Pediatric Health and System Impacts of Mass Incarceration, 2009-2020: A Matched Cohort Study.

OBJECTIVE: The US has the highest incarceration rate in the world; incarceration's direct and indirect toll on the health and health care use of youth is rarely investigated. We sought to compare the health of youth with known personal or family justice involvement and a matched cohort of youth without known personal/family justice involvement. METHODS: A cross-sectional matched parallel cohort study was conducted. We queried electronic health records on youth (<21 years) with a visit in a large Midwestern pediatric hospital-based institution from January 2009 to December 2020. Youth were located by searching for justice-related (eg, prison, jail) keywords within all clinician notes. Health diagnostic profiles were measured using ICD 9/10 codes. Health care use included total admissions, inpatient days, emergent and urgent visits, and outpatient visits. RESULTS: Across all youth at one institution over an 11-year period, 2.2% (N = 38,263) were identified as having probable personal or family justice-involvement. Youth with personal or familial justice involvement had 1.5-16.2 times the prevalence of mental health and physical health diagnoses across all domain groupings compared to a matched sample and the total population sample. From 2009-2020, approximately two-thirds of behavioral health care and nearly a quarter of all hospital inpatient days were attributed to the 2.2% of youth with probable personal or familial justice system involvement. CONCLUSION: The study illuminates the vast disparities between youth with indirect or direct contact with the criminal legal system and matched youth with no documented contact. Better investment in monitoring and prevention efforts are needed.

Adult Children of the Prison Boom: Family Troubles and the Intergenerational Transmission of Criminal Justice Contact.

Intergenerational transmission processes have long been of interest to demographers, but prior research on the intergenerational transmission of criminal justice contact is relatively sparse and limited by its lack of attention to the correlated "family troubles" and familial incarceration that predate criminal justice contact. In this article, we provide a test of the intergenerational transmission of criminal justice contact after adjusting extensively for these factors that predate such contact by linking longitudinal data from the Project on Human Development in Chicago Neighborhoods with official arrest histories from 1995 to 2020. The results provide support for three conclusions. First, parental criminal justice contact is associated with a shorter time to first arrest and a larger number of arrests even after rigorously accounting for selection. Second, robustness checks demonstrate that neither the magnitude nor the significance of the findings is sensitive to model choices. Third, associations are strongest among White individuals and inconsistently significant for African American and Hispanic individuals. Despite large recent crime declines, the results indicate that parental criminal justice contact elevates the criminal justice contact of the adult children of the prison boom, independent of the often-overlooked troubles that predate criminal justice contact, and that these associations are strongest among the White population.

State-Level Variation in the Cumulative Prevalence of Child Welfare System Contact, 2015-2019.

Background: Prior estimates of the cumulative risks of child welfare system contact illustrate the prominence of this system in the lives of children in the United States (U.S.). However, these estimates report national data on a system administered at the state and local levels and are unable to detail potential simultaneous geographic and racial/ethnic variation in the prevalence of these events. Methods: Using 2015-2019 data from the National Child Abuse and Neglect Data System and Adoption and Foster Care Analysis and Reporting System, we use synthetic cohort life tables to estimate cumulative state- and race/ethnicity-specific risks by age 18 of experiencing: (1) a child protective services investigation, (2) confirmed maltreatment, (3) foster care placement, and (4) termination of parental rights for children in the U.S. Results: In the U.S., state-level investigation risks ranged from 14% to 63%, confirmed maltreatment risks from 3% to 27%, foster care placement risks from 2% to 18%, and risks of parental rights termination from 0% to 8%. Racial/ethnic disparities in these risks varied greatly across states, with larger disparities at higher levels of involvement. Whereas Black children had higher risks of all events than white children in nearly all states, Asian children had consistently lower risks. Finally, ratios comparing risks of child welfare events show these prevalences did not move in parallel, across states or racial/ethnic groups. Contribution: This study provides new estimates of spatial and racial/ethnic variation in children's lifetime risks of maltreatment investigation, confirmed maltreatment, foster care placement, and termination of parental rights in the U.S., as well as relative risks of these events.

The Cumulative Prevalence of Congregate Care Placement for U.S. Children by Race/Ethnicity, 2019.

Congregate care placement is among the most consequential forms of foster care placement that youth can experience, as it means a removal from both the family of origin and a family setting more broadly. Unfortunately, little research has estimated how common this intervention is. In this article, we use data from the Adoption and Foster Care Analysis Reporting System (AFCARS) and synthetic cohort life tables to show what proportion of children ever placed in foster care will ever be placed in congregate care, what proportion of children in the entire population will ever be placed in congregate care, and how these proportions vary by state of residence and race/ethnicity. Our results support four main conclusions. First, roughly 15% of all children ever placed in foster care will experience congregate care placement. Second, among children who will ever be placed in foster care, the risk of congregate care placement peaks at age 16. Third, congregate care placement is highly stratified by race/ethnicity. Finally, there are vast geographic differences in both congregate care placement and ethno-racial disparities therein. Taken together, these findings enhance our understanding of the demography of the child welfare system with implications for research, policy, and practice.

Lifetime risk of imprisonment in the United States remains high and starkly unequal.

How likely are U.S. males and females of different ethnoracial groups to be imprisoned over the course of their lives, and how have these risks changed in recent decades? Using survey and administrative data, we update 20th-century estimates of the cumulative risk of imprisonment for the 21st century. In 2016, non-Hispanic Black males' lifetime risk of imprisonment remained very high-more than 16%-but decreased substantially relative to extreme levels of risk in the 1990s and early 2000s. The lifetime risk of imprisonment among people identifying as American Indian or Alaska Native was nearly 50% for males and more than 14% for females. Although national prison admission rates are declining, imprisonment remains a pervasive and highly unequal life-course experience.

Are the Average Effects of Foster Care Placement Really Close to Zero?

In their provocative article, Barth and colleagues interrogate existing research on a series of claims about the child welfare system. In this reply, we focus on just one of their conclusions: that foster care placement does little, on average, to cause the poor outcomes of children who are ever placed in care. Our argument proceeds in three stages. In the first, we dispute the claim that the average effects of foster care placement on children are "settled" in any scientific sense. In the second, we note that the lack of agreement about what constitutes the appropriate counterfactual makes the idea of average effects of foster care placement in this area problematic. In the third, we problematize the idea that near-zero average effects equate to unimportant effects by showing how different types of effect heterogeneity may lead us to think differently about how the system is working.

Assessing mass incarceration's effects on families.

In this Review, we assess how mass incarceration, a monumental American policy experiment, has affected families over the past five decades. We reach four conclusions. First, family member incarceration is now common for American families. Second, individuals who will eventually have a family member incarcerated are worse off than those who never will, even before the incarceration takes place. Third, family member incarceration has negative effects on families above and beyond these preexisting disadvantages. And finally, policy interventions that address the precursors to family member incarceration and seek to minimize family member incarceration would best enhance family well-being. If the goal is to help all American families thrive, then the importance of simultaneous changes in social and criminal justice policy cannot be overstated.

Contact with Child Protective Services is pervasive but unequally distributed by race and ethnicity in large US counties.

This article provides county-level estimates of the cumulative prevalence of four levels of Child Protective Services (CPS) contact using administrative data from the 20 most populous counties in the United States. Rates of CPS investigation are extremely high in almost every county. Racial and ethnic inequality in case outcomes is large in some counties. The total median investigation rate was 41.3%; the risk for Black, Hispanic, and White children exceeded 20% in all counties. Risks of having a CPS investigation were highest for Black children (43.2 to 72.0%). Black children also experienced high rates of later-stage CPS contact, with rates often above 20% for confirmed maltreatment, 10% for foster care placement, and 2% for termination of parental rights (TPR). The only other children who experienced such extreme rates of later-stage CPS interventions were American Indian/Alaska Native children in Middlesex, MA; Hispanic children in Bexar, TX; and all children except Asian/Pacific Islander children in Maricopa, AZ. The latter has uniquely high rates of late-stage CPS interventions. In some jurisdictions, such as New York, NY, (0.2%) and Cook, IL (0.2%), very few children experienced TPR. These results show that early CPS interventions are ubiquitous in large counties but with marked variation in how CPS systems respond to these investigations.

Exposure to Family Member Incarceration and Adult Well-being in the United States.

Importance: More than half of the adult population in the United States has ever had a family member incarcerated, an experience more common among Black individuals. The impacts of family incarceration on well-being are not fully understood. Objective: To assess the associations of incarceration of a family member with perceived well-being and differences in projected life expectancy. Design, Setting, and Participants: This nationally representative cross-sectional study used data from the 2018 Family History of Incarceration Survey to examine how experiences of family member incarceration were associated with a holistic measure of well-being, including physical, mental, social, financial, and spiritual domains. Well-being was used to estimate change in life expectancy and was compared across varying levels of exposure to immediate and extended family member incarceration using logistic regression models to adjust for individual and household characteristics. Data were analyzed from October 2019 to April 2020. Exposures: Respondents' history of family member incarceration, including immediate and extended family members. Main Outcomes and Measures: The main outcome was self-reported life-evaluation, a measure of overall well-being from the 100 Million Healthier Lives Adult Well-being Assessment. Respondents were considered thriving with a current life satisfaction score of 7 or greater and a future life optimism score of 8 or greater, each on a scale of 0 to 10. Other outcomes included physical health, mental health, social support, financial well-being, and spiritual well-being, each measured with separate scales. Additionally, life expectancy projections were estimated using population-level correlations with the Life Evaluation Index. All percentages were weighted to more closely represent the US population. Results: Of 2815 individuals included in analysis, 1472 (51.7%) were women, 1765 (62.8%) were non-Hispanic White, and 868 (31.5%) were aged 35 to 54 years. A total of 1806 respondents (45.0%) reported having an immediate family member who was incarcerated. Compared with respondents with no family incarceration, any family member incarceration was associated with lower well-being overall (thriving: 69.5% [95% CI, 65.0%-75.0%] vs 56.9% [95% CI, 53.9%-59.9%]) and in every individual domain (eg, physical thriving: 51.1% [95% CI, 46.2-56.0] vs 35.5% [95% CI, 32.6%-38.3%]) and with a mean (SE) estimated 2.6 (0.03) years shorter life expectancy. Among those with any family incarceration, Black respondents had a mean (SE) estimated 0.46 (0.04) fewer years of life expectancy compared with White respondents. Conclusions and Relevance: These findings suggest that family member health and well-being may be an important avenue through which incarceration is associated with racial disparities in health and mortality. Decarceration efforts may improve population-level well-being and life expectancy by minimizing detrimental outcomes associated with incarceration among nonincarcerated family members.

Cumulative Rates of Child Protection Involvement and Terminations of Parental Rights in a California Birth Cohort, 1999-2017.

Objectives. To document the cumulative childhood risk of different levels of involvement with the child protection system (CPS), including terminations of parental rights (TPRs).Methods. We linked vital records for California's 1999 birth cohort (n = 519 248) to CPS records from 1999 to 2017. We used sociodemographic information captured at birth to estimate differences in the cumulative percentage of children investigated, substantiated, placed in foster care, and with a TPR.Results. Overall, 26.3% of children were investigated for maltreatment, 10.5% were substantiated, 4.3% were placed in foster care, and 1.1% experienced a TPR. Roughly 1 in 2 Black and Native American children were investigated during childhood. Children receiving public insurance experienced CPS involvement at more than twice the rate of children with private insurance.Conclusions. Findings provide a lower-bound estimate of CPS involvement and extend previous research by documenting demographic differences, including in TPRs.Public Health Implications. Conservatively, CPS investigates more than a quarter of children born in California for abuse or neglect. These data reinforce policy questions about the current scope and reach of our modern CPS.

Paternal Jail Incarceration and Birth Outcomes: Evidence from New York City, 2010-2016.

OBJECTIVES: To examine population-level associations between paternal jail incarceration during pregnancy and infant birth outcomes using objective measures of health and incarceration. METHODS: We use multivariate logistic regression models and linked records on all births and jail incarcerations in New York City between 2010 and 2016. RESULTS: 0.8% of live births were exposed to paternal incarceration during pregnancy or at the time of birth. After accounting for parental sociodemographic characteristics, maternal health behaviors, and maternal health care access, paternal incarceration during pregnancy remains associated with late preterm birth (OR = 1.34, 95% CI = 1.21, 1.48), low birthweight (OR = 1.39, 95% CI = 1.27, 1.53), small size for gestational age (OR = 1.35, 95% CI = 1.17, 1.57), and NICU admission (OR = 1.14, 95% CI = 1.05, 1.24). CONCLUSIONS: We found strong positive baseline associations (p < 0.001) between paternal jail incarceration during pregnancy with probabilities of all adverse outcomes examined. These associations did not appear to be driven purely by duration or frequency of paternal incarceration. These associations were partially explained by parental characteristics, maternal health behavior, and health care. These results indicate the need to consider paternal incarceration as a potential stressor and source of trauma for pregnant women and infants.

Women's Health in the Era of Mass Incarceration.

Dramatic increases in criminal justice contact in the United States have rendered prison and jail incarceration common for US men and their loved ones, with possible implications for women's health. This review provides the most expansive critical discussion of research on family member incarceration and women's health in five stages. First, we provide new estimates showing how common family member incarceration is for US women by race/ethnicity and level of education. Second, we discuss the precursors to family member incarceration. Third, we discuss mechanisms through which family member incarceration may have no effect on women's health, a positive effect on women's health, and a negative effect on women's health. Fourth, we review existing research on how family member incarceration is associated with women's health. Fifth, we continue our discussion of the limitations of existing research and provide some recommendations for future research.

Cumulative Prevalence of Confirmed Maltreatment and Foster Care Placement for US Children by Race/Ethnicity, 2011-2016.

Objectives. To estimate the cumulative prevalence of confirmed child maltreatment and foster care placement for US children and changes in prevalence between 2011 and 2016.Methods. We used synthetic cohort life tables and data from the Adoption and Foster Care Analysis and Reporting System and the National Child Abuse and Neglect Data System and population counts from the Centers for Disease Control and Prevention.Results. US children's cumulative prevalence of confirmed maltreatment remained stable between 2011 and 2016 at about 11.7% (95% confidence interval [CI] = 11.6%, 11.7%) of the population and increased by roughly 11% for foster care placement from 4.8% (95% CI = 4.8%, 4.8%) to 5.3% (95% CI = 5.3%, 5.4%). American Indian/Alaska Native children experienced the largest change, an 18.0% increase in confirmed maltreatment risk from 13.4% (95% CI = 13.1%, 13.6%) to 15.8% (95% CI = 15.6%, 16.1%) and a 21% increase in foster care placement risk from 9.4% (95% CI = 9.2%, 9.6%) to 11.4% (95% CI = 11.2%, 11.6%).Conclusions. Confirmed child maltreatment and foster care placement continued to be experienced at high rates in the United States in 2012 through 2016, with especially high risks for American Indian/Alaska Native children. Rates of foster care have increased, whereas rates of confirmed maltreatment have remained stable.

Solitary confinement placement and post-release mortality risk among formerly incarcerated individuals: a population-based study.

BACKGROUND: With more than 10 million people incarcerated worldwide, some of whom will have experienced solitary confinement, a better understanding of health and mortality after release is needed. The aim of this study was to assess the relationship between placement in solitary confinement and mortality in the 5 years following release among formerly incarcerated individuals. METHODS: In this population-based study we used data from Danish administrative registers and administrative dataset from the Danish Prison and Probation Service. We linked information on all Danish individuals who had been incarcerated for more than 7 days during 2006-11, with information on mortality for the 60 months following release. We used Cox proportional hazards models to estimate the association between being placed in solitary confinement and mortality (death and cause of death) among formerly incarcerated Danish individuals, controlling for several possible confounders (prison security level, release year, sentence length, reason for conviction, age at admission, sex, ethnic minority background, and education level) and using a reference group of incarcerated Danish individuals who had been sanctioned for in-prison infractions but not placed in solitary confinement in some models. FINDINGS: Our study included 13 776 individuals, which translated to 812 374 person-months of exposure to the risk of mortality up to Dec 31, 2016. Formerly incarcerated Danish individuals who spent time in solitary confinement had higher overall mortality 5 years after release (4·5%) than did those who had not spent time in solitary confinement (2·8%; p<0·0001). After adjusting for possible confounders, our results suggested an association between solitary confinement and elevated mortality due to non-natural causes (hazard ratio 2·342, 95% CI 1·527-3·592). We did not identify a significant association with natural causes. INTERPRETATION: The results from these analyses indicate that solitary confinement placement might be a key moderator of the association between a history of incarceration and post-release outcomes. Our findings suggest that incarcerated individuals ever placed in solitary confinement are a vulnerable population in need of interventions. FUNDING: ROCKWOOL Foundation.

Exposure to the US Criminal Legal System and Well-Being: A 2018 Cross-Sectional Study.

Objectives. To assess the association between exposure to the US criminal legal system and well-being.Methods. We used data from the 2018 Family History of Incarceration Survey, a nationally representative cross-sectional study of family incarceration experience (n = 2815), which includes measures of participants' own criminal legal system exposure, including police stops, arrests, and incarceration. We measured well-being across 5 domains-physical, mental, social, spiritual, and overall life evaluation-and analyzed trends in well-being by criminal legal system exposure using logistic regression.Results. Exposure to police stops, arrests, and incarceration were each associated with lower well-being in every domain compared with those not exposed. Longer durations of incarceration and multiple incarcerations were associated with progressively lower well-being. Those who were stopped and frisked by the police had low well-being similar to that of those who had been incarcerated multiple times.Conclusions. Any exposure to police contact or incarceration is associated with lower well-being in every domain. More involved exposure is associated with even lower well-being.Public Health Implications. Jail diversion and broader criminal justice reform may improve population-level well-being by reducing police contact and incarceration.