Health care standards for youth in custodial facilities
Posted: Jun 1 2005 | Reaffirmed: Feb 1 2016
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JY Frappier, D Sacks; Canadian Paediatric Society, Adolescent Health Committee
Paediatr Child Health 2005;10(5):287-9
Scope and definition of problem
In Canada in 2000/2001, 25,000 youth court cases resulted in a sentence of either jail or open custody in less structured facilities, such as group homes . During that year, 1254 youth were in secure facilities and 1564 were in more open centres, according to Youth Custody Community Services (Quebec statistics unavailable) . Past surveys of these youths in both the United States and Canada have revealed a high prevalence of health problems, with between 23% and 50% in need of medical or mental health care -. The principal problems are: skin lesions; upper respiratory tract infections or problems; sexually transmitted infections; contraception needs; pregnancy; mental health and violence issues; substance abuse; and respiratory, dental, endocrine and urological problems. More recent surveys in Quebec  and British Columbia  have confirmed that a high number of youths in custody have issues requiring medical attention, much more than the general population of youths attending regular school.
When youths in custody are admitted to the care of the state, institutions are obliged to provide appropriate attention to these problems. By promoting the physical and mental well-being of youths in custodial facilities, the Canadian Paediatric Society hopes that the health care system can contribute to the overall rehabilitation of such youths .
In Canada, custodial facilities for youth are under provincial jurisdiction. While in a facility, youths younger than 18 years of age have the same rights as all other children and youth younger than 18 years of age in that province with respect to health care, consent to health care and confidentiality. If the court decides to send a youth younger than 18 years of age to an ‘adult’ court, the youth is judged as an adult but retains the rights of a youth younger than 18 years of age.
The Canadian Paediatric Society urges health care professionals to assume a more active role in advocating for these youths. To advocate for health care standards in custodial facilities, health care professionals should address a number of groups and government departments, including ministries of justice, social affairs and public security, as well as children’s aid societies, human rights groups and other organizations.
The present statement addresses issues related to the type, timing, continuity and record of care. No attempt has been made, however, to define standards for the physical facilities themselves, except where specific components could directly affect the health of youths. The Canadian Paediatric Society recommends that the following medical protocol be adopted as guidelines for the health care of young people in custodial facilities.
Within each facility, a staff member should be designated to oversee the health program. While this person could be a nurse, in smaller settings where there are no nurses, he or she need not be a health care professional. Health programs should have clearly established policies and operating procedures for all matters concerning the physical and mental health of youths in the facility’s custody.
In the majority of facilities, these policies and operating procedures should be set by an advisory committee. The advisory committee should include individuals who can address issues related to administration, medical and psychiatric care, dental care, educational and psychological needs, and resident advocacy. The advisory committee should periodically review the standards to respond to changes within the facility or among the resident population.
In settings that are too small, which may be at remote locations and lack extensive staff, appropriate policies and operating procedures should be determined by the advisory committee of a larger facility within the region or province, or by a smaller consultant group. This consultant group could include a physician, a psychologist or psychiatrist, a dentist and a facility administrator. This consultant group could benefit from the work of others, such as another advisory committee or other specialists.
Larger facilities should have a physician and smaller facilities should consult a physician in a community clinic, if possible. The physician can be a paediatrician, family physician or internist with experience in youth health issues. If the physician does not have expertise in youth health, he or she should have access to support from youth health physicians and other specialists in the field of youth health and custodial care.
Services provided by the facility
Guidelines for short-term placements: Intake assessment
All facilities admitting youths to care should medically evaluate each individual within 72 h of admission. The necessary protocol should be in place for dealing more rapidly with acute illness, trauma or contagious disease, both to initiate treatment and to protect those already in the facility. After taking a medical and psychiatric history, a behavioural questionnaire is recommended to determine whether the youth presents a danger to either himself/herself or to others. Where appropriate, a family history should be taken to add any significant health information. This initial assessment can be performed by a suitably trained nurse, nurse clinician or physician.
Youths with a history of recent substance use should be assessed for signs and symptoms of withdrawal. The majority of substances abused by youths cause withdrawal syndromes, with the most problematic being withdrawal symptoms from opioids (eg, heroin), and benzodiazepines or barbiturates. Youths in opioid withdrawal may exhibit depression, severe myalgias, nausea, chills, autonomic instability or diarrhea. Youth withdrawing from regular benzodiazepine use have a risk of withdrawal-related seizures. These youth require a medically supervised treatment setting.
Guidelines for longer-term placements: Individual health assessment
A case manager from the staff should be assigned to each youth to organize an individual health assessment. The manager should request a medical history and psychosocial information, ensuring that the following guidelines are met:
- A recent medical history and physical examination have been performed and recorded.
- The medical and mental health history from the family has been obtained and recorded.
- Any investigations and assessments that were ordered have been performed and the results have been reviewed.
- A plan for both short- and long-term health goals has been established and detailed on the youth’s chart so that further evaluation will be carried out, either in the community on discharge or in any other institution to which the youth is transferred. This will reduce duplication and ensure that the assessment is done. These plans should be communicated to the youth and could involve family members as the youth consents.
- The youth has been involved in any plans concerning his/her health and that consent and confidentiality issues have been respected. Any plans or decisions made about the youth’s health and health care have been discussed with him/her and he/she has agreed to them. Health care professionals and case managers should ensure that consent to gather information about the youth is obtained, and that consent to any part of the plan or any health intervention is not forced on the youth by any staff member or anyone outside the facility. Every effort should be made to protect the confidentiality of the youth’s health record.
Emergency care plan
It is essential that facilities have a clearly detailed 24 h, seven-day-a-week emergency care plan that is fully understood by all staff. This plan should cover medical, behavioural and psychiatric emergencies. A health care manual listing relevant issues and local resources appropriate for each facility should also be available. A list of around-the-clock emergency medical, psychiatric, crisis response, police and social work resources should be posted. Someone trained in first aid and cardiopulmonary resuscitation, as well as management of violent or confrontational behaviour, should be present at all times. Everyone employed by the institution should be familiar with the health care program and should know which individuals are in charge of addressing acute medical, psychiatric and behavioural problems.
Continuing health assessment
Once the initial assessments have been completed, facilities should ensure that the following measures are in place for continued care and ongoing assessment.
- All previous medical, psychological, educational, psychiatric and laboratory evaluations should be available to assist with the current or future health care of the youth.
- A complete and confidential history, including psychiatric symptoms, sexual behaviour, substance abuse and history of physical/sexual abuse should be included in the youth’s assessment.
- Complete dental and medical examinations, including a genital examination where appropriate, should be performed once explanations have been given to the youth and consent has been obtained.
- If recommended, hearing, visual screening and laboratory evaluations should be arranged.
- Assessments of cognitive ability and any specific learning disabilities should be organized when appropriate.
- Immunizations should be updated according to provincial guidelines (with youth and parental consent where required).
- All youths should receive appropriate anticipatory guidance, including the following:
- education on healthy eating, an active lifestyle and additional treatment as needed;
- explanation of and counselling on the consequences of high-risk sexual behaviours, such as hepatitis, unplanned pregnancy, HIV and other sexually transmitted infections (this information should be detailed and appropriate to the youth’s cognitive ability); and
- ongoing counselling on contraceptives and safer sex (this should be offered to all youths, without judgment of their sexual orientation or practices).
Health records and transfers of cases
The findings of these investigations, as well as an appropriate health care plan to provide treatment for any conditions detected, should be explained to the youth. The youth’s health record should be made available (within the custodial network and after discussion and consent) to family and appropriate health care personnel in the community at the time of discharge or transfer.
Special considerations for the facility
Society is responsible for providing incarcerated youth with living facilities conducive to good physical and emotional health. In meeting the standards set for such institutions, special consideration should be given to providing the following:
- smoke-free areas;
- smoking cessation efforts and promotion, understanding that some youth use smoking to alleviate stress and that withdrawal may ensue because of physical dependence;
- recreation facilities that promote safe, active living practices;
- a medical room, ensuring privacy to carry out history-taking and physical examinations;
- nutrition services that promote healthy eating for youths;
- health education, including relevant information for pregnant, sexually active or substance abusing youth;
- a safe environment that provides youth with protection from themselves or others as needed; and
- a safe place to store medication records for each youth, as well as medication logs for both individuals and the institution.
Youth in detention may have a number of health conditions that contribute to their problems. As part of our commitment to maintaining and improving the health of Canadian children and youth, we are responsible, as health care professionals, to advocate the investigation and treatment of these conditions. Proper health care for youth in detention will provide long-term benefits to both the youths and the wider community. The attention that these youths receive while detained in society’s care could help improve their overall general health, self-esteem and outlook on life, and may ultimately mean a new beginning for them.
ADOLESCENT HEALTH COMMITTEE
Members: Sheri M Findlay MD; Jean-Yves Frappier MD (chair); Eudice Goldberg MD; Jorge Pinzon MD; Koravangattu Sankaran MD (board representative); Danielle Taddeo MD
Liaison: Karen Mary Leslie MD, Adolescent Health Section, Canadian Paediatric Society
Principal authors: Jean-Yves Frappier MD; Diane Sacks MD
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Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication.