ambulatory and hospitals settings, necessitating urgent action to protect a group of children already known to face significant vulnerabilities.

Young people can experience significant COVID-19 morbidity and even fatality. In response, the pediatric community has galvanized and innovated to swiftly meet youth’s medical needs, such as through national advocacy efforts and by ramping up telehealth services. We must also remember youth impacted by the justice system. Although it can be easy to forget the plight of youth and adults in custody, especially during the COVID-19 global crisis, doing so will threaten the health of children and families across the nation.

Several factors make correctional settings susceptible to COVID-19 outbreaks. It can be difficult to feel healthy in a juvenile detention center on the best of days. Emotional stresses and physical and sexual assaults are common, creating stressors that can weaken the immune system. Adult jail and prison environments are even harsher; they have even more of a punitive focus than juvenile facilities and many are severely overcrowded. In correctional facilities of all types, limited access to supplies (eg, soap, hand sanitizer) to support hygiene practices and to personal protective equipment are of concern, and significant barriers to social distancing exist. Additionally, correctional facilities, like a cruise boat, hold a contained population, but unlike cruise boats, a daily influx of people (new detainees, staff, visitors) can bring infections into facilities. Thus, limiting spread of COVID-19 outbreaks in correctional facilities is difficult. Meanwhile, movement out of correctional facilities creates opportunities for COVID-19 to spread from corrections to surrounding communities.

As of May 1, 2020, COVID-19 outbreaks in correctional settings are growing. New York is reporting an infection rate in Rikers jail, a complex that confines youth and adults, 5 times higher than in the city.4  Nationally, >24 300 cases and 260 deaths are documented in US adult jails and prisons, including one facility with 21 resident deaths.5  Nineteen states are reporting COVID-19 cases in youth facilities, including 92 staff cases and 63 cases in incarcerated adolescents.5  A downtrend is not yet in sight, reinforcing the need for health professionals to engage in solutions.

The United States incarcerates a larger percentage of adolescents than any other nation. On a given day, 44 000 youth (ie, children and adolescents <18) are detained or incarcerated in US juvenile detention facilities, jails, and prisons.1  One in 5 youth in custody are pretrial. Most are held for low-level, nonviolent offenses.1  As with the adult criminal justice population, the majority are from low-income families and belong to racial or ethnic minority groups.6  Incarcerated youth have disproportionate medical morbidity compared with peers,6  which portends COVID-19 susceptibility.

Additionally, the juvenile justice population has profound mental health morbidity, often related to previous trauma,6  that may become exacerbated by fear, social distancing, and disruptions in care, housing, schooling, and routine because of COVID-19. Most juvenile detention facilities have suspended in-person schools, with many offering only “in cell” instructional packets, and facilities have significantly reduced extracurricular and rehabilitative programming.5  Should an incarcerated youth develop symptoms of COVID-19, experiences of isolation will likely resemble solitary confinement, which is especially harmful for youth.7  Although the juvenile justice system was established as separate from the adult penal system to promote “the best interests of the child” and provide rehabilitation, in the current pandemic, in which rehabilitative programming has largely been suspended, youth are likely to fare better if returned to their families whenever safe to do so. Finally, it is important to remember that in many jurisdictions, children age 14 or younger may be in jails or prisons, alongside adults. Nearly 1 in 10 incarcerated youth <18 are in adult facilities.1 

In the United States, 2.7 million children have a parent currently incarcerated, including 1 in 9 black children.2  Jails and prisons are being hit hard by COVID-19. For youth and parents not in physical contact during the pandemic, mental health and social implications of COVID-19 may create challenges that intensify the experience of family separation and parental incarceration. Children may feel increased worry for their incarcerated parents because of the known dangers COVID-19 poses in correctional settings. Because of COVID-19, visitations in many facilities have been suspended, which may further strain families and enhance fear for each other’s wellbeing. Once visitation resumes and/or on release, children of parents returning from incarceration may also face a heightened risk of COVID-19 disease transmission.

US correctional facilities employ >400 000 correctional officers,3  all of whom are at risk from infection spread from outbreaks within prisons. Many thousands of essential workers, including officers, health workers, and food and maintenance staff, enter and exit facilities each workday, creating a bidirectional portal for infection. Children of the correctional workforce, like children of other essential workers, are vulnerable to transmission and may feel psychological strain as COVID-19 cases and deaths in corrections increase, including in their parents’ workplace.

Several urgent advocacy and clinical priorities exist for child health professionals to minimize the impact of COVID-19 on youth impacted by the justice system (Table 1). The priorities call for pursuing alternatives to incarceration, delivery of clinical care and support services equal in quality to standards applied to all children, and attentiveness to the unique needs and vulnerabilities of children impacted by the justice system. The advocacy and clinical priorities signify actions child health professionals should take at all times and are of heightened importance during the COVID-19 pandemic. Advocacy will likely be needed to drive the necessary clinical change. The advocacy priorities are a worthy focus for all child health professionals because correctional health is intertwined with community health and delivery of care in correctional and community settings is similarly interrelated. Finally, in the immediate and long-term, protecting children from structural racism and poverty exacerbated by COVID-19 will become critical in a sustained pediatric response to addressing health inequities and justice reform.

TABLE 1

Priorities to Protect Children Impacted by the Justice System From COVID-19

Advocacy priorities 
  Evidence-based downsizing of youth and adult criminal justice population. Smart, rapid decarceration is needed. Prioritization of individuals not deemed a public safety risk or with medical vulnerabilities is recommended. Health experts can contribute medical expertise to inform judicial decision-making and reentry plans. 
 Infection control standards and care delivery in correctional facilities equal to community standards of care. Needed prevention measures include screening, social distancing, education, access to personal protective equipment, and improving hygiene and disinfection. Quarantining is critical and likely to be challenging. Prompt data reporting is key. 
 Youth-centered approach to COVID-19 response. Many facilities have ended family visitation, and court processes are delayed. Youth need to be provided with frequent free video or telephone calls to families and legal counsel. Legal rights must be maintained and, to the extent possible, court procedures expedited, not delayed. Quarantine should not resemble solitary confinement; youth in isolation should be provided education, recreation materials, and other privileges, to the extent possible. 
 Robust medical care, mental health care, education, and rehabilitative programming during the pandemic. Ramped up telehealth and remote learning opportunities should be pursued. Youth wellbeing and rights should be prioritized. 
 Access to supportive medical care for patients with COVID-19 who are incarcerated. Moderate and severe cases will likely require care in community hospitals. 
Clinical priorities 
 Ambulatory: health providers should consider screening for (1) youth incarceration, (2) parental incarceration, and (3) parental occupational health risk as essential workers in correctional settings. If exposure to a correctional setting is identified or known, providers can address the risks and stressors from the COVID-19 pandemic that add to those already faced by families affected by the justice system. 
 Ambulatory: as many youth undergo repeat cycles of incarceration, support at-risk youth by increasing surveillance and provide appropriate referrals (mental health, social services) to prevent youth incarceration, even during the pandemic. 
 Correctional health: providers caring for incarcerated youth in detention should adhere to infection control guidelines, responding to medical and mental health risks. 
 Hospital settings: recognize that, given the likelihood of outbreak in correctional facilities, incarcerated adolescents may require hospital-level care for COVID-19. Treating providers should be compassionate and treat the patients humanely, as they would any other adolescent. 
 Hospital settings: understand that the quality and availability of care youth receive in correctional settings may be low (eg, limited overnight nursing or diagnostic equipment). Consider having a lower threshold for initiating a diagnostic evaluation and for admission and a higher threshold for discharge. Facilities are trying to limit movement, so if an incarcerated youth was sent to the emergency department because of COVID-19 or for an unrelated condition, it is likely important. 
Advocacy priorities 
  Evidence-based downsizing of youth and adult criminal justice population. Smart, rapid decarceration is needed. Prioritization of individuals not deemed a public safety risk or with medical vulnerabilities is recommended. Health experts can contribute medical expertise to inform judicial decision-making and reentry plans. 
 Infection control standards and care delivery in correctional facilities equal to community standards of care. Needed prevention measures include screening, social distancing, education, access to personal protective equipment, and improving hygiene and disinfection. Quarantining is critical and likely to be challenging. Prompt data reporting is key. 
 Youth-centered approach to COVID-19 response. Many facilities have ended family visitation, and court processes are delayed. Youth need to be provided with frequent free video or telephone calls to families and legal counsel. Legal rights must be maintained and, to the extent possible, court procedures expedited, not delayed. Quarantine should not resemble solitary confinement; youth in isolation should be provided education, recreation materials, and other privileges, to the extent possible. 
 Robust medical care, mental health care, education, and rehabilitative programming during the pandemic. Ramped up telehealth and remote learning opportunities should be pursued. Youth wellbeing and rights should be prioritized. 
 Access to supportive medical care for patients with COVID-19 who are incarcerated. Moderate and severe cases will likely require care in community hospitals. 
Clinical priorities 
 Ambulatory: health providers should consider screening for (1) youth incarceration, (2) parental incarceration, and (3) parental occupational health risk as essential workers in correctional settings. If exposure to a correctional setting is identified or known, providers can address the risks and stressors from the COVID-19 pandemic that add to those already faced by families affected by the justice system. 
 Ambulatory: as many youth undergo repeat cycles of incarceration, support at-risk youth by increasing surveillance and provide appropriate referrals (mental health, social services) to prevent youth incarceration, even during the pandemic. 
 Correctional health: providers caring for incarcerated youth in detention should adhere to infection control guidelines, responding to medical and mental health risks. 
 Hospital settings: recognize that, given the likelihood of outbreak in correctional facilities, incarcerated adolescents may require hospital-level care for COVID-19. Treating providers should be compassionate and treat the patients humanely, as they would any other adolescent. 
 Hospital settings: understand that the quality and availability of care youth receive in correctional settings may be low (eg, limited overnight nursing or diagnostic equipment). Consider having a lower threshold for initiating a diagnostic evaluation and for admission and a higher threshold for discharge. Facilities are trying to limit movement, so if an incarcerated youth was sent to the emergency department because of COVID-19 or for an unrelated condition, it is likely important. 

During the COVID-19 pandemic and its aftermath, we must remember the millions of children impacted by the US criminal justice system. Failing to do so will perpetuate the tremendous health disparities already existing in our nation. It can be difficult to hear the voices or remember the faces of children and caregivers in locked facilities, but we must recognize that they need our support and our swift, evidence-based, coordinated action.

I thank Brie Williams and Cyrus Ahalt for their forward thinking that helped to shape the concepts in this article. Thank you to Paul Chung for his encouragement and for reviewing a draft of the essay.

Dr Barnert conceptualized the opinion article, prepared the manuscript, and approved the final manuscript as submitted.

FUNDING: Dr Barnert’s time is funded by the National Institute on Drug Abuse (K23 DA045747-01), the California Community Foundation (BA-19-154836), and the University of California, Los Angeles Children’s Discovery and Innovation Institute. Funded by the National Institutes of Health (NIH).

COVID-19

coronavirus disease

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The author has indicated she has no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The author has indicated she has no financial relationships relevant to this article to disclose.