Caring for Kids in the Juvenile Justice System

There’s no question that, for teenagers who end up on the wrong side of the law, being sentenced to juvenile detention is an unwelcome fate. But at Santa Clara County juvenile hall, there’s at least one silver lining: an opportunity for teens to have their medical, dental and mental health needs met, in some cases for the first time.

Arash Anoshiravani, MD, a clinical assistant professor of adolescent medicine at Stanford University School of Medicine, is medical director of the primary care clinic at Santa Clara County juvenile hall, where he sees patients aged 13 to 19 three days a week. He describes the clinic as an “inpatient-outpatient hybrid”—an outpatient clinic embedded in the facility where inmates are like inpatients, though they’re not in for medical reasons.

On a regular day, between 8:30 am and 5 pm, Anoshiravani and his staff of three nurses and at least one doctor-in-training see between 15 and 30 patients, 80 to 90 percent of whom are male. A nurse is on-site 24 hours a day. Anoshiravani is proud that, of California’s 52 county juvenile detention facilities, Santa Clara’s is “very well-staffed and very well-funded by the county. We have no problems getting the kids the health care they need.”

That’s important, because even though the medical needs of patients in juvenile detention are categorically the same as other teens, those needs are more extreme, largely because teens in juvenile detention haven’t had adequate care before coming in. “So, if they’re going to have cavities, they’re going to be big cavities,” says Anoshiravani. “If they’re going to be at high risk for sexually transmitted infections, they’re going to have the infection when they come in here. Some have asthma that has never been treated at all. We screen kids at regular teen clinics for the same conditions, they just come up less often and when they do come up they’re less severe.”

In addition to treating routine illnesses, the clinic staff provides thousands of vaccines for the teens each year, screens for and treats sexually transmitted diseases, refers teens for reproductive health needs like contraception, and provides dental services onsite from a dentist scheduled at the clinic one day a week. A psychiatrist is also on staff daily.

More than anything, Anoshiravani says, the teens in juvenile detention require mental health support, an especially acute problem because of the high rate of untreated trauma among the teens when they arrive. The National Center for Mental Health and Juvenile Justice reports that up to 50 percent of youth in the juvenile justice system suffer from post-traumatic stress disorder—a rate higher than their non-detained peers—with more than 90 percent of detainees having experienced at least one traumatic incident. The rates are higher still for girls.

“It’s just constant here,” says Anoshiravani. “Most of these kids have had traumatized lives, and most of the time it isn’t their fault. You hear about kids whose parents have been murdered, whose brother was shot in front of their house, kids who’ve been raped. And very few of these kids have been connected in the community with the mental health services they need. That becomes a big part of what our primary practice is, getting them that support.”

Because of the stigma surrounding mental illness, many of the teens don’t want to talk directly to a psychologist or psychiatrist at first. “They say ‘No, no, I’m fine, I don’t need any help,’ because people will think they’re crazy if they’re talking to a psychiatrist. But when they talk to a primary care doctor, we don’t have the same stigma. With us, they reveal a fair amount of what’s going on in their lives, and then we can refer as necessary to help them choose to talk with someone and get therapy to deal with their PTSD or depression.”

The medical clinic at Santa Clara County juvenile hall is part of the Santa Clara Valley Medical Center, a large community hospital and clinics that provide care for about 300,000 adults and children each year. The Santa Clara Valley Medical Center also has served as one of the primary training sites for the Stanford University School of Medicine’s students, interns, residents and fellows since 1972. Santa Clara County juvenile hall includes Stanford medical trainees as part of its staff: a medical student may spend a month in the clinic as part of their pediatrics rotation; a pediatrics resident may rotate through on their adolescent medicine rotation; and an adolescent medicine fellow might spend one day per week or month at the clinic as part of their specialized training.

Being able to care for patients who haven’t been seen by several, if any, doctors before, and in some cases being the first doctor to diagnose a previously unknown condition, or to help kids get the medicine or counseling they need, or to connect them with a specialist, can all be transformative learning experiences for doctors-in-training, not to mention beneficial and even life-changing for the kids they’re treating.

“Medical training experiences in high-impact areas, whether you’re talking about going out of the country or working in public hospitals or low-income areas, are incredible learning opportunities as well as service opportunities,” says Anoshiravani, who was assigned to a month-long rotation in the Los Angeles County juvenile hall when he was a student at Harvard Medical School in 1998. “The people you see really need you, and that can be a powerful motivation and learning tool. At the same time, having experiences with broad patient populations really expands a trainee’s worldview as well as how they can interact and show respect to different cultures and different populations. From an educational standpoint, it’s really useful.”

Caring for kids in juvenile hall has an added challenge that also teaches trainees about the importance of self-care. “It’s an emotionally draining job,” says Anoshiravani. “The kids you care for have had horrible lives and face horrible circumstances, and that takes a lot out of you.” Anoshiravani works on campus at Stanford two days each week doing research and advocacy work. “It gives me a chance to think about things in a different way and step back a little bit.”

Anoshiravani’s past research projects include a study on the health benefits of allowing high-risk youth in the juvenile justice system access to their electronic medical records. He also conducted a qualitative study with a medical student interviewing sexually exploited teen girls about the nature of their experiences to better identify their care needs. (At least 10 to 20 percent of girls in juvenile hall disclose risk factors associated with sexual exploitation or trafficking, though they are detained on other charges.)

The studies he currently has underway, in partnership with Paul Wise, MD, Richard E. Behrman Professor in Child Health at Stanford, examine the health outcomes, such as causes of hospitalization and mortality rates, of teens involved in the juvenile justice system in California.

“Most people don’t realize that 99 percent of the kids who come through juvenile hall end up back in the community,” says Anoshiravani. “So the real issue is: How do you want them to return? Do you want them to return more broken? Or do you want them to return with skills and a sense of compassion and to be healthy and to be able to contribute to society?”

Anoshiravani’s dedication to his patients is his answer. As he sees it, providing medical care to kids in juvenile hall is one undeniable step in the right direction. “We see many cases where an undiagnosed medical condition can be a contributing factor to behavioral problems,” he says. “The more we can take the opportunity to improve kids lives when they’re here in juvenile hall, the more we can help improve their chances of success when they get out.”