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Practice Guidelines| Volume 71, ISSUE 1, 101889, January 2023

American Academy of Nursing expert panel consensus statement on inequities in the juvenile justice system rooted in systemic and structural racism

Published:December 30, 2022DOI:https://doi.org/10.1016/j.outlook.2022.10.002

      Highlights

      • The overrepresentation of youth of color has long been acknowledged and accepted in juvenile justice and legal systems.
      • Many risk factors contribute to the detention and incarceration of youth; however, there is little evidence to explain how structural inequities and systemic racism add to that vulnerability.
      • Historically, laws were passed to benefit the White society and resulted in outcomes that caused grave aftereffects for people of color and in some cases, ethnic minorities.
      • Within the context of juvenile justice and the lens of critical race theory, the authors of this paper seek to illuminate selected historical educational, environmental, legal, and health care policies, practices, and decisions that led to their detrimental consequences.
      • Recommendations for mitigating both intended (through law, funding, policies) and the unintended barriers as experienced by youth of color are presented.

      Abstract

      The overrepresentation of youth of color has long been acknowledged and accepted in juvenile justice and legal systems. Many risk factors contribute to the detention and incarceration of youth; however, there is little evidence to explain how structural inequities and systemic racism add to that vulnerability. Historically, laws were passed to benefit the White society and resulted in outcomes that caused grave aftereffects for people of color and in some cases, ethnic minorities. Within the context of juvenile justice and the lens of critical race theory, the authors of this paper seek to illuminate selected historical educational, environmental, legal, and health care policies, practices, and decisions that led to their detrimental consequences. Recommendations for mitigating both intended (through law, funding, policies) and the unintended barriers as experienced by youth of color are presented.

      Keywords

      He who is holding another down is holding himself down ∼∼ African proverb

      Introduction

      People of color (POC) have been overrepresented in the juvenile and adult criminal justice systems across America (
      • Gase L.N.
      • Glenn B.A.
      • Gomez L.M.
      • Kuo T.
      • Inkelas M.
      • Ponce N.A.
      Understanding racial and ethnic disparities in arrest: The role of individual, home, school, and community characteristics.
      ;

      Office of Juvenile Justice and Deliquency Prevention (OJJDP) (2022). OJJDP fact sheet: Key amendments to Office of Juvenile Justice and Delinquency Prevention Act Made by the Juvenile Justice Reform Act of 2018. https://ojjdp.ojp.gov/sites/g/files/xyckuh176/files/pubs/252961.pdf

      ). Over policing, defined for this paper as repressive and racially disparate policing resulting in distinct social consequences (
      • Jones-Brown D.
      • Williams J.
      Over-policing Black bodies: The need for multidimensional and transformative reforms.
      ) for POC, highlight a propensity for racial disparities and greater contact with the criminal justice system, often resulting in dangerous conflicts with law enforcement, prosecution, and incarceration. Systemic and structural racism may be perceived as synonymous; however, subtle differences contribute to what
      • Alexander M.
      The new Jim Crow: Mass incarceration in the age of colorblindness.
      calls invisibility, a nuance which allows racism to persist. The optics of structural racism were nationally amplified with the Black Lives Matter movement in 2020. A harsher level of justice was meted out to POC than the general population. Extreme law enforcement responses to POC, including youth, reaffirmed the inequities experienced by communities of color. Racial inequities often contribute to subsequent detention and incarceration of adolescent black males compared to other races and ethnicities (

      Rovner, J. (2021). Black disparities in youth incarceration. The Sentencing Project. https://www.sentencingproject.org/publications/black-disparities-youth-incarceration/

      ). Further, undiagnosed mental health disorders play an enormous role in juvenile detention and incarceration (
      • Teplin L.A.
      • Potthoff L.M.
      • Aaby D.A.
      • Welty L.J.
      • Dulcan M.K.
      • Abram K.M.
      Prevalence, comorbidity, and continuity of psychiatric disorders in a 15-Year longitudinal study of youths involved in the juvenile justice system.
      ;
      • Teplin L.A.
      • Abram K.M.
      • McClelland G.M.
      • Dulcan M.K.
      • Mericle A.A.
      Psychiatric disorders in youth in juvenile detention.
      ).
      There is growing recognition of the extent to which incarceration reflects and contributes to racial and ethnic inequity in the United States. Furthermore, there is growing public recognition that laws contributing to established policies governing everyday life contribute to racial disparities (

      Pew Research Center. (2020). Amid protests, majorities across racial and ethnic groups express support for the Black Lives Matter Movement. https://www.pewresearch.org/social-trends/2020/06/12/amid-protests-majorities-across-racial-and-ethnic-groups-express-support-for-the-black-lives-matter-movement/

      ). The purpose of this paper is to examine the consequences of selected policies that led to racial inequities and to provide recommendations for mitigating racial disparities for youth of color at risk for juvenile detention and incarceration.

      Background

      Adolescence, defined as 13 to 18 years of age for this paper, is a critical developmental period with challenges related to the transition into adulthood. Decision-making of adolescents across all populations and their subsequent behaviors are affected by immature brain development and an undeveloped frontal cortex (
      • Steinberg L.
      The influence of neuroscience on US Supreme Court decisions about adolescents' criminal culpability.
      ). Adolescents who have experienced childhood adversities (
      • Goddard A.
      Adverse childhood experiences and trauma-informed care.
      ) are at greater risk for poor decision-making that is influenced by both internal and external risk factors which can lead to subsequent high-risk for entry into the juvenile justice system. Adolescent internal risk factors include anxiety, social isolation, and depression, may develop over time, and be expressed through behaviors of delinquency, aggression, or mental health and substance use disorders (
      • Nelson C.A.
      • Scott R.D.
      • Bhutta Z.A.
      • Harris N.B.
      • Danese A.
      • Samara M.
      Adversity in childhood is linked to mental and physical health throughout life.
      ). External risk factors, such as parental incarceration, parental psychiatric and/or substance use disorders, housing instability, and child maltreatment also affect decision making skills (
      • Bonham E.
      A theory of hoping for a better life grounded in youthful offender experiences.
      ;
      • Bradshaw D.
      • Hannigan A.
      • Creaven A.M.
      • Muldoon O.
      Longitudinal associations between parental incarceration and children's emotional and behavioural development: Results from a populations cohort study.
      ;
      • Dubowitz H.
      • Roesch S.
      • Lewis T.
      Child maltreatment, early adult substance use, and mediation by adolescent behavior problems.
      ;
      • McCarthy K.
      • Yoon S.
      • Pei F.
      Developmental differential impact of child maltreatment: The practitioner's perspective.
      ). Experiencing these external risk factors can have a life-long impact on childhood health outcomes, specifically, emotional, developmental, social, and educational performance (
      • Bailey Z.D.
      • Feldman J.M.
      • Bassett M.T.
      How structural racism works: racist policies as a root cause of U.S. racial health inequities.
      ;
      • Bonham E.
      Developmental issues and mental health.
      ;
      • Bronfenbrenner U.
      Making human beings human: Biological perspectives on human development.
      ;
      • Huynh-Hohnbaum A.
      • Bussell T.
      • Lee G.
      Incarcerated mothers and fathers: How their absences disrupt children's high school graduation.
      ;
      • Sabates R.
      • Dex S.
      The impact of multiple risk factors on young children's cognitive and behavioural development.
      ;
      • Yan N.
      • Dix T.
      Mothers’ depressive symptoms and children's cognitive and social agency: Predicting first-grade cognitive functioning.
      ).
      Youth with a history of parental incarceration, compared to their counterparts, are more likely to experience behavioral problems and be suspended from school (
      • Huynh-Hohnbaum A.
      • Bussell T.
      • Lee G.
      Incarcerated mothers and fathers: How their absences disrupt children's high school graduation.
      ). Additionally, youth with incarcerated parents have expressed feelings of shame and stigma, which can adversely impact children's mental and emotional health, behaviors, and overall academic performance (
      • Nosek M.
      • Stillman J.A.
      • Whelan Z.
      Youth experiences of parent incarceration: Doing time from both sides.
      ).
      Youth of color are placed at further risk for poor decision-making when experiencing unstable living situations, such as unsafe neighborhoods, insufficient and sub-standard educational opportunities, and homelessness. The parent/child relationship is the foundation of childhood and adult emotional development as exhibited by healthy relationships, effective coping skills, and thoughtful impulse control (
      • Punamäki R.L.
      • Flykt M.
      • Belt R.
      • Lindblom J.
      Maternal substance use disorder predicting children's emotion regulation in middle childhood: The role of early mother-infant interaction.
      ). Parental psychiatric or substance use disorders impact early childhood development by affecting the quality of parent-child relationships. Disrupted parent–child relationships interfere with the trajectory of developmental milestones and the ability to form meaningful and trusting relationships.
      The nursing profession asserts longstanding tenets of regard for all populations, the environment, and social justice. Thus, the authors are outraged that continued racial disparities are instrumental in contributing to the incarceration of youth of color. Using a historical context and through the lens of Critical Race Theory (CRT), this paper examines policies perpetuating racial inequity within four selected domains the authors view as critical to communal public life—education; neighborhood and community; legal and juvenile justice; and health care.
      Table 1
      Table 1Recommendations for Mitigation of Unintended Barriers to Youth Development
      RecommendationGoalAction Steps
      Recommendation I.

      Implement policies and programs that reduce the number of referrals to law enforcement by instituting alternative responses to delinquent behavior which prevent youth from entering the juvenile justice system, thereby decreasing detention and incarceration
      Prevent referrals to law enforcement that result in arrest, petition, and/or status offense which often provide the first exposure of youth to the justice system.Resource schools with mental health providers

      Integrate social, emotional and cultural humility learning programs across public school systems

      Establish in school peer panels for restorative justice implementation
      Recommendation II.

      To mitigate risk taking behaviors, increase the number of safe spaces, recreational facilities, and after school programs in neighborhoods with community engaged policing.
      Provide positive reinforcement activities that enhance youth engagement in safe environmentsEstablish resident & government planning units to discuss special equity commissions, land use, housing, zoning and other city planning issues

      Create and engage youth in community gardening

      Partner with local police departments to implement positive youth development strategies
      Recommendation III.

      Support ending the youth prison model by shifting the habilitation model from one of large detention centers to smaller, therapeutic facilities.
      Improve access to and quality of mental and behavioral health services for at-risk youth in order to reduce the number of affected youths inappropriately entering the juvenile justice system.Implement early identification through screening, community education programs

      Develop crossover programs that bridge child welfare and juvenile justice

      Apply wraparound model as a system of care
      Recommendation IV.

      Elevate the mental and behavioral health services for youth in the community including in detention.
      Increase number of accessible mental and behavioral health services and providers, as well as care coordination for youth.Increase integrated behavioral care services across primary care settings

      Incentivize recruitment and retention of providers in community mental health services (loan forgiveness, increased salary etc.)

      Provide child-centered and parent engaged services while child is incarcerated.

      Legislation, Policies, and Consequences

      The advancement of civil rights through legislation and policy are linked to public health improvements. Unfortunately, the attainment of civil rights through legislation and policy alone is not enough. Implementation and enforcement of policy completes the circle of societal change that transforms relationships, cultural and social systems (
      • Klau M.
      Race and Social Change: A Quest, a Study, a Call to Action.
      ). Interpretation of legislation and policy are not finite; rather they are fluid in response to contextual influences, challenges, interpretation, vigilance, and unforeseen circumstances. Until policies to ensure civil rights are implemented through the lens of social justice are embraced, enforced and maintained, civil rights are merely words and unkept promises.
      Historically, the enforcement and maintenance of civil rights policies are uneven, incomplete, and vulnerable to resistance. Health promotion and disease prevention initiatives became a national concern when US Surgeon General Julius B. Richmond wrote Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention (

      Healthy People. (1979). Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention. United States Public Health Service. https://profiles.nlm.nih.gov/101584932X92

      ). Consequently, those initiatives evolved to contain social determinants of health which include economic stability, health care and education access, and supportive community. Additionally, when thinking of addressing health from an equitable space,
      • Dawes D.E.
      The political determinants of health.
      frames the structures, processes, and outputs set in place in communities as the political determinants of health that require upstream solutions. In the following sections, the consequences and inequities of unenforced civil rights statutes and policies in the author selected domains of education; neighborhood and community; legal and juvenile justice; and health care are discussed.

      Education

      Historically, universal public education for all citizens was valued as a means of bridging poverty by creating a more equal society. After the Civil War, Black Americans rightfully sought public education. The reconstruction era abounded with public education issues that culminated in the 1896 U.S. Supreme Court Plessy v. Ferguson decision of a "separate but equal" approach which guaranteed segregated schools for the next 60 years (). In 1954, the U.S. Supreme Court Brown v. Board of Education of Topeka decision declared that racial segregation in public schools violated the equal protection clause of the Fourteenth Amendment, effectively overturning Plessy v. Ferguson decision of "separate but equal" (

      Brown v. Board of Education. (1954). National Archives and Records Administration Educator Resources. https://www.archives.gov/education/lessons/brown-v-board

      ).
      Laws were enacted in the United States to ensure that all citizens had equal civil rights regardless of race, ethnicity, and gender (
      • Hahn R.A.
      • Truman B.I.
      • Williams D.R.
      Civil rights as determinants of public health and racial and ethnic health equity. Health care, education, employment, and housing in the United States.
      ;

      Legal Highlight, The Civil Rights Act of 1964. Office of Assistant Secretary of Administration & Management. Retrieved January 30, 2022, from https://www.dol.gov/agencies/oasam/civil-rights-center/statutes/civil-rights-act-of-1964

      Civil Rights Law, 1964). However, due to inconsistent enforcement of equity laws, inequity in education remains for youth of color (
      • Haelermans C.
      • Korthals R.
      • Jacobs M.
      • de Leeuw S.
      • Vermeulen S.
      • van Vugt L.
      • de Wolf I.
      Sharp increase in inequality in education in times of the COVID-19-pandemic.
      ;
      • Hahn R.A.
      • Truman B.I.
      Education improves public health and promotes health equity.
      ). Even within the same state or town, differences in the youth's formal education exist based on the funding structure in place supporting the school's public education. Youth attending a well-funded school system can expect robust resources vs. youth residing within an impoverished school district with limited assets (

      Barshay, J. (2020, June 20). A decade of research on the rich-poor divide in education. The Hechlinger Report https://hechingerreport.org/a-decade-of-research-on-the-rich-poor-divide-in-education/

      ). The quality of educators recruited to teach within a school system often depends on the strength of salary and benefits. When students from marginalized communities, largely made up of underrepresented populations, have fewer resources, their formal education will not be equivalent to that of children in privileged communities (
      • Hahn R.A.
      • Truman B.I.
      • Williams D.R.
      Civil rights as determinants of public health and racial and ethnic health equity. Health care, education, employment, and housing in the United States.
      ).
      Disparity in educational support for children with cognitive and physical disabilities drove advocacy for change resulting in the Education for All Handicapped Children Act (Public Law 94-142) enacted by Congress in 1975 and subsequently revised and renamed in 1990 as the Individuals with Disabilities Education Act (

      US Department of Education. (2020). A history of the Individuals with Disabilities Act (IDEA). https://sites.ed.gov/idea/IDEA-History#1980s-90s

      ;

      US Department of Education. (2020). IDEA: Individuals with Disabilities Education Act. https://sites.ed.gov/idea/

      ). While the intention of this law was to provide equity in educational opportunities for disabled youth, evidence suggests that racial and ethnic minority students are less likely to be identified for special education than white students (
      • Morgan P.L.
      • Farkas G.
      • Hillemeier M.M.
      • Maczuga S.
      Replicated evidence of racial and ethnic disparities in disability identification in U.S. schools.
      )

      Neighborhood and Community

      Under resourced low socioeconomic neighborhoods with few safety nets for youth present major risk factors for Black and ethnic youth involvement with the juvenile justice system (
      • Baumer E.
      • Horney J.
      • Felson R.
      • Lauritsen J.L.
      Neighborhood disadvantage and the nature of violence.
      ;
      • Loyd A.
      • Hotton A.
      • Walden A.
      • Kendall A.
      • Emerson E.
      • Donenberg G.
      Associations of ethnic/racial discrimination with internalizing symptoms and externalizing behaviors among juvenile justice-involved youth of color.
      ;
      • Sampson R.J.
      • Raudenbush S.W.
      • Earls F.
      Neighborhoods and violent crime: A multilevel study of collective efficacy.
      ). In 1934, the federal government created the Federal Housing Administration and passed the National Housing Act which was amended over time to accommodate community development as population changes occurred. In 1965, the Housing and Urban Development Act created housing expansions to mitigate identified urban problems such as deteriorating neighborhoods. One such solution was the construction of high-rise housing developments which families eventually deemed unsafe. The housing developments placed youth at greater risk for living in neighborhoods with limited resources, underfunded schools, over policing, violent and/or fatal encounters with police, and ethnic/racial discrimination, all of which add to a higher risk for justice system involvement and incarceration (
      • Alang S.
      • McAlpine D.
      • McCreedy E.
      • Hardeman R.
      Police brutality and Black health: Setting the agenda for public health scholars.
      ;
      • Hinton E.
      Creating crime.
      ;
      • Li J.
      • Kim C.
      Household food shopping locations beyond residential neighborhoods: An exploratory study using a GPS-based household survey.
      ;
      • Loyd A.
      • Hotton A.
      • Walden A.
      • Kendall A.
      • Emerson E.
      • Donenberg G.
      Associations of ethnic/racial discrimination with internalizing symptoms and externalizing behaviors among juvenile justice-involved youth of color.
      ).
      Home ownership is a longstanding indicator of financial stability. The basic need of shelter is a family's largest budget item. Families with limited resources are challenged to find affordable housing. Federal legislation, initially constructed in 1937 with multiple revisions, provides resources to subsidize housing for families with limited incomes, including section eight housing. Unfortunately, section eight housing is not always readily available in all communities, especially if there is a high demand for subsidized housing. Additionally, families with young children often need to consider whether the affordable housing is located near public transportation, schools, grocery stores, and employment (
      • Nguyen Q.C.
      • Acevedo-Garcia D.
      • Schmidt N.M.
      • Osypuk T.L.
      The effects of a housing mobility experiment on participants’ residential environments.
      ).
      The Fair Housing Act of 1968 reinforced the right of every citizen to rent or buy a home, regardless of color, religion, or ethnic origin (

      History of Fair Housing (n.d.). U.S. Department of Housing and Urban Development. Retrieved January 30, 2022, from https://www.hud.gov/program_offices/fair_housing_equal_opp/aboutfheo/history

      ). Obscured from public view in many communities was the practice by mortgage lenders of outlining maps to form a red line around areas which were populated by residents of color, which was evidence of the practice of racism by zip code. Realtors would limit the homes that were shown to persons of color, to homes inside of that red line on the map. Additionally, banks would not extend mortgages to persons of color who wanted to buy a home that was outside of the red line. The ongoing practice of redlining has prevented investment in communities of color, effectively robbing residents of home ownership wealth for generations (
      • Aaronson D.
      • Faber J.
      • Hartley D.
      • Mazumder B.
      • Sharkey P.
      The long-run effects of the 1930s HOLC “redlining” maps on place-based measures of economic opportunity and socioeconomic success.
      ; ). Additionally, redlining in communities has been associated with serious adverse health outcomes such as preterm birth, cancer, asthma, and decreased life expectancy (
      • Lee E.K.
      • Donley G.
      • Ciesielski T.H.
      • Gill I.
      • Yamoah O.
      • Roche A.
      • Martinez R.
      • Freedman D.A.
      Health outcomes in redlined versus non-redlined neighborhoods: A systematic review and meta-analysis.
      ).

      Legal and Juvenile Justice

      Grounded in early 20th century social justice reforms, the juvenile justice system evolved from an orphanage model to reform school (
      • Greenwood P.W.
      • Turner S.
      Juvenile crime and juvenile justice.
      ) to current rehabilitation practice and community-based interventions. To provide protective supervision, the juvenile justice system possesses broad latitude in law interpretation which results in racial disparity regarding youth dispositions and treatment (
      • Robles-Ramamurthy B.
      • Watson C.
      Examining racial disparities in juvenile justice.
      ). In 1961 Congress passed the Juvenile Delinquency and Youth Offenses Control Act, (further modified in 1974 as the Juvenile Justice and Delinquency Prevention Act) to provide direction for the care of youthful offenders. Despite this direction, selective handling of youth of color in the areas of judicial decision enforcement, treatment opportunities, risk assessment instruments, and administrative practices was cited as a continuing cause for inequity at contact points in the juvenile justice system well into the 2000s (

      Office of Juvenile Justice and Deliquency Prevention (OJJDP). (2012). OJJDP in focus fact sheet: Disproportionate minority contact. https://ojjdp.ojp.gov/library/publications/ojjdp-focus-fact-sheet-disproportionate-minority-contact

      ). The law was reauthorized as the Juvenile Justice Reform Act (JJRA) of 2018 and updated in 2021, requiring facilities to develop a minority overrepresentation plan (

      Office of Juvenile Justice and Deliquency Prevention (OJJDP) (2022). OJJDP fact sheet: Key amendments to Office of Juvenile Justice and Delinquency Prevention Act Made by the Juvenile Justice Reform Act of 2018. https://ojjdp.ojp.gov/sites/g/files/xyckuh176/files/pubs/252961.pdf

      ). Disposition is influenced by parental legal literacy, financial competence, and race, as youth whose family has financial means are frequently mandated to psychiatric care while youth of color who may not have financial means are at greater risk for being incarcerated (

      Rovner, J. (2021). Black disparities in youth incarceration. The Sentencing Project. https://www.sentencingproject.org/publications/black-disparities-youth-incarceration/

      ;

      Sawyer, W. (2019). Youth confinement: The whole pie 2019. Prison Policy Initiative. https://www.prisonpolicy.org/reports/youth2019.html

      ).

      Health Care

      Health care inequities have long been a part of the history of the health care system in America. Although the US spends more on health care than any other high-income country, inequities in health, access to health care, and poor health outcomes persist (
      • Mizelle R.M.
      • Burnham John C.
      Healthcare in America: A history by.
      ;
      National Academies of Sciences, Engineering, and Medicine (NASEM)
      The future of nursing 2020–2030: Charting a path to achieve health equity.
      ). Two important areas where health inequities are most pronounced are in health insurance and hospital-based clinical care. Many Americans receive their health insurance as an employee benefit, a remnant of political maneuvering during World War II to support business growth (
      • Thomasson M.A.
      From sickness to health: The twentieth-century development of US health insurance.
      ). Others receive their health insurance from Medicare and/or Medicaid, federal government programs signed into law in 1965 (

      Centers for Medicare and Medicaid Services. (n.d.) Centers for Medicare and Medicaid Services program history. https://www.cms.gov/About-CMS/Agency-Information/History

      ). In 1997, the Children's Health Insurance Program became law providing health insurance for families with children not qualifying for Medicaid (

      Children's Health Insurance Program. (n.d.). Centers for medicare and medicaid services. https://www.medicaid.gov/chip/index.html

      ). The Affordable Care Act, enacted in 2010, further expanded Medicaid to improve health care access (

      Affordable Care Act (n.d.). Healthcare.gov. https://www.healthcare.gov/

      ). Currently, despite these programs, over 8% of Americans do not have any health care coverage; Black, Asian, and Hispanic (any race) populations encompass respective insurance rates of 10.4%, 5.9%, and 18.3% (

      US Census Bureau. (2021, October 18). Healthcare insurance coverage in the U.S:2020. https://www.census.gov/library/publications/2021/demo/p60-274.html

      ). For those employed, inequities in employment (type of coverage offered, number of hours worked) determine the comprehensiveness of health insurance coverage. Even though 90% of Americans had insurance in 2020, having insurance does not always reflect meaningful coverage for health care costs.
      The passage of the Civil Rights Act of 1964 (Title VI) and Medicare (1965) tied federal funding to non-discriminatory practices within the health care industry (
      • Barton Smith D.
      The "Golden Rules" for eliminating disparities: Title VI, Medicare, and the implementation of the Affordable Care Act.
      ). Since Medicare funds provided a significant proportion of financial support to health care facilities, non-discriminatory health care was necessary for ongoing financial security. The 2003 Institute of Medicine Report found that racial and ethnic minorities, when compared with Whites, were more likely to face significant barriers to equitable access to health care and health disparities persisted (
      Institute of Medicine (IOM)
      ). Despite progress being made, a wide range of health care inequities remain in relation to cancer outcomes, heart disease, maternal and child health, and infectious disease (
      • Bailey Z.D.
      • Krieger N.
      • Agénor M.
      • Graves J.
      • Linos N.
      • Bassett M.T.
      Structural racism and health inequities in the USA: Evidence and interventions.
      ;
      • Cogburn C.D.
      Culture, race, and health: Implications for racial inequities and population health.
      ;
      • Collier A.Y.
      • Molina R.L.
      Maternal mortality in the United States: Updates on trends, causes, and solutions.
      ;
      • Tai D.
      • Shah A.
      • Doubeni C.A.
      • Sia I.G.
      • Wieland M.L.
      The disproportionate impact of COVID-19 on racial and ethnic minorities in the United States.
      ;
      • Zavala V.A.
      • Bracci P.M.
      • Carethers J.M.
      • Carvajal-Carmona L.
      • Coggins N.B.
      • Cruz-Correa M.R.
      • Davis M.
      • de Smith A.J.
      • Dutil J.
      • Figueiredo J.C.
      • Fox R.
      • Graves K.D.
      • Gomez S.L.
      • Llera A.
      • Neuhausen S.L.
      • Newman L.
      • Nguyen T.
      • Palmer J.R.
      • Palmer N.R.
      • Pérez-Stable E.J.
      • Fejerman L.
      Cancer health disparities in racial/ethnic minorities in the United States.
      ). In addition, although there is substantive evidence of the roles that historical trauma, social and political determinants of health, and chronic stress from racism play in an individual's health, more work is needed to eliminate the influence these forces play in preventing equitable access to health care and quality health outcomes (
      • Braveman P.A.
      • Arkin E.
      • Proctor D.
      • Kauh T.
      • Holm N.
      Systemic and structural racism: Definitions, examples, health damages, and approaches to dismantling.
      ;
      • Dawes D.E.
      The political determinants of health.
      ;
      • McGee E.O.
      Addressing systemic racism as the cancer of black people: Equity ethic-driven research.
      ;
      • Siegel M.
      • Critchfield-Jain I.
      • Boykin M.
      • Owens A.
      Actual racial/ethnic disparities in COVID-19 mortality for the Non-Hispanic black compared to Non-Hispanic white population in 35 US states and their association with Structural Racism.
      ). Work at the systemic level has the potential to achieve an integrated health care system where multiple social domains are supported, funded, and enforced to be mutually reinforcing (
      • Reskin B.
      The race discrimination system.
      ).

      Discussion and Recommendations

      CRT provides a framework for understanding how public policies continue to perpetrate inequities (
      • Bell D.A.
      Who's afraid of critical race theory.
      ;
      • Crenshaw K.
      • Gotanda N.
      • Peller G.
      • Thomas K.
      Critical Race Theory: The Key Writings That Formed the Movement.
      ). Concepts such as minimizing race may result in a color blindness construct that necessitates the use of CRT to explain racism (
      • Neville H.A.
      • Awad G.H.
      • Brooks J.E.
      • Flores M.P.
      • Bluemel J.
      Color-blind racial ideology: Theory, training, and measurement implications in psychology.
      ). A prevailing societal attitude of racial bias and stereotyping makes implementation of policies difficult. As discussed earlier, the oppression of persons of color remains largely invisible or ignored, perpetuating inequity in education, communities, juvenile justice, and health care.
      Critical social theory (
      • Habermas J.
      Knowledge and Human Interests (Shapiro, J., trans).
      ) examines how the critique of sociopolitical issues can transform a society's status quo. Thus, using CRT as a framework may provide a mechanism to explore how legal mechanisms perpetuate an unequitable dominant society that must be transformed. Risk factors that contribute to juvenile delinquency are driven by a failure to develop, implement and maintain local, state and federal laws and regulations that mitigate racialized discrimination in education, housing, justice, and health care, including mental health care. A large percentage of detained youth have mental health disorders that fail to be diagnosed or treated until a youth is in the juvenile justice system.
      Beginning with the United States Constitution in 1787, Black Americans were considered as “three fifths a person” and remained so until ratification of Amendment XIV one hundred years later to “whole number of male citizens twenty-one years of age” (
      US Constitution
      The Constitution of the United States with Index and The Declaration of Independence.
      , p. 26). A national regard of POC as "other" has persisted for centuries with intermittent mitigation by federal laws resulting in a caste system (
      • Wilkerson I.
      Caste: The origins of our discontents.
      ). A caste system is eloquently described by
      • Wilkerson I.
      Caste: The origins of our discontents.
      as a way to “use rigid, often arbitrary boundaries to keep ranked groupings apart, distinct from one another and in their assigned places” (p. 17). A notion of caste system implementation extends invisibly but is evident within poorly resourced school systems, unsafe neighborhoods, justice meted out based on race, and health care delivered by zip code. It is crucial that invisible structural racism is named to make oppression visible, so that racial inequalities can be addressed and indeed ensure the rights for all people to have healthy lives.
      Improving health and achieving health equity requires development of strong policies that possess the ability to be implemented and enforced with timely reevaluation which informs appropriate revision. Policy is one small component in a series of steps that when used positively, allows society to self-govern, grow, and thrive. A community's health is measured by its ability to advance, reexamine, and adjust to provide conditions that sustain health and resilience. Policies also represent a series of compromises from stakeholders. As such, unintended consequences are a norm, not an aberrance of policy implementation. Policies are reflected by stakeholders and the communities served; evolution in communities and stakeholders require periodic policy reevaluation and revision. The following recommendations are presented through the lens of policy as living documents, not static entities, to learn from historically good legislation that has, over time, demonstrated unintended consequences, largely through not closing the loop with scheduled reevaluation and revision.
      Policies to reduce racial disparities in youth at-risk for unfair and unjust juvenile incarceration include those that can be pursued prior to, during and post-juvenile incarceration with special emphasis on education, neighborhood and community, legal and juvenile justice, and health care domains. The following policy recommendations support adolescent development and are aimed at achieving equitable outcomes for all youth, especially those of color, charged with delinquency.
      Recommendation I. Implement policies and programs that reduce the number of referrals to law enforcement by instituting alternative responses to delinquent behavior which prevent youth from entering the juvenile justice system, thereby decreasing detention and incarceration. Referrals to law enforcement resulting in an arrest typically provide the first exposure of youth to the criminal justice system. Infractions and disciplinary issues by students in schools, typically handled by school policy, increasingly result in law enforcement referrals which bolster the school to prison pipeline (). One alternative is school-based restorative justice programs which have been shown to address school-related disciplinary problems (
      • Todić J.
      • Cubbin C.
      • Armour M.
      • Rountree M.
      • González T.
      Reframing school-based restorative justice as a structural population health intervention.
      ). Examples include peer jury programs that utilize student jurors to address issues such as disruption in the classroom, truancy, and property damage. Additionally, peer mediation promotes conflict resolution between young people in conflict, particularly when there is no clearly identified offender. Elimination of “zero tolerance” policies that impose mandatory suspension or expulsion from the school environment support school-based leadership discretion in addressing offenses committed by students. Policies and protocols that reduce mandatory referrals to law enforcement support implementation of positive alternative approaches to referral by school systems. Uninterrupted education during incarceration is critical to mitigating further regression or disparities in education among all incarcerated youth. Maintaining access to academic programming during detention and re-entry planning with a support team promotes successful transition to regular school post incarceration and reduces recidivism (
      • Kubek J.B.
      • Tindall-Biggins C.
      • Reed K.
      • Carr L.E.
      • Fenning P.A.
      A systematic literature review of school reentry practices among youth impacted by juvenile justice.
      ).
      Recommendation II. To mitigate risk taking behaviors, increase the number of safe spaces, recreational facilities, and after school programs in neighborhoods with community engaged policing. Safe neighborhoods and communities are necessary to mitigate risky behaviors that lead to juvenile delinquency. Additionally, development of community-based programs keeps youth within their homes and communities and decriminalizes non-violent offenses. These detention alternatives are likely to decrease dependency on detention at the beginning of the juvenile justice system reducing overrepresentation of youth of color. Additionally, governing structures such as city councils, banks, and businesses can invest in their local communities through providing mortgage loans to persons of color, plan and cultivate multifamily housing developments, and conduct comprehensive redlining assessments of their community.
      Recommendation III. Support ending the youth prison model by shifting the habilitation model from one of large detention centers to smaller, therapeutic facilities. Detention alternatives include youth and family focused interventions and community-based alternatives that provide intensive supervision, graduated levels of independence, and desistance support from delinquency (). Community-based alternatives increase provision of a program continuum while designing small age-appropriate therapeutic facilities for youth who require secure confinement (

      Community change. (2022). The Annie E. Casey Foundation. https://www.aecf.org/work/community-change

      ). Program interventions include monitoring and reporting programs, home detention, victim-offender mediation and restitution, community service, recreation, counseling, and treatment programs. Additionally, youth separation from families, home and community is reduced. Non-institutional options for youth can be pursued by decision makers further diverting youth from the criminal justice system while incarcerating those that pose a significant threat to public safety. Parent participation and collaboration ameliorate disparate legal outcomes while improving access to quality defense services, reducing failure-to-appear rates, modifying harsh sentencing for juvenile offenders, and reducing retention of youth in the juvenile justice system. For example, parents need legal literacy skills to navigate the legal process and advocate for their child. Youth and family friendly legal advice and representation, especially those that consider social determinants of health factors such as level of education, financial, and community resources, assists adherence to probation and reduces failure to appear rates.
      Recommendation IV. Elevate the mental and behavioral health services for youth in the community including in detention. The overrepresentation of youth with mental and behavioral disorders in the juvenile justice system has resulted in the primary treatment of these disorders as commonplace in detention centers. Improving access to quality mental and behavioral health services for at-risk youth can significantly reduce the number of affected youths inappropriately entering the juvenile justice system. Programs that screen for mental and behavioral health using culturally sensitive screening instruments; initiate or resume treatment during detention; engage parents as active partners in care and decision making about the adjudication plan; and divert affected youth to a community-based provider or treatment center have been shown to reduce risk for recidivism (
      • Teplin L.A.
      • Potthoff L.M.
      • Aaby D.A.
      • Welty L.J.
      • Dulcan M.K.
      • Abram K.M.
      Prevalence, comorbidity, and continuity of psychiatric disorders in a 15-Year longitudinal study of youths involved in the juvenile justice system.
      ).

      Conclusion

      Early identification, screening, family assistance, and safe community provision are acknowledged strategies that support youth development. Systemic racism, including established structures such as redlining impact health, social and political determinants of health for POC and contribute to unsafe communities. Supporting youth in their trajectory to be healthy adult citizens requires a multidisciplinary approach. There are known system interventions being applied nationally to effectively diminish youth involvement with the juvenile justice system (
      • Bouffard J.
      • Cooper M.
      • Bergseth K.
      The effectiveness of various restorative justice interventions on recidivism outcomes among juvenile offenders.
      ;
      • Demeter L.
      • Sibanda N.
      Neighborhood risks and resources correlated with successful reentry of youth returning from Massachusetts detention centers.
      ;
      • Rhodes D.
      • Cox C.
      • Herbert P.
      • Bylina H.
      • Heman P.
      • Rembush E.
      • Mehl J.
      Delivering trauma-informed care in the juvenile justice setting.
      ). Policies can have unintended consequences, and therefore need to be periodically reviewed and revised, to ensure they are meeting the needs of the targeted population, especially for youth of color.

      Authors' Contributions

      The work in the paper is original content of the authors and has not been previously published. Bonham: Conceptualization, Methodology, Visualization, Writing-Original draft preparation, Writing-Reviewing and Editing. Snethen: Conceptualization, Methodology, Visualization, Writing-Original draft preparation, Writing-Reviewing and Editing. Marino: Conceptualization, Methodology, Visualization, Writing-Reviewing and Editing. Oruche: Conceptualization, Methodology, Visualization, Writing-Reviewing and Editing. Browne: Conceptualization, Methodology, Visualization, Writing-Reviewing and Editing.

      Acknowledgments

      This consensus paper represents the partnering of four American Academy of Nursing Expert Panels: Psychiatric Mental Health Substance Use; Children, Adolescents & Family; Violence, and Cultural Competence & Health Equity. We gratefully acknowledge the review and expertise of JoEllen Schimmels, DNP, PMHNP-BC, ANP-BC, CNE, FAAN; Deborah Antai-Otong, APRN, RN, PMHCNS-BC, FAAN; Cynthia Greenberg, DNSc, RN, CPNP-PC, FAAN; and Jose Alejandro, PhD, RN, NEA-BC, MBA, FACHE, FAAN.

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