Mental Illness Drives Hospitalizations for Detained California Youth

Abstract

Objective

To describe inpatient hospitalization patterns among detained and non-detained youth in a large, total population of hospitalized adolescents in California.

Methods

We examined the unmasked California Office of Statewide Health Planning and Development Patient Discharge Dataset from 1997-2011. We considered hospitalized youth aged 11-18 years “detained” if admitted to California hospitals from detention, transferred from hospital to detention, or both. We compared discharge diagnoses and length of stay (LOS) between detained youth and their non-detained counterparts in the general population.

Results

There were 11,367 hospitalizations for detained youth. Hospitalizations differed for detained versus non-detained youth: 63% of all detained youth had a primary diagnosis of mental health disorder (compared to 19.8% of non-detained youth). Detained girls were disproportionately affected, with 74% hospitalized for a primary mental health diagnosis. Detained youth hospitalized for mental health disorder had an increased median LOS compared to non-detained inpatient youth with mental illness (≥6 days versus 5 days, respectively). This group difference was heightened in the presence of minority status, public insurance, and concurrent substance abuse. Hospitalized detained youth discharged to chemical dependency treatment facilities had the longest hospital stays (≥43 days).

Conclusions

Detained juvenile offenders are hospitalized for very different reasons than the general adolescent population. Mental illness, often with comorbid substance abuse, requiring long inpatient stays, represents the major cause for hospitalization. These findings underscore the urgent need for effective, well-coordinated mental health services for youth before, during, and after detention.

Introduction

Detained youth are a high-risk population with numerous unmet medical and mental health needs.^1,2,3 Previous studies within the juvenile justice system demonstrated increased prevalence of a variety of medical conditions, including sexually transmitted diseases, pregnancy, asthma, and obesity.^4,5,6,7 The prevalence of psychiatric illness in detained adolescents is striking, with studies suggesting that up to two-thirds of these youth have mental health disorders.^8,9,10 Despite this increased burden of illness, little is known about the severity of these conditions among detained youth. Hospitalization, as an indicator of disease severity, can provide insight into the burden of unmet health care needs. Moreover, since many of the conditions observed in these youth are potentially amenable to coordinated outpatient care, characterization of hospitalizations for this group could help elucidate the nature and scope of their unmet health needs.

Few previous studies have examined hospitalizations among detained youth, and none have examined the causes of hospitalization in a large, total population of hospitalized adolescents.^3,11,12 Using data from the California Office of Statewide Health Planning and Development (OSHPD) Patient Discharge Database, we examined all hospital discharges among adolescents aged 11-18 years in California over a 15-year time span. Our objectives were to characterize hospitalization patterns among detained youth and to compare these patterns with those for the general, non-detained adolescent population in the large, ethnically diverse state of California utilizing a large database.

Methods

Patients and Study Variables

Data Source

We used the private, unmasked OSHPD Patient Discharge Database from 1997-2011. This dataset contains information (submitted biannually) on all hospital discharges from non-federal acute care hospitals. Variables in the “unmasked” version of the dataset include all available patient identifiers (date of birth, social security number, zip code of residence, hospital identification number), as well as other sociodemographic information (ethnicity, race, gender), expected source of payment (health insurance), admission source, diagnosis and treatment codes, length of hospital stay, and disposition.

Study Population

We queried the dataset for all adolescents aged 11-18 years of age, excluding non-California residents (n=35,662) from the analyses. We considered patients admitted to California hospitals from detention facilities, transferred from a hospital directly to a detention facility, or both during the study period to be “detained youth.” We identified admissions from detention by Admission Source of “jail” in the OSHPD database, and discharges to detention by Disposition to “jail.” Based on our clinical experience, we divided hospitalizations for detained youth into three patterns: 1) hospitalizations for youth admitted from detention and then transferred back to detention (hereafter referred to as “Detention-Hospital-Detention”); 2) hospitalizations for youth admitted from the community and then transferred to detention (hereafter referred to as “Community-Hospital-Detention”); and 3) hospitalizations for youth admitted from detention and subsequently discharged or transferred to another facility, including psychiatric hospitals or substance abuse treatment centers (hereafter referred to as “Detention-Hospital-Treatment”). Throughout the manuscript, we use “hospitalizations” among detained youth or non-detained youth as shorthand for “discharges among detained youth” or “discharges among non-detained youth,” particularly in the tables.

Sociodemographic, Health Insurance, and Geographic Characteristics

Sociodemographic variables we examined included patient age, gender, and race/ethnicity (Caucasian, Black, Hispanic, Asian-American, and other). We categorized health insurance as public insurance, private insurance, and other.¹³ We used ZIP code of residence to create a dichotomous variable reflecting major metropolitan population centers versus rural areas.

Diagnosis Identification

We determined the principal discharge diagnosis and up to 24 secondary diagnoses to identify co-occurring or co-morbid conditions.^13,14,15 We collapsed International Classification of Disease 9^th Revision (ICD-9) codes into broad categories: Mental Health, Trauma, Pregnancy, and Other Acute and Chronic Medical conditions. The Mental Health category comprised psychiatric DSM-IV discharge diagnostic codes (ICD-9-CM codes 290xx– 319xx). This category reflected three major groups: mental disorders, substance use disorders, and developmental disorders. We subdivided mental disorders into clinically relevant psychiatric categories that included anxiety/stress, depressive, disruptive, and psychotic disorders.¹⁶ Finally, we identified mental health comorbidities (defined as a psychiatric diagnosis that occurred with one or more lower ranked psychiatric diagnoses) since such conditions are predictors of poorer outcomes.^17,18

We defined Trauma diagnoses as ICD-9 CM codes 800xx-959xx. We calculated Injury Severity Scores (ISS) for all hospitalizations with trauma diagnoses, and stratified them into mild (ISS = 1-8), moderate (ISS = 9-15), and severe (ISS > 16). ^15,19 Diagnoses associated with pregnancy included 630xx-677xx. We categorized all other ICD-9 codes as “Other acute and chronic medical” diagnoses. Although we examined both primary and up to 24 secondary discharge diagnoses, we only counted each discharge once.

Statistical Analysis

We compared discharge diagnoses between detained adolescents (including stratification by gender, race/ethnicity and by the three hospitalization patterns) and their non-detained counterparts using chi square tests. We compared length of stay (LOS) between detained and non-detained youth within diagnosis categories (ie. Mental Health, Trauma, Pregnancy, Other Medical). To account for skewness in LOS, we used non-parametric tests (Wilcoxon and Kruskal-Wallis) to compare sociodemographics, insurance status, disposition subgroup, diagnosis categories, and hospital type among detained and non-detained youth. We designated p-values less than 0.05 to indicate statistical significance, and we report 95% confidence intervals. We used SAS 9.3 (Cary, NC, USA) for all analyses.

Human Subjects

The Institutional Review Board at Stanford University and the State of California Committee for the Protection of Human Subjects reviewed and approved this study.

Results

Of the 3,562,644 pediatric discharges during the study period, 1,936,513 involved adolescent California residents. Six-tenths of one percent (0.6%) of adolescent discharges (n=11,367) either originally came to the hospital directly from a juvenile detention facility, were discharged to such a facility, or both. (Figure 1)

Figure 1.

Flowchart of study population from California Office of Statewide Health Planning and Development (OSHPD) Hospital Discharge Dataset, 1997-2011

Table 1 shows the significant differences in general characteristics and distribution of hospital discharge diagnoses between the detained and non-detained adolescent populations. Detained youth were more likely to be older (mean age 16.1 vs. 15.5 years, p<0.001), male (63% vs 32%, p<0.001), and publicly insured (71.8% vs. 51.8%, p<0.001) compared to the non-detained, inpatient adolescent population. In addition, hospitalized detained youth were disproportionately black and from larger metropolitan counties: Los Angeles (24.9%), Alameda (13.7%), San Diego (7.8%), Orange (5.9%), Contra Costa (4.9%), and Santa Clara (4%). (Data not shown) Sixty-two percent of all hospitalizations among detained youth vs. 53.6% (p<0.001) of hospitalizations among non-detained adolescents in the general population came from these six, mostly urban counties.

Table 1.

Comparison of demographic characteristics among detained and non-detained youth hospitalized in California.

	Detained, Hospitalized N=11,367	Non-Detained, Hospitalized N=1,925,146	p
Mean age, years	16.1	15.5	p <0.001
Sex, n (%)
Male	7,772 (63)	718,441 (32)	p <0.001
Female	3595 (37)	1,206,705 (68)
Race/Ethnicity, n (%)			p <0.001
Black	2,550 (22.8)	193,847 (10.2)
Caucasian	3,834 (34.3)	718,273 (37.7)
Hispanic	4,092 (36.6)	845,041 (44.4)
Asian	303 (2.7)	85,471 (4.5)
Other	401 (3.6)	62,500 (3.3)
Payer, n (%)
Private	2,285 (20.1)	843,501 (43.9)	p <0.001
Public	8,156 (71.8)	997,268 (51.8)
Other	918 (8.1)	83,479 (4.3)
County
Major Metropolitan**	6,959 (61.2)	1,031,108 (53.6)	p <0.001

* “Public” includes Medicare, Medicaid, county indigent programs, State Children's Health Insurance program and Title V-supported CCS; “Other” includes worker's compensation, self-pay and other payer.

^**Larger metropolitan counties include Los Angeles, Alameda, San Diego, Orange, Contra Costa, and Santa Clara counties.

Among all non-detained adolescents in California, the main causes of hospitalization by diagnosis category included: 1) Other Acute and Chronic Medical conditions (43%; most commonly appendicitis, pulmonary/gastroenterologic/genitourinary infections, and hematologic conditions); 2) Pregnancy-related conditions (28.2%; most commonly normal deliveries, gestational diabetes, pre-eclampsia, and pre- and post-delivery infections); 3) Mental Health (19.7%; most commonly depression and substance use disorders); and 4) Trauma (9.1%; most commonly extremity fractures, abdominal/thorax/head injuries, and “other trauma”). (Table 2; data in parens not in table) Most primary trauma diagnoses were “unintentional” (77.5%), and the vast majority was mild-to-moderate in severity (86.5%; not in table). Of note, for non-detained youth, the number of discharges associated with co-occurring conditions across diagnostic categories (e.g. Mental Health and Trauma) was quite small.

Table 2.

Primary hospital discharge diagnoses and length of stay for detained and non-detained youth in California, stratified by mental health diagnostic categories, race/ethnicity, and insurance type, 1997-2011.

Primary Discharge Diagnoses (by race/ethnicity & payer type)	Detained N=11,367		Non-Detained N=1,925,146
	n (%)	Median LOS (IQR)*	n (%)	Median LOS (IQR)*	p-value LOS
Mental Health**	7,158 (63)	6 (3-14)	380,183 (20)	5 (3-8)	<0.001
Race/ethnicity**
Black	1,630 (23)	7 (3-14)	45,935 (12)	6 (3-9)	<0.001
Caucasian	2,805 (39)	6 (2-12)	195,836 (52)	5 (3-8)	0.001
Asian	204 (3)	6 (3-12.5)	13,757 (4)	5 (3-8)	<0.005
Hispanic	2,125 (30)	7 (3-15)	105,260 (28)	5 (3-8)	<0.001
Other	254 (4)	6 (3-17)	12,949 (3)	5 (3-8)	0.038
Insurance**
Public	5,225 (73)	7 (3-16)	176,454 (46)	5 (3-9)	<0.001
Private	1,632 (23)	5 (3-10)	190,364 (50)	5 (3-8)	0.0001
Other	298 (4)	4 (2-9)	12,895 (3)	4 (2-7)	0.458
MH Subcategories**
Depressive**	2621 (37)	6 (3-11)	199,846 (53)	5 (3-9)	<0.001
Anxiety/Stress**	1900 (27)	6 (2-18)	77,515 (20)	5 (3-8)	<0.001
Disruptive**	2616 (37)	7 (3-19)	86,409 (23)	6 (3-9)	<0.001
Psychotic**	1377 (19)	8 (4-15)	46,024 (12)	7 (4-12)	<0.001
Substance Abuse**	3015 (42)	6 (3-17)	12,949 (3)	5 (3-8)	0.038
Trauma**	1,314 (12)	2 (1-4)	175,359 (9)	2 (1-4)	<0.001
Race/ethnicity**
Black	292 (22)	2 (1-5)	15,764 (9)	2 (1-4)	0.008
Caucasian	232 (18)	2 (1-4)	74,305 (42)	2 (1-3)	0.110
Asian	35 (3)	2 (1-6)	8,191 (5)	2 (1-4)	0.201
Hispanic	577 (44)	2 (1-5)	58,983 (34)	2 (1-4)	0.339
Other	48 (4)	2 (1-4.5)	6,685 (4)	2 (1-4)	0.979
Insurance**
Public	905 (69)	2 (1-5)	64,986 (37)	2 (1-4)	0.009
Private	218 (17)	2 (1-3)	95,233 (54)	2 (1-3)	0.476
Other	189 (14)	2 (1-3)	15,072 (9)	2 (1-3)	0.702
Pregnancy**	363 (3)	2 (2-3)	542,585 (28)	2 (2-3)	0.027
Race/ethnicity**
Black	89 (25)	2 (2-3)	48,638 (9)	2 (1-3)	0.507
Caucasian	96 (26)	2 (1-3)	109,359 (20)	2 (1-3)	0.738
Asian	10 (3)	3 (2-3)	16,089 (3)	2 (1-2)	0.022
Hispanic	150 (41)	2 (2-3)	352,278 (65)	2 (2-3)	0.238
Other	13 (4)	3 (2-3)	12,329 (2)	2 (2-3)	0.223
Insurance**
Public	261 (72)	2 (2-3)	397,376 (73)	2 (2-3)	0.111
Private	51 (14)	2 (2-3)	123,898 (23)	2 (1-3)	0.469
Other	50 (14)	2 (2-3)	21,203 (4)	2 (1-3)	0.035
Other Acute/Chronic Medical**	2,532 (22)	2 (1-4)	827,020 (43)	2 (1-4)	0.766
Race/ethnicity**
Black	539 (21)	2 (1-5)	83,510 (10)	3 (1-5)	0.352
Caucasian	701 (28)	2 (1-4)	338,773 (41)	2 (1-4)	0.820
Asian	54 (2)	3 (1-4)	47,434 (6)	3 (1-5)	0.345
Hispanic	1240 (49)	2 (1-4)	328,520 (40)	2 (1-4)	0.875
Other	86 (3)	2 (0-4)	30,537 (4)	2 (1-5)	0.005
Insurance**
Public	1,765 (70)	2 (1-4)	358,452 (43)	3 (1-5)	0.002
Private	384 (15)	2 (1-4)	434,006 (52)	2 (1-4)	0.136
Other	381 (15)	2 (1-4)	34,309 (4)	2 (1-3)	0.083

^*IQR: interquartile range

^**Distributions across discharge diagnoses, race / ethnicity, insurance status and mental health subcategories were ALL significantly different for detained vs. non-detained hospitalized adolescents, with p-values of <0.001. (p-values for LOS are listed separately for each comparison in the table)

Table 2 demonstrates that for detained youth, the distribution of hospital discharge diagnoses was strikingly different: Mental Health was the most common diagnostic category (63.0%), followed by Other Acute and Chronic Medical conditions (22.3%), Trauma (11.6%), and Pregnancy-related conditions (3.2%). The vast majority of hospitalizations for detained youth in all categories were covered by public insurance, and racial/ethnic distributions for detained versus non-detained youth were also significantly different. Detained blacks and Hispanics were disproportionately hospitalized in every diagnostic category except pregnancy (non-detained Hispanics were more likely to have a pregnancy-related discharge diagnosis than detained Hispanics).

Mental Health diagnoses included a wide range of overlapping psychiatric illness, including substance use (42.1%), depressive (36.6%), and disruptive disorders (36.6%). Of interest (but not shown in table), the diagnostic distributions within the categories of Other Acute and Chronic Medical conditions and Pregnancy-related conditions were quite similar to those described for the general adolescent population. Trauma diagnoses for detained youth were overrepresented by intentional assault-related injuries (35.6% vs. 14.6% in non-detained youth; most commonly facial fractures, head traumas/concussions, and open chest wounds) and suicide attempts (5.0% vs. 0.8% in non-detained adolescents). Detained youth had fewer motor vehicle accidents leading to hospitalization (22.6% vs. 27.7%) and more injuries classified as “mild” (67% vs. 60%) than non-detained youth.

The proportion of hospitalizations for detained boys with a primary diagnosis in the Mental Health category was 57.8% vs. 74.1% for detained girls (not shown in table). However, hospitalizations for detained boys were more than 5 times as likely to be associated with a primary diagnosis in the Trauma category than were detained girls (15.6% vs. 2.8%). Finally, approximately 1 in 15 hospitalizations among all detained youth were associated with cooccurring diagnoses in the Mental Health and Trauma categories (e.g. concurrent principal mental health diagnosis with a secondary trauma diagnoses, or a principal trauma diagnosis with a secondary mental health diagnosis).

Median LOS for hospitalizations in Pregnancy, Trauma, and Other Acute and Chronic Medical categories was 2 days for both detained and non-detained youth, as Table 2 demonstrates. However, for hospitalizations of youth with a primary diagnosis in Mental Health category, median LOS was increased for those who were detained compared with non-detained (6 and 5 days respectively; p<0.001), and in particular for blacks (7 vs. 6 days , p <0.001), Hispanics (7 vs. 5 days, p <0.001), and those with public health insurance (7 vs 5 days, respectively; p<0.001). Discharge diagnoses of all subcategories of Mental Health were associated with increased LOS for detained youth versus non-detained youth.

Table 3 summarizes the analyses of the three clinically distinct hospitalization discharge patterns (based on the admission source and disposition of detained youth) and their differences in diagnoses. In the “Detention-Hospital-Detention” pattern (n= 3,024), 47% of hospitalizations for detained youth were associated with primary diagnoses within Mental Health category (vs. 20% in the general population; p<0.0001); of those, almost 40% were for substance use disorders (vs. 25% in the general population; p<0.0001; not shown in table). Next, in the “Community-Hospital-Detention” pattern (n= 4,924), 57% of hospitalizations for detained youth were associated with primary diagnoses within Mental Health category (vs. 20% in the general population; p<0.0001), with approximately 35% for substance use disorders (vs. 26% in general population; p<0.0001; not shown in table). Eighteen percent of this discharge pattern were associated with primary diagnoses within the Trauma category (vs. 9% in non-detained youth; p<0.0001). Finally, in the “Detention-Hospital-Treatment” pattern (n= 3,419), 85% of hospitalizations for detained youth were associated with primary diagnoses in the Mental Health category (vs. 20% in the non-detained population; p<0.0001), with about 44% for substance use disorders (vs. 26% in general population; p<0.0001; not shown in table).

Table 3.

LOS for mental health (by disposition facility type) and trauma among detained and non-detained youth in California by discharge pattern, 1997-2011.

	Detained									Not Detained
	(1) Detention→ Hospital→ Detention (“D2D”) (n=3,024, 26.6%)			(2) Community→Hospital→Detention (“C2D”) (n=4,924, 43.3%)			(3) Detention→ Hospital→ Treatment (“D2PS”) (n=3,419, 30%)			Hospitalized Adolescents (n=1,925,146)
	n	%	Median LOS (IQR)	n	%	Median LOS (IQR)	n	%	Median LOS (IQR)	n	%	Med LOS (IQR)
Mental Health	1,418	47***	7 (3-14)	2,830	57***	6 (3-11)	2,910	85***	6 (2-20)	380,182	20	5 (3-8)
“Chemical Dependency” Inpatient Facility	134		71 (26-145)	49		43 (14-94)	685		52 (12-205)	2910		28 (11-45)
Psychiatric Facility	656		7 (4-11)	1519		6 (3-10)	1737		4 (2-9)	271,390		5 (3-8)
Trauma	332	11***	2 (1-4)	862	18***	2 (1-5)	120	4***	2 (1-4)	175,359	9	2 (1-4)
Other**	1,274	42***	2 (1-4)	1,232	25***	2 (1-4)	389	11***	2 (1-4)	1,369,605	71	2 (1-4)

* “Chemical Dependency” Inpatient Facility represents the term the OSHPD dataset uses for inpatient substance abuse facilities

^**In this instance, “Other” includes pregnancy-related diagnoses, infectious processes, appendicitis, and other medical diagnoses.

^***p<0.0005 for comparison of each column value to the reference Not Detained Hospitalized Adolescents (last column)

Median LOS was increased for hospitalizations associated with diagnoses in Mental Health category (Detention-Hospital-Detention 7 days; Community-Hospital-Detention and Detention-Hospital-Treatment both 6 days; vs. 5 days for non-detained adolescents). For all youth with primary diagnoses in the Mental Health category, detained or non-detained, the discharge disposition to substance-abuse-related facilities (referred to as “Chemical Dependency” facilities in the OSHPD dataset) was associated with longest stays (median LOS of 71, 43, and 52 days for Detention-Hospital-Detention, Community-Hospital-Detention, and Detention-Hospital-Treatment, respectively). Non-detained youth transferred to similar facilities for substance abuse / “chemical dependency” treatment had a median LOS of 28 days.

Discussion

This study provides a first look at hospitalization patterns among a large population of adolescents detained within the juvenile justice system. Hospitalizations among these youth occur for reasons that are different than for adolescents in the general population in California. Mental health-related diagnoses account for a far larger proportion of hospital discharges among detained youth in California than among non-detained adolescents in the state. Further, compared to non-detained youth, detained youth who were hospitalized for mental health-related diagnoses had an increased LOS, especially among racial/ethnic minorities, those with public insurance, and those with co-occurring substance abuse disorders requiring specialized inpatient chemical dependency care. These findings underscore the frequency and severity of mental health conditions among detained youth, as well as the special role the juvenile justice system can play in assuring health-related services for youth with severe, comorbid psychiatric illness in California.

Mental Health

The finding that mental illness was the principal cause of hospitalization for detained youth supports the evidence that these youth have significant unmet mental health needs. The literature suggests youth in the justice system suffer disproportionately from mental illness and have poor access to needed care in the community setting. ^{4,8,20,21,22,23} While studies have documented that youth previously involved in juvenile court proceedings were more likely to be hospitalized for psychiatric illness later in life, none have systematically compared hospitalizations among detained youth with their non-detained counterparts.^11,12,24 Further highlighting the disproportionate impact of mental illness for detained youth, a recent national study examining pediatric inpatient care found that approximately 10% of all hospitalizations in the under 21 years age group were for mental health-related conditions, a frequency that is still almost 6 times lower than demonstrated among detained youth in this study.²⁵

Gender Differences

Although detained girls’ physical and mental health needs are significant and may have lifelong consequences, ^{6,26,27,28,29,30} few studies have examined the severity of their health needs or documented the services required to address them in large populations. The finding that almost three-quarters of hospital discharges for detained female youth were related to a primary mental health diagnosis underscores the critical need for mental health services for this group. Detained female youth were less likely to be hospitalized for pregnancy-related conditions than are non-detained female adolescents, a finding that stands in contrast to previous studies documenting their higher risk sexual behaviors, decreased use of contraception and condoms, and high rates of pregnancy.^5,31,32,33 However, clinical experience suggests that few pregnant girls remain in detention for the entirety of their pregnancy, and even fewer deliver while detained. The finding that hospitalizations for physical trauma are more common among detained male youth is consistent with the existing literature and is consistent with the observation that poor mental health may influence risk behaviors associated with trauma. ^7,34 Although emergency room and hospital-based interventions have shown promise for connecting high-risk youth to mental health services,³⁵ such efforts may be too late. Community-based efforts to address the interaction of mental illness, violence and trauma among youth must play a larger role in enhancing access to mental health services prior to entering the juvenile justice system.

Hospitalization Patterns for Detained Youth

The transfer patterns from hospitals to facilities specializing in treating mental illness and substance abuse highlights the role of gateway into the mental health care system that the juvenile justice system can sometimes play. Recognition of this role, and the responsibility it implies, strongly suggests the need for enhanced screening protocols and coordination with outpatient, social and educational services for detained youth.

Resource Utilization

Despite recent decreases in violent and property crimes among adolescents,³⁶ it is possible that societal norms and political priorities during the last several decades have favored a shift of resources from community mental health systems toward the justice system --an inverse relationship that Penrose first described in the 1930s.³⁷ Given that most detained youth are publicly insured,³⁸ and that a majority of hospitalized detained youth in this study had a public payer at time of hospitalization, the longer inpatient stays imply increased public expenditures. More broadly, policies that enhance the equitable provision of effective mental health and substance abuse services for high-risk youth in the community and in juvenile detention facilities could potentially reduce both health disparities and expenditures related to youth crime, juvenile detention, and hospitalizations.

Limitations

This study has several limitations. First, the reliance on a large administrative database such as the OSHPD discharge dataset does not provide detailed clinical information that would allow greater definition of the psychosocial, behavioral, and management attributes associated with hospitalizations among detained youth. However, this dataset has been used successfully in analyzing hospitalization patterns for a variety of population groups^14,16,39,40 and provides important insights into the special characteristics of hospitalizations among a large population of detained youth. Second, while many of our findings were associated with very large effects sizes, some were relatively small and may have reached statistical significance because of our large sample size. However, with LOS in particular, a seemingly small 1 day difference between Mental Health hospitalizations in detained vs non-detained youth may actually represent significant health system-wide utilization and expenditures, particularly among the publicly insured. Finally, as in prior studies using this dataset, the current study only examined hospitalizations, not individual patients. As a result, we can neither account for multiple admissions by individual patients nor calculate detained youths’ hospitalization rates for comparison to the general adolescent population. Instead, this study documents overall utilization patterns and the service demands this special group of California youth generates on both the juvenile justice and hospital systems in the state.

Conclusions

This total population study of hospitalized adolescents in California documents the serious health and mental health needs of youth involved in the juvenile justice system. These findings underscore the complex interaction between the health care and juvenile justice systems and outline potential opportunities to more effectively and compassionately address the profound needs of this special group of high-risk youth.