Health care and prevention efforts within the juvenile justice system should address the extant risks and conditions of incarcerated youth, focusing on treatment and guidance on healthier living on release. As adolescents are different from children and adults, emotionally, physically, and mentally, their health care services should reflect these differences. Services should be devel-opmentally appropriate and adolescent specific, paying particular attention to the many factors affecting health decisions and behaviors.
Juvenile justice facilities detain youth of varying ages. The needs of these youth differ by stage of development and mental ability. The early adolescent (usually ranging from 10 to 13 years old) is mostly very concrete in his/her thought process. Therefore, counseling and behavioral interventions must reflect this concrete thinking. For instance, a tobacco prevention/cessation program for a young person in this age group should focus on the physical unpleasantness associated with smoking, i.e., bad breath and yellowing teeth, instead of the later health complications that may resound with an older teenager. At this age, the majority of young people will begin the process of physical sexual maturation but this does not mean that the individual has not already initiated sexual activity.
In middle adolescence (ranging from age 14 to 16), the physical changes of puberty are complete and thought processes become more abstract. In this stage, the individual develops a stronger sense of identity and is more susceptible to the influences of peer groups. Counseling and interventions for these teens should incorporate the role of friends and peers in risk-taking behaviors.
Late adolescence encompasses 17 years old and above. In this stage, the body continues to take on adult form and the process of identity development continues. These young men and women, on the verge of becoming legal adults, are of particular concern for juvenile justice authorities and the public health community. Though they might look and often act like adults, these young men and women are still in need of counseling, care, and intervention.
The major causes of morbidity and mortality in these adolescents are unintentional injuries, many of which are related to alcohol and drug use. Other causes of morbidity include unintended pregnancy, sexually transmitted diseases, eating disorders, and depression (Eaton et al., 2006). These factors are not easily discernable from the traditional patient provider model of health interviewing. An alternative model, the HEADSS Model, was developed in 1972 by Dr. Harvey Berman of Seattle and refined by Dr. Eric Cohen and Dr. John M. Goldenring. An acronym for Home, Education/Employment, Activities, Drugs, Depression, Safety, and Sexuality, this model can be particularly useful in the juvenile justice system as health care practitioners explore the complex forces affecting an adolescent's behavior and health outcomes (Goldenring & Cohen, 1988).
In addition to being adolescent specific, services provided to juvenile justice detainees should be culturally and linguistically competent. This includes sensitivity to the ways that culture and health interact. An individual's culture can have profound impact on how pain and illness manifest and when and how individuals seek care. Youth from cultures with stoic attitudes toward illness, may not present for treatment. Also, the acknowledgment and treatment of mental illness may not be acceptable in some cultures which could prevent those youth from seeking treatment for symptoms. As the juvenile justice system is so diverse, professionals need to be trained to assess the effect of culture (including aculturization and cultural isolation) on a detainee's health and risk behavior. Youth may be the first generation in their family to be born in the United States, or may have immigrated recently. These youth may be trapped between the health perceptions of two cultures during the already difficult period of adolescence. Additionally, care must be taken when communicating with youth who do not speak English proficiently. Efforts to address this can include the use of translators and hiring health professionals who are fluent in different languages.
Medical professionals in the juvenile justice system should be aware that insensitive attitudes on the part of practitioners, lack of knowledge and skills regarding reproductive and sexual health, insufficient or inadequate communication, and clinician discomfort with different cultures or the discussion of risk behaviors with adolescents can prevent a young person from disclosing vital health information (Huppert & Adams Hillard, 2003). The final important factor in providing adolescent-friendly health services involves discussing and assuring confidentiality wherever possible. Concerns regarding confidentiality keep many young people from disclosing crucial health information and from seeking care. For instance, a recent study of girls younger than 18 attending family planning clinics found that 47% would no longer attend if their parents had to be notified that they were seeking prescription birth control pills or devices, and another 10% would delay or discontinue STI testing or treatment (Reddy, Fleming, & Swain, 2002).
In the juvenile justice system, parents and/or guardians are not present but concerns about confidentiality still exist and detainees should be assured that their disclosures will be kept confidential. There are times when the provider may need to contact a parent and times when the law allows such contact, but the bias should be toward confidentiality. If a patient appears to be a danger to him/ herself or to another person, state laws mandate that a provider inform parents or authorities. Laws governing minors' access and confidentiality to services differ state by state, and many health care providers are unaware of minors' ability to consent to certain confidential health services. Title X dictates that family planning services must be confidential. In many states, confidentiality is decided by the provider but because Title X is federal, it preempts state statutes. Medicaid provides for confidential services to minors, along with Title X.
Federal Medical Privacy Regulations also apply. There is variation across the country among juvenile correctional facilities regarding federal HIPAA compliance. There is a general HIPAA exclusion for correctional facilities; however, if any part of a juvenile justice system is billing electronically for medical services such as Medicaid, they should be HIPAA compliant. It is also advisable that public health and juvenile justice both be HIPAA compliant, so that medical information can pass freely between agencies for improved continuity of care, allowing for appropriate consents from youth and parents/ guardians to be utilized. Memoranda of Understanding (MOUs) between agencies can address any HIPAA concerns regarding sharing of confidential medical information.
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