How Better Health Strategies Could Reduce Juvenile Crime

Voters list violent crime as a major issue influencing their decisions in the November election. Despite data showing a fairly steady decline in violent and major property crime in the US since the 1990s, the public perceives that crime is now on an upward trajectory. The public’s perception reflects the uptick in crime during the COVID-19 pandemic and seems linked to highly publicized incidents of juvenile crime, including school shootings by students and carjackings by young teens (again, despite the general decline in youth arrests since the 1990s).

Many states and cities, unsurprisingly, have passed or are considering laws aimed at deterring delinquency, such as curfews and stiffer penalties. But punitive approaches often ignore the relationship between psychological trauma and adolescent brain development, and how such trauma can increase the probability of criminal behavior as well as depression and other mental health conditions.¹

Recent studies of early brain development have caused many researchers of youth justice to reject a judicial emphasis on rehabilitation and deterrence, and to focus on addressing early threats to normative brain development.² The brain’s prefrontal cortex, which governs self-control and immediate decision-making, does not fully develop until a person is in their mid-20s. Normative development can be seriously affected by early adverse childhood experiences, such as child abuse, neglect, bereavement, and other traumas.³ Indeed, children’s and adolescents’ exposure to gun violence has the hallmarks of posttraumatic stress disorder.⁴

The consequences of such experiences typically include hypervigilance, hyperarousal, poor decision-making, and other behaviors likely to result in an interaction with the juvenile legal system.⁵ A review of 2019-2020 data from the District of Columbia, for instance, shows that 23% of youth involved in the criminal justice system reported abuse compared with 10.2% of youth without involvement. Psychotic disorders were present in 4.8% of youth involved in the justice system compared with 0.7% of youth without involvement. School absences and suspensions and other problematic behavior patterns were also much higher in justice system–involved youth. Regrettably, in many jurisdictions a zero tolerance approach to school behavioral problems, often leading to expulsions and even arrests, exacerbates the effect of early childhood traumas and makes it more likely the young person will end up in the criminal legal system.⁶

Fortunately, the legal system is coming to recognize that health and social services are a better approach for most adolescents rather than jail terms.⁷ Appreciating that adverse childhood experiences can affect judgment and behavior, courts are increasingly turning (especially for first-time offenders) to pretrial diversion programs that address education, health, or other risk factors in the least restrictive setting. The goal is to reduce recidivism by improving the young person’s health and education trajectory, and perhaps living circumstances. Such programs have shown some success. The recent introduction of the national 988 hotline for mental health crises, together with the expansion of crisis intervention teams as first responders to such crises, could also help many young people get the mental health treatment they need and avoid becoming entangled in the legal system.

There are still many barriers to preventing behavioral health conditions that can lead to crime and incarceration. For example, although diversion programs are increasing, funding and staffing shortages often impede progress. Poor integration of behavioral health and child support services, such as the foster care system, may result in some youth not receiving the full complement of services and increases the likelihood of later rearrest and incarceration.

Some states are rising to the challenge of improving service coordination. Arkansas, for instance, recently produced a roadmap based on collaboration between Medicaid, child welfare, and the juvenile legal system to coordinate services. It includes pilot programs to ensure services for children experiencing a life transition (such as entering foster care or leaving detention) and for when a potential crisis could involve law enforcement.

It is important to avoid a build it and they will come assumption when seeking to connect young people with behavioral health challenges and the services they need. Trust and familiarity are essential, therefore, familiar institutions are often the best entry points for receiving help. School-based behavioral health services, for instance, provide a perceived safe setting for students (and their parents) and can address mental health issues at an early stage and without stigma. States can cover direct services in schools to children eligible for Medicaid and more need to do so. Federally Qualified Health Centers and Community Mental Health Centers are also familiar community institutions and can provide a wide range of services, as can Certified Community Behavioral Health Clinics that are increasingly available. Increasing their roles can enable more traumatized youth to obtain treatment.

Tackling the causes of childhood trauma, and addressing the behavioral health needs of high-risk young people before they cause harm, could do much to help prevent delinquency and reduce the probability that incarcerated youth will become repeat offenders. About two-thirds of youth in the justice system have a diagnosable mental health or substance abuse disorder, but most youth detention facilities do not provide appropriate mental health evaluations and treatment. Although a juvenile might normally be eligible for Medicaid or the Children’s Health Insurance Program (CHIP), the inmate exclusion rule prohibits them from receiving health services under those programs. Thus, any previous treatment is interrupted and released youth are less likely to obtain treatment—and thus are more likely to become repeat offenders.

Fortunately, at the beginning of 2025, new statutory and administrative changes will authorize Medicaid and CHIP to cover certain services just before and after their release, including behavioral health screenings and case management. States will also be permitted to cover certain youth and adult services for longer periods using Medicaid 1115 waivers. With good reentry planning, this creates an important opportunity for states and communities to help reduce recidivism.

In health care, it is important to look upstream and address factors that lead to ill health rather than focus only on treating its consequences. This approach includes recognizing and dealing with factors such as child abuse, neighborhood gun violence, and other traumas that can lead to crime, especially crimes committed by children. That is beginning to happen in court systems across the country. But health systems and policymakers must assist by ensuring that child mental health services are available for all youth in need. Failure to provide services and address the health and social roots of delinquency can mean decades of future crime and costly incarceration.

Published: August 22, 2024. doi:10.1001/jamahealthforum.2024.3371

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2024 Butler SM. JAMA Health Forum.

Corresponding Author: Stuart M. Butler, PhD, Brookings Institution, 1775 Massachusetts Ave NW, Washington, DC 20036 (smbutler@brookings.edu).

Conflict of Interest Disclosures: None reported.