Incarceration and the health of detained children

Historically, the incarceration of children has been used limitedly. The two reasons used to justify depriving youth of their freedom have been specific and serious threats to either public safety or to the young person’s own wellbeing (such as suicidal ideations). Incarceration should only be a last resort, with the standard being to place children in the least restrictive environment, such as in the community, because of the high risks of physical and mental health harms associated with detention. Although a large body of literature has shown the harms of incarceration in adult populations, less is known about children and adolescents. In their Scoping Review in The Lancet Public Health, Rohan Borschmann and colleagues¹ synthesised the literature relevant to the health of incarcerated children. Mirroring findings for adult populations, the authors found that children in correctional facilities often have poor health and a disproportionate burden of disease. In particular, a substantial proportion of adolescents who are incarcerated have mental health issues, self-harm or suicidal behaviours, substance use disorders, neurodevelopmental disabilities, and an increased incidence of sexually transmitted infections. Less has been documented about the socioeconomic, minority, and disadvantaged statuses of incarcerated youth, but it is likely that those follow the same patterns found in adult populations, with higher incarceration rates for people of lower socioeconomic status and people of colour.

The Scoping Review¹ also pointed to some major takeaways relevant to future research. For instance, most existing studies come from high-income countries, highlighting the need for more studies in jail and prison settings in low-income and middle-income countries. In addition, few validated tools are available to measure specific domains, including oral health and cardiopulmonary disease, and varied definitions are used to measure both health outcomes and incarceration. The findings of Borschmann and colleagues¹ underscore the negative impact that incarceration can have on children and lend a voice to a loudening call for decarceration.

In the USA, where rates of incarceration are the highest in the world, some actions have been taken to decrease incarceration rates among the children. Over the past decade,² many states have introduced so-called raise-the-age legislation that limits the use of adult corrections for those under the age of 18 years. This legislation acknowledges that housing children in adult facilities increases their risk of abuse and exposure to violence, and leads to high rates of recidivism.² However, the increasing involvement of youth in the opioid epidemic threatens to offset those gains.³ Furthermore, there has been a concurrent rise in the number immigrant children held in Immigration and Customs Enforcement detention centres in the USA. This increase represents a troubling departure from the standard of only incarcerating those children who represent a serious and specific threat. Between October, 2018, and June, 2019, the US Border Patrol detained 234 443 adults, 390 308 family units, and 63 624 unaccompanied children.⁴ Access to detention facilities is very limited and the operations and processes in place, for health care or otherwise, have not been detailed or disclosed. Clear, though, is that children detained in these facilities are not receiving adequate health care. Some reports have chronicled the unsafe and unsanitary conditions to which many children are exposed.⁵ Children in these facilities often have insufficient access to food, live in overcrowded cells, are exposed to untreated contagious illnesses, and have inadequate clothing.⁶ Incarceration itself is a known determinant of health, but an emerging body of research shows that the carceral context, including the various types of deprivation, punishment, and social conditions.⁷ The carceral contexts that these children are exposed to are most probably causing irrevocable harm.

Incarceration of children should be a last resort. Norway serves as an example for rehabilitative frameworks that are more appropriate for adolescents. Norway has 10% of the incarceration rate of the USA, and, perhaps more impressively, only 20% of people with a previous conviction recidivate (compared with more than 75% in the USA).^8,9 Key to these successes is the country’s orientation not to punishment but to restorative justice, with a main aim of identifying and repairing harm caused by crime. Restorative justice programmes have been implemented and show promise in possibly reducing future behaviour that increases risk of incarceration among children.¹⁰ However, more research is necessary to optimise the efficacy of these programmes.¹¹ Many such programmes, though, exist alongside tradition juvenile justice institutions that are oriented to punishment. A major and important step is to eradicate juvenile justice programmes using a punishment framework and replace them with evidence-based rehabilitative programmes focused on restorative justice.