Association of Childhood History of Parental Incarceration and Juvenile Justice Involvement With Mental Health in Early Adulthood

Key Points Question Is a childhood history of parental incarceration and juvenile justice involvement associated with mental health conditions in early adulthood? Findings In this nationally representative cross-sectional study, young adults with a history of both parental incarceration and juvenile justice involvement reported more mental health conditions compared with peers with no justice system exposure during childhood. Meaning Parental incarceration and juvenile justice involvement may be associated with mental illness in young adult populations.


Introduction
Approximately 6.6 million individuals are under the supervision of the US adult correctional system. 1 As a result, 5 million US children have had a resident parent incarcerated. 2 Parental incarceration (PI) has long-term, negative health consequences that are independent of underlying racial/ethnic and socioeconomic disparities. 2-6 Children of incarcerated adults have been shown to have significantly worse health behaviors, health outcomes, and health care utilization patterns in adulthood compared with their peers. [7][8][9][10][11][12] For example, individuals affected by PI are more likely to smoke cigarettes, abuse alcohol or prescription drugs, and engage in high-risk sexual behaviors, while also forgoing medical care. 8 Similarly, PI and mental health are closely associated. Young adults with PI histories have higher rates of depression, anxiety, and posttraumatic stress disorder (PTSD) than those without histories of PI. 7 Parental incarceration is also strongly associated with juvenile justice involvement (JJI). Youth affected by PI are estimated to be involved in the juvenile justice system at 3 times the rate of their peers without PI. 13 In 2017, more than 800 000 US youth younger than 18 years were arrested, 14 and 53 000 were held in correctional facilities. 15 Juvenile justice involvement is independently associated with poor health outcomes into adulthood. [16][17][18][19][20] Similar to the association of PI, youth with JJI have increased rates of depression, anxiety, panic disorder, and substance abuse. 16,21 Youth affected by PI or JJI also may have lower income, lower rates of employment, and higher rates of substance abuse than their counterparts in young adulthood. 22,23 Thus, justice system exposure creates psychosocial and health risks that become intergenerational and span the life course. 13 Although the association between PI and subsequent JJI has been established, national data on the frequency with which young adults are exposed to both types of criminal justice involvement are limited. Furthermore, little is known about the long-term mental health of this dually vulnerable population. Adverse childhood experiences, such as PI, have a cumulative association with health outcomes in adulthood. 3,4,6,[24][25][26][27] However, much of the current health research focuses on PI or JJI individually, largely ignoring the intergenerational cycle of incarceration in the United States. The cumulative influence of PI and JJI (PI plus JJI) on subsequent adult mental health reflects a critical knowledge gap.
This study aims to describe the population affected by PI plus JJI and to identify the association between mental illness and PI plus JJI. We hypothesized that adolescents who experienced the combination of PI plus JJI would have higher rates of mental illness in young adulthood than youth who experienced neither, or either in isolation. By focusing on this unique group, we may better inform public health and clinical practice, as well as criminal justice and juvenile justice policy and practice.

Study Design
We used data from the National Longitudinal Study of Adolescent Health to Adult Health (Add Health, 1994-2008) 28

Data and Study Population
Add Health 28 was a nationally representative longitudinal study that followed adolescents from high schools in the United States into adulthood. Junior high and high schools (grades 7-12) served as the primary sampling unit for the clustered study design. In this study, we used data from both waves I

Exposure to Parental Incarceration
Respondents were asked in wave IV whether their biological mother or father ever spent time in jail or prison and their ages at both the first and most recent time their biological mother or father was in jail or prison. Individuals who reported any history of PI from birth to before age 18 years were included in the PI exposure group. Individuals who reported a history of PI after age 18 years were excluded to examine the associations of criminal justice exposure in childhood.

Exposure to Juvenile Justice Involvement
In wave IV, participants were asked whether they had ever been convicted of or pled guilty to a crime or been found delinquent in juvenile court and their age the first time they were incarcerated in a jail, prison, juvenile detention center, or correctional facility. They were asked to report the number of times they were arrested before their 18th birthday. Individuals who reported any history of arrest, conviction, pleading guilty, or being found delinquent in juvenile court before age 18 years were considered to have a history of JJI. In addition, any individual who reported being incarcerated in jail, prison, juvenile detention center, or correctional facility before age 18 years was included in the JJI exposure group.

Mental Health Outcomes
Data on adult mental health were collected in wave IV. Respondents were asked whether they had ever received a diagnosis of anxiety, depression, or PTSD. In addition, they were asked whether they had received psychological or emotional counseling within the last year, experienced suicidal ideation within the last year, or had attempted suicide within the last year. Respondents were designated to have 1 of the aforementioned mental health conditions if they responded "yes" to any of these questions.

Covariates
We controlled for sociodemographic factors from wave I. The factors included sex, race/ethnicity, age, family structure (2-parent, 1-parent, or no-parent households), parental education (mother and father), receipt of public assistance, and geographic classification of residence (urban, suburban, or rural). 7,8,29

Statistical Analysis
Data analysis was completed in 2019. We summarized sociodemographic characteristics of the study population by 3 exposure groups: PI only, JJI only, and PI plus JJI. The analytic sample was restricted to participants who had complete sociodemographic and exposure data (94.4% of wave IV respondents). We used logistic regression models to examine associations between the 3 exposure groups and mental health outcomes. In adjusted multivariable models, we controlled for the aforementioned covariates. We calculated 3 measures to evaluate interaction-relative excess risk due to interaction, attributable proportion due to interaction, and synergy index-and their 95% confidence intervals to test for additive interaction of combined PI and JJI exposures. Relative excess risk due to interaction estimates additive interactions in case-control study designs. Attributable proportion due to interaction refers to the proportion of disease that is due to interaction among persons with both exposures. Synergy index measures whether the risk ratio for both exposures together is greater than the sum of each of the risk ratios considered separately. 30 All analyses were conducted using Stata statistical software version 14.0 (StataCorp), accounting for the clustered, stratified survey design, and used survey weights (provided with the data set) to generate national population estimates unless otherwise noted.

Results
The 13

Unadjusted Analyses
In unadjusted analyses, individuals with histories of PI, JJI, or PI plus JJI had higher odds of adverse mental health outcomes compared with individuals with no PI or JJI history (

Adjusted Analyses
Individuals with any history of childhood justice system exposure had significantly worse mental health outcomes than their peers without histories of PI or JJI ( For each mental health outcome, we used relative excess risk due to interaction, attributable proportion due to interaction, and synergy index to test for additive interaction. None of the outcomes demonstrated a statistically significant additive interaction (results not shown).

Discussion
In this analysis of a nationally representative sample, a consistent association exists between combined PI and JJI exposures in childhood and subsequent adverse mental health outcomes in  early adulthood. Our findings suggest that dual exposure (PI plus JJI) in childhood is associated with increased risk of depression, anxiety, and PTSD in young adulthood. Although childhood exposure to both PI and JJI may not contribute to additional risk, there may be differential susceptibility to adverse mental health outcomes depending on the type of justice exposure experienced during childhood.

JAMA Network Open | Public Health
Previous studies 7,16,21,31 have shown that PI alone and JJI alone are independently associated with worse mental health outcomes. Adults who were exposed to PI during childhood are more likely than their peers without exposure to PI to have anxiety, depression, and PTSD. 7 Our results support those previous findings and add that the young adults who experience childhood PI are more likely to experience thoughts of suicide compared with those with no PI or JJI history. In other samples, 21,31,32 individuals with JJI exposure were also more likely to have substance abuse disorders, mood disorders, anxiety, depression, and sexually transmitted infections compared with peers. Our mental health findings are consistent with the extant studies and also indicate that individuals with JJI are more likely to experience PTSD and report suicide attempts compared with peers without PI or JJI.
Our analyses highlight that a history of combined PI and JJI during childhood, although less common than either PI or JJI alone, occurs for 1 in 100 US children overall (1.2%) and is disproportionately more common among youth of color (Table 1). Parental incarceration plus JJI was associated with the highest odds of depression and anxiety in adulthood in this sample.
Posttraumatic stress disorder was also associated with the dual exposure group, with the odds slightly lower than those for JJI only. The associations of PI plus JJI with depression, anxiety, and PTSD did not appear to be additive above PI or JJI exposure alone. However, certain mental health outcomes did appear to be associated with a particular type of justice exposure. For example, in the adjusted models, suicidal thoughts were associated with PI only, and suicide attempts were associated with JJI only.
Interestingly, the JJI only and PI plus JJI groups had the highest odds of receiving mental health counseling within the last year. Receipt of counseling could be a reassuring sign that at-risk adults are receiving needed mental health treatment or could also signify that adults most in need of counseling had accessed such services. Many individuals in this population have public insurance coverage, which may diminish cost as a barrier to receiving mental health care. 29,33 In addition, contact with the justice system may connect individuals more directly with mental health resources compared with those who might not interface with the system. Still, with 22.2% of young adults with PI plus JJI reporting depression and 12.4% receiving mental health counseling, there still may be unmet mental health needs in this population. This may explain the higher odds of suicide attempts in the population exposed to JJI compared with the individuals without PI or JJI exposure. This finding, along with the paucity of data regarding the quality, frequency, and reason for the counseling make it difficult to determine whether this population of young adults at-risk for mental illness is receiving adequate mental health care.

Limitations
This study must be interpreted within the context of its limitations. First, the unweighted sample of individuals with PI plus JJI was small and focused exclusively on biological parents. However, it is one of a few nationally representative data sets that incorporate PI, JJI, and long-term health outcomes.
Our focus on the incarceration of biological parents in childhood may not fully account for young adults who experienced the incarceration of nonbiological caregivers, those who had limited relationships with their biological parents, or those who experienced the incarceration of their biological parents after age 18 years. In addition, both mental health diagnoses and incarceration are sensitive topics that may be underreported because of social desirability bias or shame, 34 which may lead to underestimates of effect sizes in the associations we report or affect the nature of the findings. Also, although single-item self-reports for suicidal ideation and attempts within the past year reduce recall biases, they limit our understanding of the lifetime risk. Furthermore, our findings relied on self-reported mental health diagnoses, which could have been underreported. Also, the experiences, may predispose individuals to justice system involvement, which, in turn, may make them more likely to be incarcerated in a juvenile detention center. 35 This study did not account for either the type of offense contributing to JJI or PI 8 or the duration or frequency of the justice system exposure. These facets of PI and JJI were beyond the scope of this study but should be considered for future studies, because they may further explain the observed associations.

Implications
Individuals who experience PI and JJI during childhood have an increased risk of mental health concerns in adulthood. These associations suggest that policy makers should consider the multiple avenues through which children are affected by the criminal justice system and the intergenerational health risks such contact perpetuates. These findings also generate additional questions as to the timing or emergence of mental health conditions in this group. Previous research has suggested that children with PI have evidence of behavioral health concerns but not diagnosed mental health problems during childhood. 34,36 In addition, PI may represent an important opportunity for policylevel intervention, because previous studies have shown that PI may have a stronger influence on children than other types of parental absence. 37 Future research that examines the influence of PI on bonding and attachment and those aspects of childhood development associated with JJI involvement, as well as future mental health outcomes, would further explicate the intergenerational connection between PI and JJI. Furthermore, although PI and JJI are linked, currently, PI exposure is considered an adverse childhood experience and JJI is not. 3 Given the association of JJI with adverse mental health outcomes in adulthood in this study, perhaps JJI should be considered an adverse childhood experience going forward.
Future studies should evaluate whether pediatric screening for criminal justice-related exposures followed by early mental health interventions may mitigate some of the precursors for adult mental health conditions. In particular, integrating routine screening for PI and JJI within the typical health care visit for youth may reduce stigma. Screening can also allow health care professionals who focus on children and young adults to refer families for additional services for unmet needs, such as housing and food insecurity, which are known to disproportionately affect this justice-involved population and also may have implications for adult mental health. 36 In addition, examining the benefits of the integration of legal services within the pediatric medical home, such as medical-legal partnerships, may aid clinicians and families in navigating associated unmet social, health, and educational needs. These findings also suggest that such approaches may be beneficial into adulthood.
It is important to note that pediatricians and other health care professionals can screen and treat only those who receive health care, which suggests that additional public health approaches beyond clinic-based services are needed. Juvenile detention centers could help link adolescents to either new or their established primary care homes after incarceration. For youth experiencing PI, the courts might consider the impact of PI on children and take parental status into account during sentencing. Parents and their children jointly experiencing justice involvement may benefit from support services to help address additional needs that arise during incarceration and likely reverberate beyond the end of a sentence.