I thought the next visit would be a straightforward suture removal. I entered the examination room on a busy morning in a primary care clinic and met Mrs Johnson and her 14-year-old grandson, who had stitches in his right knee. Michael’s laceration was well healed, and I made small talk as I coaxed out the sutures.
“What’d you do to your knee?” I asked. Michael was silent. Mrs Johnson described how Michael had been hanging out with a new crowd and had injured his knee in an auto crash. He and some friends had robbed a stranger and stole a car to get away, but they crashed the car, she explained, and his best friend died in the auto crash. His grandmother was worried about him and had been neglecting her own health to take him to medical and legal appointments.
As we spoke, I noticed a small red light out of the corner of my eye. Plugged into the wall was an L-shaped black box with a cord that traced to a device looped around Michael’s left ankle. Michael was not only in with a new group of friends, but he was also newly involved with the juvenile justice system. The electronic monitoring device was the assigned redress for his offenses.
The United States incarcerates more people than any other nation.1 As such, most pediatricians will see patients with experiences like Michael’s in their practice. In 2018, >700 000 youth <18 years old were arrested.2 Youth may interface with the justice system in a variety of ways, including encounters with school security or truancy officers, police contact, arrest, detainment, and postencounter monitoring. Youth of color, girls with a history of sexual abuse, and youth with disabilities continue to be overrepresented across the spectrum of justice involvement, and this disparity has widened over time.3,4 According to the Department of Justice, Black youth were 5 times more likely to be detained or committed, in comparison with their white counterparts.5 Youth of color do not commit more crimes than their peers6 ; this disparity likely reflects implicit and explicit biases on the part of individual adults and structural racism, rather than race-based differences in youth deviancy. Justice involvement during adolescence has important implications. In a 2017 study, researchers found that even incarceration of less than a month’s duration during adolescence was associated with poor adult mental health outcomes, and a dose-response relationship between incarceration length and adverse adult general health outcomes was observed.7 Justice-involved youth (JIY) are also more likely to use emergency services than preventive care and experience longer gaps in Medicaid coverage compared with their non–justice-involved counterparts.8 As a result, JIY may have unmet medical, psychological, and social needs during their formative years.
As Michael’s story suggests, pediatricians may be unaware of encounters with JIY because there are not always cues (like an ankle monitor) to prompt a discussion. What is the primary care pediatrician’s role? Our experience, supported by data, is that this population is socially marginalized and interacts with the medical home infrequently.8 Caring for JIY is an opportunity for pediatricians to advance health equity. How then can primary care pediatricians better reach this marginalized group? We need to first enhance provider knowledge about juvenile justice involvement as a public health issue to then engage pediatricians with their local systems for patient-centered care and advocacy.9
To provide equitable care for JIY, providers’ knowledge of local systems must be enhanced. Trainees and seasoned pediatricians are encouraged to first learn about their local justice system structure and then develop familiarity with resources that empower caregivers to advocate for their children. Some steps to these ends may include assessing formal and informal relationships with community partners, such as social workers, medical-legal partnership colleagues, and youth advocates. During my training, I have found it eye-opening to learn about resources for JIY, use elective time to build partnerships with leaders in the local juvenile justice system, and execute quality improvement projects in this space. This exposure has helped me to develop rapport with families and advocate for patients in more informed ways. Knowing the proper vocabulary, including what it means to be “on probation” or “on electronic monitoring,” and steering away from deviancy dialogue and toward a restorative model can help us start to ask the right questions and build rapport with patients and families.
Restorative justice is an evidence-based model that pediatricians can learn about to enhance equitable care for JIY and stands in contrast to the traditional criminal justice approach.10 As a foundational theory for successful programs and interventions worldwide, restorative justice seeks to mitigate the harm caused by crime by bringing all stakeholders (including the offender and the offended) to the table. It has been found to curb repeat offending and, pertinent to our work, has been implemented in school settings to guide disciplinary action and decrease missed school days. This is relevant to child health because missed school days are correlated with poor health and social outcomes.11 As experts in child and adolescent health and development, pediatricians can learn about restorative justice in their own communities and consider serving as allies to community groups. For example, in our community, the local public school district’s Office of the State Superintendent of Education has developed restorative justice resources and trainings that pediatricians may consider learning from and using.12
Addressing health insurance coverage is another avenue for advocacy for JIY. Nineteen states terminate and the remainder will suspend Medicaid during periods of incarceration. Children’s Health Insurance Program’s coverage for youth is also terminated during periods of incarceration.13 Stoppage of insurance coverage creates challenges after reentry to society, and reentry procedures vary by state. Addressing gaps in coverage by public health insurance programs for JIY is another critical step to reduce barriers to care. There are opportunities for collaboration between community pediatricians and health care providers within juvenile justice institutions to encourage seamless transitions of care. There are also advocacy opportunities, like addressing risk factors (such as adverse childhood experiences or mental illness), to prevent initial or repeat engagement with the juvenile justice system.
Daily, we bear witness to both the success and struggle of our patients and their caregivers, like Michael and his grandmother, as clinician-advocates. Supporting JIY, through evidence-based clinical care, provider education, and advocacy efforts across disciplines, can help to close existing gaps in health outcomes. Short periods of incarceration in adolescence are associated with negative health outcomes, and JIY deserve a transformed, comprehensive model of pediatric primary care.
We acknowledge Dr William Dietz for his feedback on this piece.
Dr Sims conceptualized this perspectives piece on the basis of her clinical experiences; Dr Dooley critically reviewed the manuscript for important intellectual content; and both authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
Dr Sims’ current affiliation is Department of Pediatrics, College of Medicine, University of Cincinnati and Division of General and Community Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH.
FUNDING: No external funding.
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.