The United States is the most heavily incarcerated country in the developed world, and with that comes many secondary consequences, including children growing up with incarcerated parents. Approximately five million children in the United States, or 7% of American children, have at least one incarcerated parent. Although efforts have been made to mitigate the harm associated with having an incarcerated parent, few are focused on meeting the direct health needs of these children through preventative health care. One author’s family experience inspired the 2018-2019 Missouri State Medical Association (MSMA) Medical Student Section Board to further research the effects of parental incarceration on children and ultimately create a resolution to address this important issue.
Having an incarcerated parent is one of the original exposures in the seminal report on Adverse Childhood Experiences (ACEs). This study and extensive subsequent research have demonstrated the long-term health consequences in children exposed to a traumatic childhood event. If multiple exposures occur, each additional trauma increases the risk of negative health outcomes proportionally. These health consequences are sobering and include substance abuse, obesity, depression, sexually transmitted infections and chronic conditions such as ischemic heart disease, cancer and diabetes.
As further research substantiates the link among ACEs and poor health outcomes, increased attention has been devoted to identifying children experiencing ACEs, preventing exposure and providing appropriate treatment. Many physician groups, such as the American Academy of Pediatrics, and various governmental organizations, like the Centers for Disease Control and Prevention, The National Child Trauma and Stress Network and the Substance Abuse and Mental Health Services Administration have clear policy directed toward these goals and provide resources to health care providers. Current efforts include physician education about ACEs and trauma-informed care, as well as increased screening and treatment development.
Although the link between ACEs and long-term health outcomes has been well established, the MSMA’s resolution focuses on a particularly vulnerable population exposed to at least one known traumatic adverse childhood experience: parental incarceration. Research has shown that children with incarcerated parents, in particular, are at risk for poor health outcomes due to forgone health care, prescription drug abuse, 10 or more lifetime sexual partners, higher likelihood of emergency department use, illicit injection drug use, HIV/AIDS, obesity and behavioral or conduct problems.
Other studies have shown that children with either parent incarcerated are more likely to suffer from more specific issues such as ADD/ADHD, depression, marijuana use, developmental delays and learning disabilities. Children with incarcerated parents may benefit from initial ACE screening to identify those who require further assessment, health behavior counseling or the establishment of a medical home to help them gain access to care.
This population deserves our attention in an effort to diminish the potential negative health outcomes they may face. There remains a need to further address these concerns, as one author’s personal experience with the consequences of parental incarceration demonstrate. This author had witnessed the impact her sister’s incarceration had on her young nephew’s health, as he spent many years of his short life with his mother incarcerated. Although two loving grandparents raised him in his mother’s absence, his mental and behavioral health suffered and often went unaddressed during his medical encounters.
His grandparents personally sought community resources, counseling services and behavioral health programs to address these issues; however, they found that it was difficult to find or gain access to many resources, especially affordable options. They often felt frustrated with the lack of recognition by health care providers of the impact that his mother’s incarceration was having on his health and wished this was something that his health care providers felt more comfortable addressing.
This experience, along with the lack of evidence-based research about how to best screen for and care for this population of children, inspired the MSMA Medical Student Section Board to research a meaningful way to address this issue. The resolution below was therefore written with the intent of furthering research on evidence-based practices, legislation and initiatives that could benefit this population of children and ultimately improve their long-term health.
Although searching the literature demonstrates that there are significant health consequences for children with incarcerated parents, there is little research that addresses evidence-based practices to help screen for or provide interventions for children at risk for these negative health outcomes. Thus, the 2018-2019 MSMA Medical Student Section Board wrote a resolution that called for the MSMA to encourage the AMA to support “screening to identify unmet needs of children with incarcerated parents and promote earlier intervention for those children who are at risk.”
This resolution was subsequently presented to the St. Louis Metropolitan Medical Society by authors from St. Louis University School of Medicine and Washington University School of Medicine, the Boone County Medical Society by an author from University of Missouri School of Medicine, the Greene County Medical Society by an author from University of Missouri School of Medicine at their Springfield campus and the Kansas City Medical Society by an author from University of Missouri-Kansas City School of Medicine. The resolution received positive feedback from each of these four county societies and was ultimately voted to be supported by each of them as the final resolution was submitted to be heard at the 2019 MSMA Annual Convention.
Although the resolution received great feedback and support from many of the state’s largest county societies, numerous questions were brought forth by other MSMA members about the resolution, specifically in regards to how it was different than existing AMA policy. For example, AMA policy H-60.910 titled Addressing Healthcare Needs of Children in Foster Care calls for the AMA to advocate “for comprehensive and evidence-based care that addresses the specific health care needs of children in foster care.” Although some children in foster care may have incarcerated parents, many children with incarcerated parents are not in foster care and are raised by a single parent or other family members. Thus, it was important for this resolution to specifically address this underserved population.
Additionally, a question was also raised about what type of screening the resolution was referring to, specifically asking what the intended end goal of screening would be and how this would differ from routine screening already conducted in a primary care setting. This question brought up an excellent point, as many primary care providers likely perform routine screening for social or mental health issues in their pediatric population. However, this screening is not usually specific, and may never actually bring to the provider’s attention that a child has an incarcerated parent.
Therefore, the intent of asking for support for screening for this population was in hopes that primary care providers may include an ACE screening questionnaire on patient intake forms, which would include questions about parental incarceration, or simply ask more screening questions about a child’s social situation at well-child checks. This would allow the health care provider an opportunity to offer support and resources for the child and their caregivers, which is often difficult for them to ask for or find on their own. It would allow an important dialogue to take place that may encourage the health care provider to delve further into exploring possible effects on the child’s mental and behavioral health, and potentially allow them to provide earlier interventions that may improve health outcomes.
At the 2019 MSMA Annual Convention, the resolution was heard in Reference Committee A. Testimony about the inspiration behind this resolution was provided by one of the author’s and the intent of the resolution was further explained. A physician spoke on behalf of the St. Louis Metropolitan Medical Society in favor of the resolution and suggested a minor edit in language. Another physician spoke in favor of the intent of resolution, but expressed some caution in regards to implementing screening for children with incarcerated parents, as he provided an anecdotal account of other professions, such as social workers, not being allowed to screen for children with incarcerated parents in school settings, as this is seen as singling these children out.
Ultimately, the Reference Committee recommended the resolution for adoption as amended. This amended resolution, asking “that our Missouri State Medical Association encourage the American Medical Association to support comprehensive and evidence-based care that addresses the specific health care needs of children with incarcerated parents and promote earlier intervention for those children who are at risk,” was successfully passed in the MSMA House of Delegates with no opposition.
This resolution was then presented by the Missouri delegation at the 2019 AMA Annual Meeting and heard in Reference Committee E. The resolution had overwhelming and unanimous supportive feedback from practitioners in various fields endorsing the unmet needs of children with incarcerated parents and the utilization of screening to provide targeted treatment. Many felt this issue is pertinent to AMA members and worthy of our advocacy endeavors. A similar resolution was proposed by the Medical Student Section, asking that our AMA “support legislation and initiatives that provide resources and support for children of incarcerated parents.”
Thus, the Reference Committee combined the two proposals to create the finalized resolution. This successfully passed in the House of Delegates and is now official AMA policy titled Children of Incarcerated Parents H-60.903, which states, “That our American Medical Association support comprehensive evidence-based care, legislation, and initiatives that address the specific health care needs of children with incarcerated parents and promote earlier intervention for those children who are at risk.”
The intent of this resolution is not only to bring attention to this vulnerable population and the known consequences of parental incarceration on their health, but to also encourage more research into developing an evidence-based approach to caring for these patients, as they have unique needs and may require screening, counseling and referral to resources that other children may not. It may be beneficial to conduct research on if the inclusion of screening for parental incarceration on patient intake forms or in routine questioning during patient encounters may help to earlier identify potential health outcomes and may lead to earlier referrals to further resources.
Future initiatives may include investigating the efficacy of support groups for children of incarcerated parents, encouraging more specific counseling services that address the challenges they face, partnering with other organizations to support legislation that affects children with incarcerated parents, encouraging primary care providers to screen for and address mental health concerns of these children at routine well-child checks, and expanding resources in schools, health care settings, and for caregivers to allow influential adults in these children’s lives to appropriately address their physical, emotional, and mental needs.
This resolution was a meaningful way for the MSMA Medical Student Section Board to create impactful policy. We represent four medical schools spanning the state of Missouri and we were able to collaborate on an issue affecting many Missouri children and health care providers. We found the process of researching, writing, editing and submitting this resolution to be a relevant way to participate in organized medicine. We plan to build on this experience within our local medical societies, the MSMA and the AMA to continue to craft policy and shape health care.
Image credit: 2018-2019 MSMA Medical Student Section Board at the MSMA Annual Conventional Meeting 2019. Pictured from left to right: Craig Yugawa, Shannon Tai, Priya Jain, Calli Morris, Samantha Lund, Scott Berndt.