Children in the Juvenile Justice System Face Serious Health Risks with Linda Teplin, PhD

Erin Spain: You were listening to Breakthroughs this podcast from Northwestern University Feinberg School of medicine. I'm Erin Spain, executive editor of the Breakthroughs newsletter. On an average day, there are about 45,000 young people who are detained in juvenile facilities. These young men and women face unique health risks. Once they are released back into their communities. The landmark Northwestern juvenile project led by Dr. Linda Teplin has produced some astonishing findings about the lives of delinquent youth. For example, they are about four times more likely than other people their age to be shot and killed before they turn 30. Substance abuse and mental health disorders also plague this group disproportionately and they're at higher risk of behavior that could lead to HIV AIDS. These findings are helping to shape new services and programs to help juvenile detainees get the help they need to successfully reenter their communities and live healthier lives. Dr. Teplin joins me today to talk about her research and the future of the project, which is expanding into the first intergenerational study of people in the correctional system. Thank you so much for being here today.

Linda Teplin: Thank you.

Erin Spain: You began this project, the Northwestern juvenile project, in the mid 1990s. Explain this project to me. Why did you launch it and how far has it come in the past 20 years?

Linda Teplin: We actually started out examining adults in the correctional system. We did a large scale study of men in jail in the 80s and a large scale study of women in jail in the early nineties. We found in those studies that many of our participants first developed mental health problems when they were young. We also found that many of them got involved in the justice systems when they were young. So the obvious next step for us was to look at youth in the juvenile justice system. So we began the study by looking at two critical questions, which is one, the prevalence of psychiatric disorders in kids in detention, and then second, to see if they received needed services. And then we went from there from what we anticipated could be just a study that would last a couple of years to a study that has now lasted 20 years and still going.

Erin Spain: We should mention the young people that were recruited for this study are all from the Cook County Chicagoland area.

Linda Teplin: This is a study that is funded by national agencies. So we are funded mostly by the federal government or by national foundations. However, when you do large scale longitudinal studies like this, you can't conduct a national sample that's simply not feasible. So instead you choose a city that is typical. Chicago is perfect because it is a typical big city with typical big city problems. We also, because of our earlier work on adults, had terrific cooperation from the systems in Cook County in Illinois. We could get access to study the detention center, we could get access to follow our participants up in the jail and state correctional facilities. So because of all those reasons, we decided to do the study here and then our funding agencies were delighted because findings from Chicago are generalizable to other big cities like Cleveland, like Pittsburgh, like Detroit, like New York. Kids are kids nationwide. They're not that different.

Erin Spain: You were able to gather a very large sample. Tell me a little bit about the people who are in this study and some of the characteristics of the people. You had a nice mix of ethnic minorities. Share with me some of those statistics.

Linda Teplin: Sure. We took a random sample of kids as they entered detention and we sampled just over 1800 of them. We oversampled girls because otherwise you would get mostly boys. It's uncommon for girls to be in corrections. There are some, but not as many as boys. Obviously. We also oversampled younger kids to be able to compare their needs and outcomes to older kids. We also oversampled kids processed in the adult system, what are called automatic transfers to adult court. And then lastly, and this is perhaps the most ironic, many studies funded by the National Institutes of health are concerned that investigators include enough minorities. In our situation though had we not oversampled Non-Hispanic whites, we would have ended up with predominantly minorities, African Americans and Hispanics and that is because in Chicago, in Cook County in Illinois, like the situation nationwide and locally, racial and ethnic minorities are disproportionately incarcerated.

Erin Spain: Even at this young age?

Linda Teplin: Even at this young age, so that nationwide Hispanics comprise about 14% of the general population, African Americans about the same approximately, but in fact more than two thirds of youth and adults nationwide in detention centers, jails and prisons are racial or ethnic minorities. And I'd also like to comment on the kinds of kids who go to detention. When I go to cocktail parties, people sometimes say, Oh, you study these really bad kids. Kids who were bad enough to end up in detention. In fact, we study very poor kids. So guess how many in our sample of 1800 kids were from the wealthy North Shore, from Glencoe, Highland Park, Winnetka, Wilmet. Just take a guess what proportion of our 1800 kids were from the North Shore?

Erin Spain: Zero.

Linda Teplin: Zero. And that's because schools in those districts, if little Johnny is selling drugs on the school break, the school doesn't call the police. They call little Johnny's parents who are usually able to be found. They get to school promptly. They say, oh, please don't call the police. Little Johnny has an addiction and he was selling drugs to maintain his addiction. We will make sure that Johnny gets help for his substance abuse. And so nothing happens with little Johnny, but flash forward to an inner city school and they often have zero tolerance policies and one of their students is caught dealing drugs. And even if they tried to call the parent, the parent may not be available as mom or dad on the wealthy North Shore. And they also may have a zero tolerance policy so they call the police and not the parent. And then of course, once the police enter into that situation it just goes downhill from there. And so even if the child is detained only for a couple of weeks, let's think about what that means. They've missed school for a couple of weeks. They go back and they may find it difficult to catch up. They may become disinterested. They may start cutting class because they're disinterested, can't keep up, start hanging around on the street corner. Eventually arrested and gathered up with the usual suspects. And so what would have been a minor incident for a wealthy child becomes a life changing trajectory for the poor child.

Erin Spain: And you know, these children, you've watched them grow up. You're speaking from experience of people who, you know and followed through this study and what happens to them.

Linda Teplin: And they have dire outcomes.

Erin Spain: Let's talk about some of those outcomes. Some of the key findings from the study. Over the years, you've looked at mental health, substance abuse disorders, early death, and then what happens to them as functioning adults out in society. First, mental health that's something that you were interested in from the beginning. What were some of the key findings there?

Linda Teplin: We found that disorder was almost the rule, not the exception, especially for girls. So that about three quarters of girls in our sample at the time of their detention had one or more of the psychiatric disorders that we assessed and about two thirds of the boys. So the prevalence was a little bit less but still extremely high among both boys and girls. We found that depression was common, especially for girls. We also found that substance use disorders were common affecting about 50% of these kids, boys and girls.

Erin Spain: Under the age of 18, right?

Linda Teplin: They were all 10 to 17. May I stress that substance use disorder does not mean use. Substance use disorder means you have abuse or dependence. It's a serious disorder. To qualify for that disorder, it means that you need to exhibit a certain number of problems in your life for a specific frequency and over a certain period of time. So in fact, that's a quite serious finding that half of these kids have a substance use disorder. We also found that many of these kids didn't have just one disorder. They had more than one disorder. It's a condition called comorbidity. Comorbid disorders. For example, it was common for kids to have both major depressive episode and a substance use disorder. What does this mean? It means that they are far more difficult to treat because it's more challenging to treat people, youth or adults who have more than one disorder rather than only one.

Erin Spain: And tell me a little bit about how you assessed the young people for these different disorders.

Linda Teplin: A common question we get is, "Well, these kids were just arrested. Of course they're depressed. Of course they're anxious. In fact, we used a standard assessment used widely. It takes approximately an hour. We had a private area in which we interviewed the kids. And these assessments differentiate between symptoms that occur because of a traumatic event that's occurring now versus symptoms in the past three months, six months or lifetime. So our findings are not just because these kids were detained, rather these were disorders that these kids had before.

Erin Spain: So you were able to gather this information about them, sort of assess some of their mental health possible issues, substance use disorders. Then they're released typically back into their communities and you were still able to keep tabs on these young people. How were you able to do that? You have a very high participation rate in this study up to almost 90% in some cases. How were you able to continue tracking and being in touch with these young people?

Linda Teplin: We had a stellar staff, people at all levels of the project, the interviewers, the trackers, the people who would send birthday cards, people who would go into the neighborhoods to find people. In studies like this, you must maintain your participation rate and that's because you have to presume that the people you lose most likely have the worst outcomes. So that we worked from the beginning and Karen Abraham, my associate director, developed our tracking procedure where we spoke to major investigators in related areas asking how they tracked and retained participants. We did everything they did, but then we also took advantage of new systems available because of computers and electronic systems and everything else plus what we thought would be good for our participants. For example, we sent personalized birthday cards to our participants. Happy Birthday Joey. Happy Birthday Joanna. This kind of attention makes participants feel special and it makes them more likely to want to be retained in the study.

Erin Spain: Something for them to look forward to every year as well. It's consistent.

Linda Teplin: We received a generous donation from Jerry Reinsdorf who owns the White Sox and he sent us two tickets for each participant every year since the study began. Now obviously if kids are still detained or are in adult jail or corrections, we don't send them white sox tickets. We then send them a substitute gift. But many of our participants use those tickets and they looked forward to it. Of course they could only receive those tickets if they agreed to continue to participate in the study. Those became incentives.

Erin Spain: Then you would go to their homes and continue doing the interviews and gathering the research.

Linda Teplin: What's unusual about our study is we retained people and re-interviewed them no matter where they lived, when their interview was due. This is quite unusual. Most studies, all of the studies, for example, funded by the National Institutes of health typically do not sample people from corrections. So they're simply never studied or if their original participants become incarcerated at followup, there's simply dropped from the study and lost to follow up. This means, ironically, that we have the least information in virtually every area - if you're talking about cancer or any area - we have the least information about the people who have the poorest health. And so we essentially redress that imbalance by focusing on a correctional population. We recognize at the outset that we needed to retain people even if they became incarcerated because otherwise you lose the people who are most likely to have the problems. We developed relationships with the county jail, other jails, correctional facilities, and we went to the person's home if they wish to be interviewed there or if they were incarcerated, we went to that facility.

Erin Spain: How many people are we talking about? There were part of your group at the time?

Linda Teplin: At one point when we were interviewing every six months we had, I think, 60 staff.

Erin Spain: Wow.

Linda Teplin: Because to conduct a study like this requires a great deal of pounding the pavement. Of course, this sample is highly mobile. They move a lot. They don't move long distances. You know, our participants are not people who would go to Harvard and moved to Boston, but they are highly mobile. They move a lot and so tracking them becomes important. That's why the gifts that we sent by mail were so important because if it was a bad address, it would come back to us and then we would hit the street to find them.

Erin Spain: So you kept this pace up for many years after your first launch of the project, and soon you were pulling some pretty interesting findings and one that you went to press with and that actually made some headlines was about the mortality rate of these young people by the time they reached 30. Tell me about what you've found and what was so alarming about this.

Linda Teplin: We never intended to study death. One does not sample kids ages 10 to 17 and anticipate studying death, but we gathered statistics on deaths just to keep track of our sample and we discovered after about six years that over 60 of our participants had died. Over 60 of the original 1800 we realized that there was a story to tell. We published our first article on death rates in the Journal of Pediatrics, which is one of the most renowned pediatric journals in the country, actually in the world. And interestingly though, that study received almost no press. It was not a story. The reaction I got was these kids are bad kids. Of course they're going to die. Fast forward another five, six years, there were so many more deaths at this point. There were I think 111 deaths that we decided to write another article which was published again in the Journal of Pediatrics. By this time the issue of violence, especially firearm violence in the inner city had become of greater interest to the public. That paper got some press and we found there that it was African American males that have the highest death rate and even higher than African American males in the general population. So how did they die? These were not kids by and large who died from disease even though they inner city populations are at great risk for asthma and other problems. These were kids who mostly died of homicide, especially the boys. So that 90% of males who died - died from homicide. And how did this happen? Mostly by firearms among our kids who were victims of homicide, more than 85% of males and just under 30% of females were killed by a firearm. Now people say, well, how can we reduce these rates? We did find some risk factors. We found that dealing drugs during adolescence predicted early violent death. We found that being a member of a gang during adolescence predicted early violent death and finally that having an alcohol use disorder, again, that's abuse or dependence, is a significant risk factor for early violent death.

Erin Spain: How many papers have you published to date on this population? Dozens?

Linda Teplin: We have a publication strategy, which is that we do have a lot of papers, but what's important to me is publishing papers in major journals, especially medical journals that will affect change in public policy. So we try to focus on the major journals. The JAMA Journals, Pediatrics, American Journal of Public Health, because those are the papers that congressional and Senate staffers read and those are the papers that can change policy. That has always been my goal to affect change in public policy.

Erin Spain: And your papers have been cited in supreme court briefings and surgeon general briefings. Tell me a little bit about some of the impacts that your findings have had, maybe that you're the most proud of.

Linda Teplin: We found that psychiatric disorders were common in detention centers. What does that mean? It means that we can't think of these kids only as bad kids, but that these are kids in need of services. As a result of our studies, detention centers nationwide began to screen kids who came into detention for psychiatric disorders and also began to provide linkage to services in detention and when they left. So we're thrilled that that was a consequence of our studies. Another finding we had was that few of our kids received any treatment while they were in detention and ironically a few of them receive treatment even after they returned to their communities. So clearly, these kids are falling through the cracks and it's not only the fault of detention centers nationwide. This was a wake up call for mental health systems nationwide that they need to partner with and liaison with detention centers to provide services after these kids leave.

Erin Spain: And not only that, but your research was able to address some stereotypes that are out there as well, especially about African Americans and hard drugs and the war on drugs on African Americans. Tell me about some of your fundings and how they help to change that conversation.

Linda Teplin: We anticipated, based on the public stereotypes of African Americans, that opiate use disorders would be higher among African Americans in our sample than among Non-Hispanic whites. We also anticipated that cocaine use disorder, which includes crack cocaine, not just powder cocaine, would also be more prevalent among African Americans than among Non-Hispanic whites in our sample. Absolutely wrong. The public stereotypes are absolutely wrong. We found, for example, that cocaine use disorder, again that includes powder cocaine and crack cocaine was nearly 30 times more likely to occur in Non-Hispanic whites than in African Americans. So it certainly does question the differential penalties that occur with crack cocaine, which disproportionately affect African Americans.

Erin Spain: You know, we were talking about these findings that have happened and that you've discovered in the past 10 years or so, but this project is far from over. You just received several new federal grants to continue this project and now make it an intergenerational project. Tell me what that means.

Linda Teplin: We're quite excited about the opportunity to do an intergenerational study. We had actually planned the study initially where we collected information on the children and we also sent birthday cards to the children so that they would know who we were in the event that in fact we could obtain funding to conduct an intergenerational study. We've just received funding from the National Institute of Justice, which is part of Office of Justice Programs, the Department of Justice, to focus on intergenerational patterns of firearm use. That's a critical issue, obviously, because so many people in this demographic are injured or die from firearms each year. We feel that understanding how the parents experience with firearms during their own adolescence affects that of their children is a key way to provide information to target preventive interventions. So that's one area. The second area that we are funded to investigate is a grant from the national institutes of health. Our Institute is the National Institute on Drug Abuse and there we are studying intergenerational patterns of substance abuse. Substance abuse was the most prominent problem in the parents. So again, the question is how do the parents experiences feed that into those of their adolescent children. So we have that grant and hand as well. Finally we have a, an application under review - got a terrific score - also, at the National Institutes of Health to study how parents incarceration, our original participants, how their experiences in incarceration and the collateral consequences of their incarceration - you know, unemployment and ability to get housing, that type of thing - affect the family and specifically the children.

Erin Spain: So while this project has really affected policy and has had an impact, I do have to ask, do you think that things have gotten better since the project launched in the mid 1990s. Have things gotten better in the juvenile justice system and for these young people?

Linda Teplin: Violent crime is down, homicide rates are down. The census of juvenile justice facilities has dropped. However, on an average day, more than 2 million Americans are incarcerated in a detention center, a jail or prison. Once they leave, they have difficulty finding work. Even though there is a Ban the Box movement nationwide, but they have difficulty finding work. They may face great restrictions in terms of housing, living in public housing. In every way they face great restrictions. So, the answer is that some of the indicators are better. For example, the rate of homicide haven't gone down, but for these people, their plight after release is still dire.

Erin Spain: Dr. Linda Teplin, thank you so much for joining me today and sharing the previous results of your study and the exciting new challenges that you are taking on with these new grants.

Linda Teplin: Thank you, Erin. A pleasure to be here.

Erin Spain: A note for physicians who listen to this program, you can now claim continuing medical education credit just by listening to this podcast. Go to our website, feinberg.northwestern.edu and search for "CME" for more details.