PROVIDING HEALTH CARE FOR YOUTH IN

CORRECTIONAL SETTINGS

MICHELLE STAPLES-HORNE MD, MS, MPH

MEDICAL DIRECTOR, GA DEPT. OF JUVENILE JUSTICE

OBJECTIVES

• Review developmental stages of adolescents and young adults

• Identify specific health needs of youthful offenders such as access to

emergency contraception and confidential services

• Discuss effective screening and treatment guidelines that can be utilized

in this specialized population.

• Understand the medical and legal challenges and opportunities for

increasing use of health care services for youth in correctional settings

GA DJJ HISTORICAL PROSPECTIVE

F I R S T T R A I N I N G S C H O O L E S TA B L I S H E D I N 1 9 0 5

I N M I L L E D G E V I L L E

D E P A R T M E N T S E P A R AT E S F R O M D H R 1 9 9 2

M E D I C A L D I R E C T O R H I R E D W I T H C Y C C G R A N T

T H R O U G H A A P A D V O C A C Y I N 1 9 9 4

F O U R R N ’ S AT 4 Y D C S O F 24 D J J S E C U R E

F A C I L I T I E S

GA. JUVENILE JUSTICE SYSTEM

Courts Vary from Jurisdiction to

Jurisdiction

Free Standing State Agency

Committed and Non Committed

Youth

Private Vendors and State

Operated Facilities

NON SECURE PLACEMENTS

Foster Care

Group Homes

Mental Health Treatment

Facilities

Substance Abuse Treatment

Probation Services

Diversion Programs

SECURE SETTINGS TO PROVIDE

PUBLIC SAFETY

Secure Facilities

Regional Detention Centers

(RYDCs)

Youth Development Campuses

(YDCs)

DJJ SECURE FACILITY POPULATION

Predominately African American

Majority Male

Over representation of minorities

Average age 15

Most there for serious crimes since

juvenile justice reform

THE GROWING DIVERSITY OF THE

ADOLESCENT POPULATION

Most minority populations and adolescents are growing faster than white populations.

By 2050, the projected percentage of non-Hispanic whites in the adolescent population will drop below 50%.

The non-Hispanic-Black share will rise from 11.8% to 15%; for Asians from 3% to 10%; for Hispanics from 9% to 21.1%; while indigenous groups hold still at about 1%.

Asian/Pacific Islanders, though small in number, are growing at the fastest rate.

The American Indian/Alaska Native population is projected to remain largely unchanged.

INCREASING NUMBERS OF JJ FEMALES

Graduating to more serious

crimes like their male

counterparts

Require gender specific

programming

Greater utilization of medical

and mental health services

ADOLESCENTS ARE DIFFERENT

Special Considerations for Providing Medical Programs

Varying Developmental Stages

Modification of Treatment Protocols and Medications

Privacy and Confidentiality more of a concern to youth

ADOLESCENTS

For the most part, adolescents are:

Healthy

Resilient

Independent yet vulnerable

Adolescents are not:

Big children

Little adults

Peer dependent

Egocentric

Distinct language and dress

Popular culture influence

Ongoing search for identity

THE CULTURE OF ADOLESCENCE

ADOLESCENCE IN CONTEXT

Changes during adolescence are shaped by

Race/Ethnicity

Religion

Socioeconomic Status

Family

Peers

Growth spurt

Begin sexual maturation

Increased interest in sexual anatomy

Anxieties and questions about size of genitals begins

Self-exploration and evaluation

EARLY STAGES OF ADOLESCENCE: 11-14

Stronger sense of identity

Relates more strongly to peer group

More reflective thought

Transitioning between dependence and independence

MIDDLE STAGES OF ADOLESCENCE: 15-17

The body fills out and takes its adult form

Distinct identity; ideas and opinions become more settled

Focus on intimacy and formation of stable relationships

Plans for future and commitments

LATE STAGES OF ADOLESCENCE: 18+

Factors Effecting Adolescent

Development History of trauma

(TBI, PTSD)

Physical, sexual and emotional abuse

Substance abuse

Exposure to criminal behaviors

Parental instability

Environmental factors

Developmental

disabilities

ADOLESCENT RISK BEHAVIORS

At risk for adverse health outcomes due to their behaviors:

•Substance Abuse

•Violence

•Sex: Pregnancy and Sexually Transmitted Infections including

HIV

•Poor Dietary and Dental Habits

•Lack of Physical Activity

MOST COMMON HEALTH PROBLEMS

Relatively few chronic diseases

Often new diagnosis identified

High risk behaviors for sexually transmitted infections

Mental health disorders

Substance use and abuse

Injuries: self inflicted or due to youthful or aggressive behavior

Lack of Dental Care

WHY FOCUS ON ADOLESCENT HEALTH?

Reduce death including suicide and preventable disease in a very

high risk population

Fulfill the rights of adolescents to health care, including reproductive

health care in an adult setting

Increase the chances for healthy adulthood since most youth will be

released back into the community at some point in time

ADOLESCENT-FRIENDLY HEALTH SERVICES

Establish a comfortable, confidential, safe space by staff and providers.

Communicate respectfully and appropriately.

Screen for high-risk behavior.

Ability, age, culture, gender identity, sexual orientation, religion, or socioeconomic status must not limit access to health care.

LEGAL REQUIREMENTS OF YOUTH IN CUSTODY

AGE

Age of adulthood determination

Age to consent for services and

treatment

Housing requirements for sight and

sound separation

LAW

Sentencing requirements

Parental custody/involvement

School requirements

Special Education

Special Health Needs

HEALTH CARE: A CONSTITUTIONAL REQUIREMENT

Youth housed in correctional settings require

specialized treatment services appropriate for

their age and developmental stage. The health

services provided must meet the community

standard of care.

HEALTH CARE AS A LEGAL RIGHT

Estelle v Gamble 1976 established the constitutional right of prisoners

to adequate health care in the United States

The Supreme Court held that “deliberate indifference” to the serious

medical needs of a prisoner violated the 8th Amendment’s

prohibition against cruel and unusual punishment.

MEDICAL CARE IN

CORRECTIONAL FACILITIES

Adequate health intake screening and assessment

Unimpeded access to care

Payment for medical services

PREA compliance

ACA and NCCHC Standards

MEDICAL CARE IN CORRECTIONS

Screenings

Infection Control

Dental Care

Medications

Diet and exercise

Confidentiality

Substance Abuse

Behavioral health

A M E R I C A N AC A D E M Y O F P E D I AT R I C S ( A A P )

B R I G H T F U T U R E S

G U I D E L I N E S FO R A D O L E S C E N T S

AG E S 11 - 21

B R I G H T F U T U R E S . A A P. O R G / C L I N I C A L _ P R AC T I C

E . H T M L

Bright Futures Guidelines Priorities and

Screening Tables

AAP BRIGHT FUTURES RECOMMENDATIONS

Physical Growth and Development

Social and Academic Competence

Emotional Well Being

Risk Reduction (ATOD, STI, Pregnancy)

Injury and Violence Prevention

31

Official BF3 Table ImagesUse for Presentations

15 TO 17 YEAR VISIT

HEALTH SCREENING AND APPRAISAL

Intake Medical, Dental and

Mental Health Screenings

Nurse Health Appraisal (ROS)

TB, UA, Hgb, PT, GC, CT, HIV

Vision and Hearing Screening

SCREENINGS

Dental

Growth Charts/BMI

Blood Pressure

Vision and Hearing

Scoliosis

Tanner Staging for sexual

maturity; specific STIs

No PAP required until 21

History of abuse with required

child protective services

notification

HIV AND STI PREVENTION

Chlamydia is the most common STI in

adolescent populations

Often Asymptomatic

Increased Sterility

Screening provided for CT, GC ,

Hepatitis C and HIV

PREGNANCY

Study of 261 juvenile detention centers by Breuner and Farrow

1-5 pregnant adolescents held in 2/3 of the facilities on any

given day

2000 pregnant girls served in one year

60% reported pregnancy complications

31% no prenatal care

70% no parent education

MEDICAL TREATMENT SERVICES

Physical Exam within

3-7 days of admission and annually

Chronic Care Clinics

Daily access to Sick Call using Protocols

Pharmacy, Laboratory and Radiology Services

COMMUNITY HEALTH RESOURCES

Availability of specialty care

Access to local hospitals and emergency rooms for medical and psychiatric needs

Existing public or government providers such as public health departments and community health centers

University Public Health, Medical and Nursing School Programs

INFECTION CONTROL PROGRAMFacility Environmental Sanitation measures

PPD Screening for Tuberculosis for youth and staff

Screening for respiratory and skin infections

Influenza Control

MRSA Control

Lice and Scabies Control

Food Service Inspections by County and DJJ

Serv Safe Certified for Food Safety

Immunizations

POD for Biohazardous Agent Release

IMMUNIZATIONS

Diphtheria/Tetanus

/acellular pertussis

(dTap)

Varicella (Chicken Pox)

Measles Mumps and

Rubella (MMR)

Hepatitis A

Hepatitis B

HPV

DENTAL SERVICES

Community Standard of

Dental Care for Children

Dental Education

Prophylaxis (Cleaning)

Restorative Dentistry

BEHAVIORAL HEALTH

Suicide Prevention

Scheduling and Sleep

Positive behavior incentive

programs

Access to Counseling

Substance Abuse Treatment

LABORATORY SERVICES

Sexually Transmitted Infections

Hemoglobin

Cholesterol

Blood Glucose

Allergy Testing

MEDICATIONS

Specialized Formulary

Medication Contraindications

Dosage adjustments

Access to newer Psychiatric drugs and stimulants

Inventory Control Measures

KOP , DOT and Commissary considerations

DIETARY NEEDS

Provide dietary guidance

through a Registered Dietician

Federal School Lunch

Guidelines:

More fresh fruits and vegetables

Low fat milk

Reduced fat and sodium

Food Allergies Identification

Special Diets provided

DIETARY NEEDS

Resources:

American Heart Association

www.ahajournals.org

US Department of Agriculture

Choose My Plate

www.choosemyplate.gov/foodgr

oups

EXERCISE PROGRAM

One hour of daily large muscle

activity required

Physical and health education

included in school curriculum

EXERCISE AND PHYSICAL ACTIVITY

Exercise care in selection of types of physical activities for youth

Youth are very creative with any object or activity

Some with little exercise tolerance leading to injuries

Horseplay is prevalent

May require extra monitoring

Exercise a requirement and essential for fighting obesity

EDUCATION

Check State and Local School

Requirements

School enrollment and accreditation

Certified teachers

Diploma versus GED and Vocational Education

Special education (IEP)

Health Education

HEALTH EDUCATION

Why are health care

and health

education services

important for

Juvenile Justice

involved youth?

IMPORTANCE OF HEALTH EDUCATION

Increase Basic Health Knowledge

Modify Risk Behaviors

Reduce Risk of Preventable Disease

Improve Long Range Health Outcomes of

Chronic Diseases

PUBLIC HEALTH COLLABORATIONS

VFC Program

Lab Support

Grant Funding

Health Education

STI Reporting and Contact

Tracing

COMMUNITY COLLABORATIONS

Nursing Schools

Schools of Public Health

Medical Schools

Private Providers

Federal Partners (CDC, HRSA,

OJJDP, NIC, etc)

HEALTH RECORD REQUIREMENTS

Health Records Documentation

HIPPA compliance

Guidelines for release and

transfer of medical

information

Establishment of an Electronic

Health Record

PROGRAM EVALUATION

Are we there yet?

QUALITY IMPROVEMENT

Establish a system of

Continuous Quality

Improvement

Program Dependent and

Independent Internal Auditing

Resources

External Credentialing

QUALITY IMPROVEMENT

Improved Clinical Outcomes

Stabilization of chronic disease states

Injury reductions

Decreased mortality and morbidity

Improved efficiency in staffing and medical management

Clinic flow analysis improvements

Reduced medical expenditures with better outcomes

MEDICAL/LEGAL ISSUES

Minors right to confidential

health services relating to

STIs and pregnancy without

parental consent

Use of mechanical restraints

including during pregnancy

Access to health records

Use of chemical restraints and

forced medication

Restrictive housing

PARENTAL DISCLOSURE

A provider is not required to disclose medical

records or other information regarding health

care services related to family planning,

pregnancy and childbirth to parents without the

patient’s consent.

MINORS’ LEGAL ACCESS TO PRENATAL CARE

AND CHILDBIRTH IN GEORGIA

A minor may consent to all health care services related to pregnancy, including pregnancy tests, options counseling and labor and delivery services, without notifying the parent (unless she chooses to do so).

A minor parent may consent to all medical care for the child.

BARRIERS TO HEALTH CARE

Perceived lack of confidentiality and restrictions (parental

consent/notification)

Poor communication by providers

Insensitive attitudes of care providers

Lack of provider knowledge and skills

Lack of a medical home in the community

Discontinuation of Medicaid/Insurance coverage reducing continuity

of care upon release

Transportation

Adolescent-specificMulti- and

interdisciplinaryAccessible Financially affordableAdolescent-focused

materials on displayPeer educator component

Adequate and separate space

Confidential Flexible schedulingComprehensive servicesContinuity of careHelp transitioning into

the adult medical care system

ADOLESCENT-FRIENDLY SERVICES

DISCUSSION

QUESTIONS?

michellestaples-

horne@djj.state.ga.us