Investigating the Health Impact of Incarceration with Linda Teplin, PhD

"We originally set up the study to look at the mental health needs of youth in the juvenile justice system, and whether or not they received services while they were in the system, as well as after they went home. Over the years, however, we broadened the study to look at trauma, suicidal ideation, even death rates, AIDS risk behaviors. So we expanded it to look at a number of health-related issues and outcomes."  — Linda Teplin, PhD 

• Vice Chair for Research, Department of Psychiatry and Behavioral Sciences 
• Owen L. Coon Professor of Psychiatry and Behavioral Sciences 
• Professor, Weinberg College of Arts and Sciences 

Teplin’s research is unique among projects studying incarcerated youth, primarily for her investigation of the “dose” of incarceration and its long-term impacts on health. With her original cohort of 1,829 teenagers now in their early 40s, Teplin hopes the study can lead to disease prevention for this subset of the population.  

• Most of the literature studying delinquent youth looks at delinquency as an outcome rather than a starting point. In contrast, Teplin studies delinquent youth in terms of their health needs and outcomes, determining the long-term impact of incarceration. 
• The project began by studying the mental health needs of teenagers in the juvenile justice system. It eventually broadened to include studies on trauma, suicidal ideation, death rates, AIDS risk behaviors, among others.  
• Psychiatric issues were common among those studied, as were abuse, neglect, and surprisingly, mortality, a category included after determining higher than expected mortality rates: there were 65 deaths within six years of the initial interviews.  
• Of the 1,829 children that were studied, zero came from wealthy neighborhoods, where Teplin says delinquency is handled privately by school administrators and parents. In poorer schools, administrators tend to call the police rather than parents. Not surprisingly, this group is also disproportionately made up of racial and ethnic minorities. 
• Teplin was able to build solid relationships with the juvenile justice system in Cook County, Illinois, because she says she prioritizes “helping them at the same time they are helping her.” She cultivates relationships with these institutions and keeps them aware of any new or negative data she collects.  
• Another primary difference between Teplin’s research and that of other studies on the effects of incarceration is that she studies the “dose” of incarceration. In the same way one might study the impacts of smoking based on multiple variables, the variables contributing to each individual incarceration experience are significant.  
• When it comes to the new $20 million grant to study age-related illnesses within this cohort, Teplin asserts that the type of facility where someone was incarcerated matters a lot. For example, there is different access to healthcare in jails versus prisons.  
• Teplin is also interested in how reentry programs might be implemented to reduce the risk factors for health. Ninety-five percent of people who are incarcerated eventually return to their communities and can struggle to find jobs, safe housing, stable relationships, public benefits and reliable healthcare.  
• Teplin has a long list of projects she wants to develop based on this same model, including the consequences of incarceration for drug abuse, on alcohol use disorders and on coronary heart disease, for example.
• For up-and-coming scientists who want to pursue projects such as the Northwestern Juvenile Project, Teplin suggests using a tactic she calls “aggressive empathy.” This means: be empathic with both your participants and the agencies you study, and to provide something of use and value to them.  

Recorded on November 8, 2024. 

Additional reading: 

• Listen to a previous episode of the Breakthroughs podcast with Teplin 
• Read a recent article in the Juvenile and Family Court Journal 
• Learn more about Teplin’s recent grant 

Target Audience

Academic/Research, Multiple specialties

Learning Objectives

At the conclusion of this activity, participants will be able to:

1. Identify the research interests and initiatives of Feinberg faculty.
2. Discuss new updates in clinical and translational research.

Accreditation Statement

The Northwestern University Feinberg School of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Credit Designation Statement

The Northwestern University Feinberg School of Medicine designates this Enduring Material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

American Board of Surgery Continuous Certification Program

Successful completion of this CME activity enables the learner to earn credit toward the CME requirement(s) of the American Board of Surgery’s Continuous Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit.

Disclosure Statement

Linda Teplin, PhD, has nothing to disclose. Course director, Robert Rosa, MD, has nothing to disclose. Planning committee member, Erin Spain, has nothing to disclose. FSM’s CME Leadership, Review Committee, and Staff have no relevant financial relationships with ineligible companies to disclose.

All the relevant financial relationships for these individuals have been mitigated.

[00:00:00] Erin Spain, MS: This is Breakthroughs, a podcast from Northwestern University Feinberg School of Medicine. I'm Erin Spain, host of the show. In the mid-1990s, Northwestern Medicine investigator Linda Teplin, launched a groundbreaking study, the Northwestern Juvenile Project. It is the only large scale longitudinal study of youth who were arrested and detained that tracks their health and outcomes after they leave detention. With more than $62 million in NIH funding over the past three decades, the project has uncovered many devastating long-term health and outcome impacts among this cohort, such as high mortality rates, mental health issues, trauma, and racial disparities. Now with a new $20 million grant from the National Institute on Aging, the project will study the long-term consequences of incarceration on age-related conditions, including risk factors for Alzheimer's and other related diseases. Dr. Teplin joins me today on the show to talk about this latest grant and all that this project has accomplished in the past 30 years. Welcome to the show, Dr. Teplin. 

[00:01:19] Linda Teplin, PhD: Thank you so much. 

[00:01:21] Erin Spain, MS: This project is really unique. It is something that's unique to Northwestern, but it's something that's also unique in the landscape of studying youth who have been detained. In fact, there's never been a project like this before, so, set it up for me. Tell me a little bit about this project and how it differs from any other NIH funded work being done. 

[00:01:39] Linda Teplin, PhD: Well, if you look in the literature, there's a lot of studies that look at delinquent youth, but when you look closely, you see that, in fact, they look at delinquency as an outcome rather than starting by investigating youth who are in the juvenile justice system. The people who actually do study kids in the system are mostly criminologists. Criminologists are interested in crime, so we have many, many studies of youth in the juvenile justice system, but they focus on crime and recidivism. We're doing something quite different because we intended to study them in terms of their health needs and long-term outcomes. 

[00:02:20] Erin Spain, MS: Take me back to the genesis of this project. What was the goal from the beginning? 

[00:02:24] Linda Teplin, PhD: So we originally set up the study to look at the mental health needs of youth in the juvenile justice system, and whether or not they received services while they were in the system, as well as after they went home. Over the years, however, we broadened the study to look at trauma, suicidal ideation, even death rates, AIDS risk behaviors. So we expanded it to look at a number of health-related issues and outcomes. Our participants were only in their teens when we sampled them. We've been tracking and re-interviewing them wherever they lived since we enrolled them in the mid-nineties. So now that our participants are older, it's the perfect study to look at how incarceration affects health and aging. 

[00:03:15] Erin Spain, MS: Just describe some of these things that you already know about this population, the biggest findings from the past 30 years. 

[00:03:21] Linda Teplin, PhD: So we found that about three quarters of the girls and two thirds of the boys had one or more psychiatric disorders. Most of our participants had more than one, and that's a problem because it's much more difficult to treat someone if they have, for example, major depressive episode and an addiction versus only an addiction or only a mental health disorder. That's one key finding. And then unfortunately, their disorders tend to abate for some, but not for others. We also found that trauma and suicidality was common. We found that abuse and neglect was common. We also found, unfortunately, that mortality was common. This is significant because you never sample youth — these kids were 10 to 17 — and anticipate being able to study mortality, to study death. It was not even a variable. We only collected information on death so that we would know when someone shouldn't be contacted anymore for their subsequent interview. That's the only reason we collected data on death. But after six years, we had so many deaths. Mostly then from gunshot wounds. I think there were 65 deaths within six years of the initial interview that we felt that we needed to focus then on mortality and mortality rates and cause of death. So that was our first paper on mortality, which we published in the medical journal, Pediatrics. 

[00:04:49] Erin Spain, MS: What has the reaction been like from not only your peers, but from policy makers to the results of your studies? Has there been any movement that's taken place because of the work that you've done? 

[00:05:00] Linda Teplin, PhD: We certainly get some attention, but it's an uphill battle, and that's because many people feel that our kids, our participants are just bad kids and kind of deserve what they get. But what I highlight when I hear people say that is I ask, well, out of our 1,829 kids that we randomly sampled when they were teens, guess how many of them were from the wealthy North Shore? From Glencoe, from Highland Park, from Northbrook. And people guess, oh, maybe 20, 40, 50, 80. And I say zero. And that's because there's actually two possible explanations. One is that kids at New Trier never use drugs, never sell drugs, and never get into fights. That is unlikely. But when kids at New Trier or other high schools in wealthier neighborhoods get into trouble, the school doesn't call the police. The school calls the parents. The parent goes to school, says, please don't call the police. I'll make sure Johnny gets treatment for his drug use disorder. That's what's driving this, and I'll make sure everything is okay. If the same behavior occurs in an inner city school, and I'm not necessarily talking about Chicago, this is across the country. If the same behaviors occur in an inner city school, a poor school, a school in a poor neighborhood, they tend not to call mom or dad, rather they call the police. And so all these, adolescent behaviors many people feel are part of normal development go unpunished if you go to a wealthy school, but they result in a trajectory into the juvenile justice system and then the adult system, if you have the unfortunate luck to live in the inner city and be from a poor family. So basically when people say, oh, you study bad kids, I say, no, I study poor kids. 

[00:06:54] Erin Spain, MS: And this also happens to be children who are racial and ethnic minorities at a higher rate. This is something else that you study is looking at racial disparities as well. Can you talk to that a little bit? What is the racial and ethnic makeup of the cohort? 

[00:07:09] Linda Teplin, PhD: So we sampled youth who were in the Cook County Juvenile Detention Center. That's how we sampled them. Uniformly the youth in the detention center are poor, and that means disproportionately they are minorities. When we conducted our study, we actually had to over sample non-Hispanic whites because otherwise we would've had almost only minority kids and mostly black youth. So it's ironic that NIH is always so worried about having enough minorities in their studies, but actually we had to over-samples non-Hispanic whites because we had so many minorities. 

[00:07:46] Erin Spain, MS: How were you ever able to launch this project and get access to these juvenile youth in the Cook County system? How did you do that? 

[00:07:53] Linda Teplin, PhD: That is probably the question I am asked most frequently when I speak. It's because we are helpful to the institutions we study. We always build in something for them. I deliver lectures to people who work in the jail, for example, I gave a one day workshop for the Illinois Department of Corrections folks who work in mental health care. We view our research as a partnership so that they allow us access because they know that we will be helpful to them. We will never issue a finding that is negative without giving them a heads up, so that they can know and then they can respond to it. So they are the first to know about our findings. We have great relationships with the courts, with the chief Judge, Judge Evans, with the jail, with Sheriff Dart and the people who run the jail, with the Illinois Department of Corrections, with probation. And I nurture those relationships because if we don't have our access, we can't do anything. And in turn, we make sure that we give something back. To be honest, I think that a lot of researchers don't use that approach. 

[00:09:03] Erin Spain, MS: So, you've been studying these youth who have been incarcerated, and now they may no longer be. Why do you think it's important to continue studying them now so many years later after their initial incarceration? 

[00:09:16] Linda Teplin, PhD:  So initially we were looking at, what happens to these kids? They're impoverished kids. They're in poor health to start with what happens to them. But the importance of that dwindles as they age because you have basically the answer to that question. So with this project, we've transformed our attention to using this sample because it is useful and actually perfect to study the consequences of incarceration for health. So people ask me, don't we already know the answer to that question? Don't we already know that the consequences for incarceration for health are dire? Don't we already know that? Why should we study that? If you do a lit search to see what's been done, looking at the relationship between incarceration and health, what you see is everyone studied general populations. And they looked at incarceration only as a dichotomous variable, Were they ever incarcerated? Yes or no? Well, that makes no sense because it means they conflate the college student who was arrested once for DWI when he was 19, with somebody who spent 30 years in prison for robbery. It doesn't take into account what we call the dose of incarceration. And this is similar to how you would study any risk factor. So for example, let's say you study smoking and the consequences of smoking, You would never categorize people into just two groups: ever smoked? Yes or no. And it's the same thing with incarceration, which includes frequency of stays, duration of stays, type of facility. Is it a juvenile detention center? Is it an adult jail? Is it an adult prison? The age when you were incarcerated, the recency, you know, all of these variables. And what's unique about our sample is we're not using them because they're juvenile detainees. We're using them because there's a range of incarceration experiences in our sample. Many of them are what we call the one and done group. They were incarcerated once when they were adolescents, never happened again, and other people were incarcerated again and again and again in jail, but never in prison. And then other people bounce back and forth between the community, jail, prison, jail, prison, jail, prison. So we can use our sample to assess dose. And then we have information on health going back to when they were kids. And then we are collecting new information on health now in the next phase of the study. 

[00:11:54] Erin Spain, MS: You have been able to stay in touch with so many of these participants over the years, and this is not easy to do. Can you explain the team that you've assembled, the work that you've done in order to continue this study 30 years later. 

[00:12:09] Linda Teplin, PhD: Well, I can't take credit for our tracking system. That was developed by Professor Karen Abram who's also at Feinberg and is the number two person on my team. But when you study high risk samples like ours that are also highly mobile, you have to set up systems so you can keep track of where they are. Otherwise you lose the people who are most likely to have the disorder or illness that you're trying to study. Also, a key feature of our study is that most longitudinal studies funded by NIH, they do not sample people from corrections. And if their original participants are incarcerated, when their followup interview is due, they're dropped and lost to follow up. So ironically, if you look at any of the longitudinal studies funded by NIH, whether heart disease or on cancer, and you look and see how they sampled, they're missing the people who are most likely to have the disorders that they're studying. So I decided a long time ago that we would track and re-interview people wherever they lived when their interview was due. You just get them wherever you can. This is why the study is so expensive, because it's pretty cheap to draw new cohorts to sample new people and find out what's going on. It's very expensive to track and re-interview the same people over time. 

[00:13:31] Erin Spain, MS: now the median age is about 43. Is that right? 

[00:13:34] Linda Teplin, PhD: Yes, correct. 

[00:13:35] Erin Spain, MS: And you're able to turn your attention to the potential effects of incarceration on now these age related illnesses such as Alzheimer's. Do you have any hunches about what you might find in this next study? 

[00:13:47] Linda Teplin, PhD: I think the value of this study is to see what happens to these people, because that tells us what we can do to prevent these diseases. Facility matters. It's critical whether you're in jail or in prison. In jail, you have hundreds of people entering big city jails per day. They have medical care, of course, and they screen for medical problems when they enter, but they can't provide in-depth treatment, nor are people there long enough to provide it, whereas prisons tend to stay there longer, obviously. To be in a prison, your sentence has to be one year or longer, otherwise you're in a jail. So by using our approach, we can inform the development of preventive interventions, meaning, which features of incarceration are the most damaging for health? To what extent is incarceration a pathway for disparities in health and in aging? What are the modifiable risk factors that we can implement? How can jails and prisons and the community set up reentry programs that reduce the risk factors for health, and then ultimately, diseases like ADRD. We need to remember that 95% of people who have been incarcerated go back to their communities. So this is not just a study that will help people who are incarcerated, but people who have been incarcerated or are at risk of incarceration, which is a huge number of people. 

[00:15:16] Erin Spain, MS: And again, you're passionate about influencing public health policy. How do you think that this next phase could help guide public health policy? 

[00:15:25] Linda Teplin, PhD: Our findings will guide the development of the programs we need to improve reentry, especially community corrections, meaning when people leave corrections to go back to the community: probation programs, parole programs, reentry programs. So for example, we anticipate that people who cycle in and out of corrections need very different types of support compared with those who have had long prison sentences. 95% of people who are incarcerated eventually return to their communities. And once they're there, they will struggle to find jobs, safe housing, stable relationships, public benefits, reliable healthcare. And it's a huge proportion of our population. We estimate that between one fifth and one third of black males being treated in the community for health will have been incarcerated. So what our study can do is guide community health providers to better address the social, emotional, and physical needs of released prisoners. 

[00:16:36] Erin Spain, MS: So, this new grant that you have just received is for five years, so this work is just kicking off right now. So what can we expect? When could we expect to see some publications and results on this work? And what are the next steps beyond this for the project. 

[00:16:45] Linda Teplin, PhD: Well, our participants are only in their forties, so we actually hope to continue to get funding to study them as they age. Also, this grant is to study the consequences of incarceration for general health and aging. My next steps, I actually have a laundry list of the funded projects I wanna develop, based on this model and based on this initial $20 million project: the consequences of incarceration for drug abuse, the consequences of incarceration for alcohol use disorders, the consequences of incarceration for coronary heart disease. 

[00:17:22] Erin Spain, MS:  The model that you have set up and the way that you work with your partners to get this research done and the relationships that your team is able to create and sustain with the participants is really special. What message would you give to young investigators who are coming up and they see what you have done and they would like to do this type of work? What advice would you give to them? 

[00:17:44] Linda Teplin, PhD: I've coined a term called aggressive empathy. It's my term. Be empathic with your participants. Be respectful with your participants. Be empathic with the agencies that you study and provide something of use and value to them. We couldn't do our work without the cooperation of all the agencies we study. And I'm eternally grateful for allowing me to be led into their facilities to collect information. 

[00:18:11] Erin Spain, MS: Well, we look forward to having you back to talk about all of these new projects as they kick off. So thank you again, Dr. Linda Teplin for coming back to the podcast to talk about the next step in the Northwestern Juvenile Project.  

[00:18:23] Dr. Linda Teplin: Thank you so much, Erin. 

[00:18:24] Erin Spain, MS: You can listen to shows from the Northwestern Medicine Podcast Network to hear more about the latest developments in medical research, health care, and medical education. Leaders from across specialties speak to topics ranging from basic science to global health to simulation education. Learn more at feinberg.northwestern.edu slash podcasts.