YOUTH INCARCERATION, HEALTH, AND LENGTH OF STAY.

• Author: Gonzalez, Thalia

TABLE OF CONTENTS Introduction 46 I. The Health Status of At-Risk and System-Involved Youth 55 A. Prior to Incarceration 55 1. Adverse Childhood Experiences 55 2. Health and Mental Health 59 3. Trauma and Post-Traumatic Stress Disorder 60 4. Poverty 62 B. The Effects of Incarceration: Compounding Existing Trauma and Health Disparities 62 1. Inadequate Treatment During Incarceration 62 2. The Compounding Effects of Incarceration 64 3. The "Dose Measure" of Youth Incarceration 66 II. Sentencing, Release Decision-Making, and Length of Stay 67 A. Typologies of Juvenile Justice Sentencing 68 B. Sentencing Reform 70 C. Release Determinations and Length of Stay 72 D. The Current Trend: Excessive Lengths of Stay 75 Conclusion 80 INTRODUCTION

Length of stay is a pressing civil and human rights issue at the intersection of juvenile justice and health policy. As research shows, the effects of incarceration during adolescence or young adulthood ("youth incarceration") are associated with damaged social networks, (1) decreased educational opportunities, (2) severe functional limitations, (3) and worsened health and mental health outcomes. (4) Over the last decade, juvenile justice reform has focused on reducing entry into the system with the goal of decreasing the overall population of youth in confinement. (5) In some states, policy makers have adopted a top down approach, introducing changes such as increased access to and eligibility for restorative justice, (6) reduced bed caps, (7) fiscal incentives for community based services, (8) and improved inter-agency collaboration by forming commissions or task forces. (9) In other states, less restrictive responses to delinquency (10) and the closure of juvenile facilities have reduced the overall population. (11) Regardless of the individualized approach taken in a given jurisdiction, from 2003 to 2013, national rates of juvenile detention decreased by forty-seven percent. (12)

Despite a growing emphasis on alternatives to detention and the reductions in rates of national youth detention achieved to date, the United States continues to incarcerate youth, in particular marginalized youth of color, (13) at higher rates than anywhere in the world. (14) For example, the most recent Office of Juvenile Justice and Delinquency Prevention ("OJJDP") data indicate that nationally, African American youth are more than four times as likely to be confined as their white peers. (15) Similar disparities exist for Latino (16) and American Indian youth. (17) Simply put, numerous studies show that youth of color are arrested and charged at higher rates than their white counterparts, (18) thus moving them swiftly into the juvenile justice system. (19) Once system-involved, youth of color are detained for longer periods of time (20) than their white peers. (21) While youth of color experience the clearest disproportionate treatment at the arrest and detention stages, this race-based disproportionality endures throughout all stages of incarceration. (22)

Entry into the juvenile justice system for these youth, the majority of whom live in urban communities, does not happen in isolation. Instead, the pathway to incarceration occurs against a backdrop of heightened surveillance, punishment, and criminalization. (23) Further, as discussed below, (24) marginalized youth and youth of color also tend to experience high levels of stress, (25) complex trauma, (26) and adverse childhood experiences. (27) Moreover, for youth exposed to high rates of community violence, (28) such exposure may amplify the cumulative negative influences of early-life adversities on their physical and mental health in adulthood. (29) As a result, disproportionately negative outcomes and heightened risks of incarceration for youth of color (30) exacerbate already existing health disparities. (31)

Despite a large body of empirical research documenting the health status of system-involved youth, there is little discussion in the reform movement of the critical relationship between incarceration, length of stay (during adolescence), and subsequent negative health and mental health outcomes experienced in adulthood. Yet this association is of particular significance given the discordance between studies evaluating best practices for length of stay, length of stay guidelines and criteria in individual jurisdictions, and the actual time youth remain in confinement. Such discrepancies not only negatively affect youth as individuals, but also raise serious questions as to how extended lengths of stay--as a systemic structure--can be a meaningful measure or metric of rehabilitation.

For jurisdictions committed to finding better ways to address youth delinquency, the lack of attention given to the relationship between length of stay and future health and mental health outcomes is a missed opportunity. First, understanding this connection is essential for achieving key objectives of the juvenile justice system--i.e., rehabilitation, decreased recidivism, and improved community reintegration. Second, it also provides an avenue to integrate and restructure surrounding systems to promote improvements that extend beyond detention. Advocacy and research has shown that longer lengths of stay are not associated with reducing recidivism, (32) and are ultimately more expensive and less cost-effective than community supervision. (33) In light of these equally important considerations, length-of-stay reform should be understood as a bipartisan (34) issue that can maximize state resources to "prioritize the use of costly facilities and intensive programming for serious offenders who present a higher risk of reoffending, while supporting effective community-based programs for others." (35)

By explicating the nexus between physical health, mental health, and length of stay, this Article seeks to transcend the dominant lines of argument for reform--recidivism and cost of confinement--and simultaneously invite all stakeholders in the juvenile justice system to consider the presumptions, approaches, and goals of contemporary sentencing systems to address unnecessarily lengthy confinement. This Article proceeds as follows: Part I presents empirical research on the health status of system-at-risk and system-involved youth. An examination of this research is essential to connect the negative outcomes of extended lengths of stay within a broader discussion of the life trajectories of marginalized youth. Part II introduces the typologies of juvenile sentencing and outlines the different categories of release decision-making. It situates both sentencing and release decisions in light of research on length of stay and provides specific examples of state practices and policies, which can lead to excessive and counterproductive confinement. (36) Although Part II discusses indeterminate sentencing at greater length, it does not aim to detract from the pressing need to revise both indeterminate and determinate statutory schemes to address the associated harms of excessive lengths of stay. The Article concludes that successful reform of the juvenile justice system in general, and length of stay in particular, requires advancing policy changes to address the health and mental health outcomes associated with extended lengths of stay. By squarely placing length of stay and the need for reform in the context of trauma, adverse childhood experiences, and health disparities, this Article widens the reform movement's discourse and encourages state-level innovation aimed at minimizing the negative cumulative effects of incarceration.

1. THE HEALTH STATUS OF AT-RISK AND SYSTEM-INVOLVED YOUTH

   Two main arguments currently frame efforts to reform length of stay--recidivism and cost of incarceration. While each of these arguments present compelling reasons for jurisdictions to consider structural reform, this Article aims to interject into the discourse a new, complementary lens, grounded in empirical research on health and mental health. With this in mind, the following sections present a snapshot of current research on the health status of system-at-risk and system-involved youth. Rather than simply asking whether incarcerating youth affects their adult health outcomes as an isolated question. Part I examines research linkages between adverse childhood experiences, trauma, health, and delinquency through a life experience trajectory.

   1. Prior to Incarceration

   1. Adverse Childhood Experiences

      For youth at risk of entering the juvenile justice system and those that are already involved in the system, the use of incarceration, and lengthy stays in particular, poses unique immediate and long-term health and mental health risks. This is especially true when considering the prevalence of adverse childhood experiences in the lives of youth from marginalized communities (37) and the distinct relationship between those experiences and delinquency. As a large body of literature has revealed, the presence of adverse childhood experiences in a youth's life places the youth at greater risk for entering the juvenile justice system, (38) compounds complex trauma, (39) and increases health disparities. (40) Each adverse childhood experience--or traumatic event--negatively affects a young person's trajectory for positive health, behavior, and/or psychological development. (41) For those youth who are exposed to multiple adverse experiences, studies have shown an exponentially more harmful or "dose" effect. (42) This is particularly true for youth who have experienced four or more of certain categories of adverse childhood experiences (namely, childhood abuse or household dysfunction) (43): their odds of experiencing long-term negative health outcomes can be up to twelve times greater than youth who have not had the same exposure. (44) While the original adverse childhood experience study (45) provided an essential baseline to assess exposure to a range of trauma and...