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Girls in the juvenile justice system: Leave no girl's health un-addressed
Girls in the Juvenile Justice System: Leave No Girl’s Health Un-addressed Barbara J. Guthrie, PhD, RN Erin Hoey, MS, RN, PNP LaWanda Ravoira, DPA Eileen Kintner, PhD
Despite an increase in middle to older aged adolescent females’ early contact with the juvenile justice system, inadequate health care remains a concern. This descriptive study surveyed the physical and mental health needs of 130 self-selected, nonrandomized girls aged 12 to18 years, with a mean age of 15.42 years (SD, 1.24), who were involved with a juvenile justice diversional program located in a southeastern region of the United States. Findings revealed early initiation of sexual-related activities (mean age, 13.9 years; SD, 1.49) and substance use (mean age, 12.9 years; SD, 1.53). The data suggest an increasing need for pediatric nurses, and in particular advanced practice nurses, to provide gender-responsive health care and health promotion services to early middle-childhood females in the juvenile justice system. Copyright 2002, Elsevier Science (USA). All rights reserved.
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IRLS TODAY, different from the past, are faced with more complex trials and tribulations in what is described by Pipher as “a more dangerous, sexualized and media-saturated culture” (1994, p.12). Navigating through these obstacles is a considerable challenge for most girls. Making it through adolescence safely in such a risk-laden society is said to not only require strength and resiliency, but a supportive and an informative environment (Johnson, Roberts & Worell, 1999). In the absence of positive and encouraging adult influences, middle-childhood females are more likely to venture off course between the ages of 8 to 11 years and engage in a variety of “delinquent” behaviors that may inevitably lead to contact with the juvenile justice system (Acoca, 1999).
From the University of Michigan, School of Nursing/Women’s Studies, Ann Arbor, MI, and PACE Center for Girls, Inc., Florida. Supported by the National Institute on Drug Abuse (grant K20-DA000233-01A1). Address correspondence and reprint requests to Barbara J. Guthrie, PhD, RN, Associate Professor, University of Michigan, School of Nursing/Women’s Studies, 400 N. Ingalls, Ann Arbor, MI 48109-0482. E-mail: [email protected]. Copyright 2002, Elsevier Science (USA). All rights reserved. 0882-5963/02/1706-0006$35.00/0 doi:10.1053/jpdn.2002.129793
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Girls between the ages of 8 to 11 years are at a crucial developmental stage. This is especially true for girls who come in contact with the juvenile justice system. For example, nationwide, about half of high school students reported engaging in sexual intercourse, with this number rising to 61% by grade 12 (Centers for Disease Control and Prevention, 2000). Only about 7% of these students had had intercourse before age 13 years. Conversely, a survey of detained adolescents in 39 juvenile correctional facilities found that 60% were sexually active by age 12 years and 90% by age 14 years (Morris, Harrison, Knox, Tromanhauser, Marquis & Watts, 1995). In the Centers for Disease Control and Prevention (2000) national sample, 16% report 4 or more lifetime sex partners, in contrast to more than half of incarcerated teens reporting 7 or more sex partners. Because of the growing downward age trend of higher rates of sexual-related risk behaviors, health care providers, especially pediatric nurses, need to focus on providing high-quality, gender- and age-responsive health care and health promotion services to detained middle-childhood females. Hence, this article is a first step toward providing a profile of the general and specific physical (i.e., illness, weight concerns, sexual history) and mental health (i.e., alcohol, tobacco, other drugs)
Journal of Pediatric Nursing, Vol 17, No 6 (December), 2002
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needs of middle-childhood female offenders. The article aims to provide a descriptive profile that has the potential to guide the development of genderand age-responsive health care and health promotion services within the juvenile justice system. In addition, future health-related services for middlechildhood females within the system are provided. By revealing relevant and useful knowledge in the form of descriptive summary, the goal is to provide gender- and age-responsive health care and health promotion recommendations for advanced practice nurses (APNs) providing care within the juvenile justice system (Guthrie, 1996). REVIEW OF LITERATURE In the past, juvenile crime was predominantly a male phenomenon (Poe-Yamagata & Butts, 1996; O’Hara Pepi, 1998). For this reason, programs in the juvenile justice system appear to reflect more the needs of boys than of girls, as does most of the literature on delinquency (Office of Juvenile Justice and Delinquency Prevention (OJJDP), 1998; O’Hara Pepi, 1998). This lack of information likely has been justified simply by the fact that girls always have been a minority in the justice system. Although juvenile crime is still mostly a male phenomenon, girls today are beginning to make up a significant number of the youth who come in contact with the juvenile justice system (OJJDP, 1998). In fact, they currently represent a rapidly growing segment of the juvenile justice system. Females are entering the juvenile justice system more frequently and at younger ages (PoeYamagata & Butts, 1996; Acoca, 1998). For example, between the years 1989 and 1993, the number of girls charged with delinquency offenses increased by 31% and the growth of juvenile female arrests during this time more than doubled, as compared with the increase for males (Poe-Yamagata & Butts, 1996). In fact, in 1993, nearly one third of persons arrested who were under 18 years of age were females (Poe-Yamagata & Butts, 1996). Even more startling is the fact that in 1996, 723,000 adolescent girls were arrested for crimes and status offenses, with more than one third being younger than 15 years of age (OJJDP, 1998). Thus, like other risk behaviors, juvenile delinquency also is experiencing a downward trend to early and middle adolescence. Accordingly, the needs as well as the reasons for females’ contact with the juvenile justice system are considerably different, as compared with their male counterparts. For example, girls more often
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will suffer from more complex vulnerabilities than will boys who are the same age, such as depression and other mental health problems, resulting in girls entering the system with more co-occurring physical and mental health concerns such as substance abuse and eating disorders (Prescott, 1998). For those reasons alone, sensitivity to such gender distinction is warranted when addressing the particular physical and mental health needs of adolescent female offenders. Subsequently, the physical and mental health needs and strengths of girls often have been disregarded or unnoticed in the juvenile justice programs (OJJDP, 1998; O’Hara Pepi, 1998). As a result, much still remains unknown about the developmental trajectory of girls as it relates to their reasons for coming in contact with or being detained within the juvenile justice system. In order to facilitate the healthy development of middle-childhood females in contact with the juvenile justice system, pediatric nurses should consider providing gender- and age-responsive health care and health promotion services for those girls. Intervening knowingly and appropriately requires gender-specific knowledge, such as the ability to differentiate between boys’ and girls’ developmental process, as well as the unique and similar precursors associated with health-compromising behaviors (i.e., drinking, smoking, and early sexual activity). In order to accomplish the aforementioned, pediatric nurses need accurate information and knowledge. A first step is to examine a profile of selected health-related characteristics of young females who have come in contact with the justice system. The growing disproportionate number of African and Latino Americans detained within the juvenile justice system raises another health concern. The health care conditions that are over-represented in detained middle-childhood females generally, and African and Latino American girls in particular, mirror the health conditions in urban communities (Andrulis, 2000; Ousey, 2000). Specifically, early use and abuse of substances, sexually transmitted diseases (STDs), HIV/AIDS, victimization by violence, mental illness, and reproductive health issues are the most noted health-related problems. Despite those findings, health screening, health care, and health promotion services generally, and in particular for middlechildhood females, often are lacking or of poor quality (Andrulis, 2000; Ousey, 2000). The few documented health-related findings about this pop-
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ulation provide substantiation that overall youth who come in contact with the juvenile justice system have a substantial number of pre-existing physical and mental problems, as well as inadequate primary and mental health access and care. In response to the aforementioned concerns, a nonrandomized, self-selected, cross-sectional sample of ethnically diverse middle-childhood females involved with the justice system was studied. A gender-specific framework guided the development and design of the study (Guthrie & Kane Low, 2000). The key concepts inherent in this framework and operationalized in this study are as follows: environmental contexts such as neighborhoods and health care resources, personal attributes such as perceptions of health and related health behaviors, perception of weight, sexual health, mental health, and substance use and abuse (Guthrie, 1996; Guthrie & Kane Low, 2000). The purpose of the study was to generate baseline data about health status and health behaviors of girls who have come in contact with the juvenile justice system. More specifically, the girls were asked to answer questions related to physical health (i.e., illness, weight concerns, sexual history) and mental health (i.e., alcohol, tobacco, other drugs). METHODS
Sample This study is a part of a larger cross-sectional research project titled “Female Adolescent Substance Experience Study” (FASES) that was conducted from 1996 to 2000. The project was funded by the National Institute on Drug Abuse (Guthrie,
Figure 1.
1996). A self-selected and nonrandom network sampling technique was used to collect data on 130 middle-childhood females between the ages of 12 and 18 years. Fliers and posters were placed in 7 of the 17 diversional programs under the auspices of a specific southeastern regional diversional program; the fliers were used to recruit this subsample of middle-childhood females. Therefore the findings cannot be generalized to all adolescent female offenders in diversional programs. All potential participants were given a consent form in order to obtain parental and legal guardian consent for participation. Once initial written assent and consent were obtained, face-to-face interviews were conducted that lasted approximately an hour and a half. Full board human subject approval was obtained through the University’s Internal Review Board before any data collection. A sample of 130 girls was recruited that reflected approximately 17% of the total population receiving direct care from this adolescent female juvenile justice diversional program. The girls interviewed ranged in age from 12 to 18 years, with a mean age of 15.42 years (SD, 1.24) (Figure 1) and a mean grade level of 9.12. The self-defined demographic characteristics of the sample by ethnic group were as follows: 47.7% European American, 28.5% African American, 13.8% Latino American, and 10% other. More than half (62.3%) resided only with their mothers, whereas 37.7% resided with both parents. Fifty-four percent of the respondents indicated that they had not moved within the past year; the remaining 46% moved between 2 and 5 times during the same time period.
Ages of participants.
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Data Analysis Univariate analyses were conducted on all scales and individual items in order to provide descriptive information regarding the girls’ perceptions of relationship with parents, health, disordered eating, weight fluctuation, early sexual activity, and substance use. When appropriate, t tests were used.
Instruments FASES data were collected with a paper-andpencil self-report Likert-type questionnaire. This survey comprises several measures; however, for the purpose of this study, demographic, physical, and psychological health; substance use; sexualrelated activities; self-perceptions; familial and peer relationships; and perceptions of neighborhoods were used. (See Appendix Figure 1 for examples of questions.) Several open-ended questions also were included in the FASES questionnaire. A list of the instruments used in this analysis follows. Substance Use: Monitoring the Future Survey Patterns of substance use were measured by single-item questions adapted from the Monitoring the Future Survey. These are standard self-reported measures of substance use, and prior research supports their validity (Johnston & O’Malley, 1985; Wallace & Bachman, 1991). Perception of Neighborhood Scale The Perception of Neighborhood Scale (Dembo, Schmeidler, Burgos & Taylor, 1996) is a 20-item scale that measures adolescents’ perception of their neighborhood and various images of adolescents
Figure 2.
such as teen moms within their neighborhood. The reported Cronbach alpha is .90. For this sample, the Cronbach alpha was .81 for perception of toughness of neighborhood and .78 for tough images in the neighborhood. In addition to the aforementioned instruments, the participants were asked 1 or 2 single-item questions related to perceptions of health, fluctuation of weight, importance of weight, selected disordered eating patterns, sexual-related practices (eg, ever had sex, ever been pregnant), and patterns of contraceptive use or nonuse. The aforementioned items were chosen in order to provide baseline data about girls’ health status and their health-related behaviors.
Data Collection The data collection was done during the first week of March 1999. The FASES team, consisting of one doctoral candidate, a research associate, and the senior author, traveled to the southeastern region of the United States and administered the survey tool to middle-childhood females in 7 of the 17 existing juvenile justice diversional programs (Guthrie, 1999). RESULTS
Perception of Health and Health-Related Behaviors Respondents’ perceptions of their health ranged from excellent to poor, with 109 respondents (84.5%) indicating good to excellent health (Figure 2). It should be noted, however, that when asked about their perception of health in relation to their peers in general, 64 of the respondents indicated
Self-rating of present health.
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that their health was average, whereas the remaining 55 reported that their health was “a little better” to “much better” than average. Over 67% percent (n ⫽ 85) reported taking prescribed medications such as birth control pills (50%), attention deficit medicines (3%), and depression-related medicines (12%). One hundred eight respondents received health care from a physician, and the remaining twenty-two respondents received care from either a midwife or a nurse practitioner. The top 4 reasons given for seeking health care were as follows: infection (50%), immunization (25%), birth control (15%), and STDs (10%). Only half of the respondents stated that they were comfortable talking to their health care provider about sex, birth control, STDs, and substance abuse. When asked whether they had been exposed to HIV/AIDS, 74 of those who responded reported “not at all likely,” whereas the remaining 42 reported “somewhat likely” (24), “pretty likely” (9), or “extremely likely” (9).
Perception of Weight The respondents were asked a series of questions related to their weight. For example, when asked about whether their weight fluctuates (meaning weight goes up and down a lot), 53 (42.4%) said yes. Ninety-three respondents indicated that they were proud of their body; however, 103 (47.3%) indicated that their weight was very important to the way they felt about themselves. In addition, 83 stated that they feared becoming fat and that their stomachs or thighs were too fat. When asked whether they had ever binged, 56 reported that they had and 34 indicated that their binge eating was out of control (Figure 3).
Figure 3.
Sexual Health Approximately 79% of the respondents had had vaginal sexual intercourse. The mean age of sexual debut was 13.9 years (SD, 1.49) and their partners’ mean age was 16.9 years (SD, 2.77). A closer examination of ethnic differences with regard to age revealed a significant difference between ethnic groups at the p ⫽ .05 level. Specifically, European American girls reported an age of initiation of 13.7 years (SD, 1.3), Latino American girls reported an age of 12.3 years (SD, 2.1), and African American girls reported an age of 14.3 years (SD, 1.3). Thus all girls reported initiation during the early to middle adolescence. The reported age of partners also was significantly different between ethnic groups. European Americans reported that their partners were at least 2.3 years older (SD, 1.67), whereas Latino and African American girls reported that their partners were 4.1 years older (SD, 2.9) and 2.7 years older (SD, 2.7), respectively. When asked whether they had used any form of birth control during first intercourse, 67 said “yes” and 42 said “no.” Of those who used birth control, the types most often used were condoms, birth control pills, and Norplant. Thirteen percent of the respondents used withdrawal. Twenty-one respondents indicated that they had previous pregnancies that ended in either an abortion (8) or miscarriage (13). The mean number of lifetime sex partners was 4.6 (SD, 5.51). European American girls reported more lifetime partners (mean, 5.7; SD, 6.8) than Latino Americans (mean, 3.8; SD, 3.6) and African Americans (mean, 2.6; SD, 2.0). Nineteen respondents indicated that they had anal sex from 1
Importance of weight.
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to 28 times. About one quarter of the respondents reported being pressured to have sex by their boyfriends, friends, or other males. Several respondents (n ⫽ 49) indicated that they had had one or more STDs (syphilis, gonorrhea, genital herpes, genital warts, chlamydia, pelvic inflammatory disease, or Trichomonas).
Mental Health/Patterns of Substance Use Cigarettes One hundred eight respondents (83%) reported ever smoking a cigarette, with the mean age of initiation being 11.7 years (SD, 2.1). Of the 108 who reported ever using cigarettes, 60 reported regular use. Seventy percent of the respondents smoked more than 1 cigarette per day. There were significant differences between European Americans (mean, 11.1 years; SD, 2.1) and African Americans (mean, 12.9 years; SD, 1.8), but not between Latino Americans (mean, 12.2 years; SD, 1.5) and African Americans or European Americans. Alcohol One hundred nine respondents reported ever drinking alcohol, and eighty-nine reported regular to occasional use of alcohol. The mean age of first use was 12.61 years (SD, 2.16). There were no significant differences between the three ethnic groups, in that they all reported age at first use of around 12 years. During the past month, 74 respondents reported drinking a range of “once” to “every day.” The majority of girls drank beer (49%) or hard liquor (43%) and only 8% drank wine. Marijuana
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The mean age at first use of crack was 14 years (SD, 1.53). Heroin Fourteen respondents reported lifetime use of heroin, with a mean age at first use of 14.47 years (SD 1.06). Of the 14 respondents, half used anywhere from once a day to every day during the past month. In addition, 9 girls reported using needles and 2 admitted to sharing needles with proper flushing. Other Substances Other substances used by respondents were barbiturates, inhalants, and tranquilizers. A majority of the respondents reported using substances first with their boyfriends, followed by use with an older sibling or same-gender friends. On the perception of harm substance scale, the mean response was 2.3 (SD, 1.39), with a range of 0 to 4 (in which 4 denotes the most harm). In other words, most of the respondents moderately agreed that drugs could be harmful in nature.
General Substance-Related Patterns Several significant substance abuse patterns were noted. For example, the data revealed a developmental substance use trajectory. Specifically, the timing of first substance used was shortly followed by more harmful and illegal substance use, in that the initiation of first use of cigarettes was 11.7 years of age, alcohol was 12.6 years of age, marijuana was 12.9 years of age, and crack was 14 years of age.
Environmental Contexts
Eighty-nine of the respondents reported lifetime use of marijuana, with a mean age at first use of 12.9 years (SD, 1.53). There were significant differences between European Americans (mean, 12.5 years; SD, 1.3) and African Americans (mean, 13.9 years; SD, 1.4), but not between Latino Americans (mean, 12.7 years; SD, 1.6) and other groups. During the past month, 56 of the 89 respondents reported a range of marijuana use from once a day to every day.
Neighborhood
Crack
Health-Related Services
Although a smaller number of respondents (20) reported lifetime use of crack, over one third of the 20 (7) reported that during the past month they had used crack anywhere from once a day to every day.
When asked about services that they used both presently and in the past, the most commonly cited services used were mental health services, followed by substance abuse treatment services and
On a scale ranging from 1 (peaceful) to 51 (very tough), the respondents’ mean rating of their neighborhoods was 27.7 (SD, 10.43). Therefore it was not surprising that when asked about the availability of substances (alcohol, marijuana, heroin, crack, inhalants, tranquilizers, or barbiturates), over 50% of the respondents indicated that substances not only were available, but also were easy to obtain in their neighborhoods or at school.
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Alateen. In response to services needed but not available, the respondents indicated a need for access to counseling, dental care, drug counseling, job training, and physical and mental health services. DISCUSSION Although the mean age of the patients in the sample was 15.42 years (SD, 1.24), most of the reported compromising behaviors were initiated during early adolescence. For example, most girls reported engaging in early sexual-related behavior before 14 years of age. Specifically, the mean age reported for initiation of early sexual intercourse was 13.9 years, with an SD of 1. This reported mean is lower than the nationwide average, which is approximately 16.7 years of age (Neinstein, Rabinovitz & Schneir, 1996). Second, almost half of the girls (approximately 42%) did not use birth control during first intercourse or report a consistent pattern of using birth control or safer sex practices, thereby increasing their likelihood of becoming pregnant or becoming infected with an STD or HIV/AIDS, which can potentially lead to pelvic inflammatory disease, cervical cancer, and infertility. In addition, inconsistent birth control use, history of unwanted pregnancy as evident by abortions, and utilization of the withdrawal method as birth control strongly suggest that the participants may not have sufficient or age-appropriate information regarding birth control methods, as well as information about resources for accessing contraceptive devices. The elective abortion rate speaks to the fact that some girls used elective abortions as a contraceptive method. Adolescent pregnancy is a major health concern for both the young girl and the fetus, as many risks have been implicated. Risks such as increased maternal mortality, lowbirth-weight babies, and increased infant mortality have been documented (Neinstein, Rabinovitz & Schneir, 1996). Therefore APNs working with or within the juvenile justice system need to address middle-childhood females’ sexual health in an attempt to not only offset the likelihood of the girls becoming teen moms, but also to increase the girls’ perceptions of their ability to engage in safer sex practices. Similarly, for some girls, substance use was initiated as early as 11 years of age. In addition, 70% of the respondents smoked cigarettes on a daily basis and 68% reported occasional or regular alcohol use, both of which have the potential for
killing and disabling youth (Neinstein, Pinsky & Heischober, 1996). This substance use data also point toward a sequential developmental timing of first substance use such as cigarette use (11.7 years of age), alcohol use (12.6 years of age), and marijuana (12.9 years of age). The mental health needs of middle-childhood females in contact with the juvenile justice system should be addressed. In particular, their concerns about fluctuating weight, identifying body parts as fat, and binge eating out of control and use of amphetamines and smoking to control weight are suggestive of disordered eating. Disordered eating potentially leads to eating disorders such as anorexia and bulimia, which are a major health concern for middle-childhood females (StriegelMoore & Cachelin, 1999; Thompson & Smolack, 2001). Enhancing emotional well-being, with specific focus given to the development of a positive body image and self-esteem, would be most beneficial, for one of the key developmental challenges for a middle-childhood female girl in the United States is to become comfortable with and take pride in her body. Puberty is associated with weight gain, and for American middle-childhood females, this change occurs within the cultural context that upholds the female beauty ideal of thinness. Therefore the physical changes of puberty often are at odds with the American culture of female beauty. If an adolescent girl feels that she is at odds with this norm, then she may have low self-esteem that in turn might lead to the development of an eating disorder (Johnson, Roberts & Worell, 1999). The aforementioned results coupled with the girls’ reported use of substances provide substantiation for the need to address these potentially related mental health issues. The co-occurrence of mental health problems such as substance use and eating disorders is one of the national public health priorities for prevention and treatment efforts identified in Healthy People 2010 (US Department of Health and Human Services, 2000). Specifically, the health consequences of eating disorders/symptoms and substance abuse are long-lasting and have the potential to negatively affect life expectancy, as well as the quality of life. Eating disorders and substance use, therefore, are viewed as a continuum, in that many middle-childhood females have similar attitudes and engage in similar behaviors associated with eating disorders/symptoms and substance abuse not considered to be severe enough for clinical diagnosis of addiction or addictive behaviors.
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The noted results indicate the need for genderand age-responsive health care and health promotion services that incorporate not only health-related information about STDs, HIV/AIDS, birth control practices, smoking, alcohol and drug use/ abuse, and eating disorders, but also comprehensive physical assessment and care and treatment related to those specific health problems. IMPLICATIONS FOR NURSING PRACTICE APNs and other health care professionals working within the juvenile justice system can apply this knowledge when working with middle-childhood females. APNs’ assessments should include the use of face-to-face interviews, observations, and health assessment questionnaires. These assessments should include sections on sexual health as well as weight concerns, disordered eating patterns, and substance use and abuse. Middle to older adolescent females who are found to have a history of using or abusing substances and/or disordered eating patterns should be referred to age- and gender-responsive treatment services. The APN should take the lead to ensure that the juvenile
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justice system has both an age-responsive and a gender-responsive substance abuse screening tool and treatment services. The APN, working within the juvenile justice system, should consider the occasion as an opportunity to facilitate the physical and mental wellbeing of middle to older aged adolescent females. With appropriate health care and health promotion services, girls’ contact with the justice system can be viewed as an opportunity in which meaningful connections and interventions can be provided that are focused on facilitating the health of all girls. An encounter with the juvenile justice system can become not only a chance to educate, rehabilitate, and enhance girls’ ability to become active and positive contributors to society, but also to provide quality gender- and age-responsive health care and health promotion services. In summary, the findings from this study point to the growing need to further examine how APNs, working within the juvenile justice system, are addressing or not addressing the influx of younger middle-childhood females with multifaceted physical and mental health needs.
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APPENDIX
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REFERENCES Acoca, L. (1998). Defusing the time bomb: Understanding and meeting the growing health care needs of incarcerated women in America. Crime & Delinquency, 44(4), 46-69. Acoca, L (1999). Investing in girls: A 21st century strategy. Juvenile Justice, VI(1) 3-13. Andrulis, D. P. (2000). Community, service, and policy strategies to improve health care access in the changing urban environment. American Journal of Public Health, 90, 858-862. Centers for Disease Control and Prevention. (2000). Youth risk behavior surveillance—United States, 1999. Morbidity and Mortality Weekly Report, 49, SS-5. Dembo, R., Schmeidler, J., Burgos, W., & Taylor, R. (1996). Environment setting and early drug involvement among inner city junior high school youths. International Journal of Addiction, 20, 1239-1255. Guthrie, B. (1996). Female adolescent substance experience study. Ann Arbor, MI: University of Michigan. Guthrie, B. (1999). PACE report. Ann Arbor, MI: University of Michigan. Guthrie, B. J., & Kane Low, L. (2000). A substance use prevention framework: Considering the social context for African American girls. Public Health Nursing, 17(5), 363-373. Johnson, N. G., Roberts, M. C., & Worell, J. (Eds.). (1999). Beyond appearance: A new look at adolescent girls (pp. 85103). Washington, DC: American Psychological Association. Johnston, L. D., & O’Malley, P. M. (1985). Issues of validity and population coverage in student surveys of drug use. In Self-report methods of estimating drug use. National Institute on Drug Abuse Research Monograph, No. 57. Washington, DC: US Government Printing Office. Kelly, P. J., Bair, R. M., Baillargeon, J., & German, V. (2000). Risk behaviors and the prevalence of chlamydia in a juvenile detention facility. Clinical Pediatrics, 39, 521-527. Litt, I. F., & Cohen, M. I. (1974) Prisons, adolescents, and the right to quality medical care: The time is now. American Journal of Public Health, 64, 894-987. Morris, R., Harrison, E., Knox, G., Tromanhauser, E. K., Marquis, D., & Watts, L. (1995). Health risk behavioral survey from 39 juvenile justice correctional facilities in the United States. Journal of Adolescent Health, 17, 334-344. Neinstein, L. S., Pinsky, D., & Heischober, B. S. (1996). Overview of drug use and abuse. In L. S. Neinstein (Ed.), Adolescent health care: A practical guide (3rd ed.) (pp. 9851007). Baltimore: Williams & Wilkins.
Neinstein, L. S., Rabinovitz, S. J., & Schneir, A. (1996). Teenage pregnancy. In L. S. Neinstein (Ed.), Adolescent health care: a practical guide (3rd ed.) (pp. 656-675). Baltimore: Williams & Wilkins. Office of Juvenile Justice and Delinquency Prevention (OJJDP) (1998). What about girls? OJJDP Fact Sheet No. 84. Office of Juvenile Justice and Delinquency Prevention, Washington, DC. O’Hara Pepi, C. L. (1998). Children without childhoods: A feminist intervention strategy utilizing systems theory and restorative justice in treating female adolescent offenders. In J. Harden & M. Hill (Eds.), Breaking the rules: Women in prison and feminist theory. New York: The Haworth Press. Ousey, G. C. (2000). Deindustrialization, female-headed families, and black and white juvenile homicide rates. Sociological Inquiry, 70, 391-418. Pipher, M. (1994). Reviving Ophelia. New York: Random House. Poe-Yamagata, E., & Butts, J. A. (1996). Female offenders in the juvenile justice system. Statistics summary. Pittsburgh: National Center for Juvenile Justice. Prescott, L. (1998). Improving policy and practice for adolescent girls with co-occurring disorders in the juvenile justice system. The GAINS Center. Delmar, NY: Policy Research Inc. Shelton, D. (2000). Health status of young offenders and their families. Journal of Nursing Scholarship, 32(2), 173-178. Striegel-Moore, R. H., & Cachelin, F. M. (1999). Body image concerns and disordered eating in adolescent girls: risk and protective factors. In N. G. Johnson, M. C. Roberts, & J. Worell (Eds.), Beyond appearance: A new look at adolescent girls (pp. 85-103). Washington, DC: American Psychological Association. Thompson, J. K., & Smolak, L. (Eds.) (2001). Body image, eating disorders, and obesity in youth: Assessment, prevention and treatment. Washington, DC: American Psychological Association. US Department of Health and Human Services. (2000). Healthy people 2010: Understanding and improving health. Washington, DC: US Government Printing Office. Wallace, J. M., & Bachman, J. G. (1991). Explaining racial/ ethnic differences in adolescent drug use: The impact of background and lifestyle. Social Problems, 38, 333-357. Woolf, A. & Funk, S. G. (1985). Epidemiology of trauma in a population of incarcerated youth. Paediatric, 75, 463-468.
Despite an increase in middle to older aged adolescent females’ early contact with the juvenile justice system, inadequate health care remains a concern. This descriptive study surveyed the physical and mental health needs of 130 self-selected, nonrandomized girls aged 12 to18 years, with a mean age of 15.42 years (SD, 1.24), who were involved with a juvenile justice diversional program located in a southeastern region of the United States. Findings revealed early initiation of sexual-related activities (mean age, 13.9 years; SD, 1.49) and substance use (mean age, 12.9 years; SD, 1.53). The data suggest an increasing need for pediatric nurses, and in particular advanced practice nurses, to provide gender-responsive health care and health promotion services to early middle-childhood females in the juvenile justice system. Copyright 2002, Elsevier Science (USA). All rights reserved.
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IRLS TODAY, different from the past, are faced with more complex trials and tribulations in what is described by Pipher as “a more dangerous, sexualized and media-saturated culture” (1994, p.12). Navigating through these obstacles is a considerable challenge for most girls. Making it through adolescence safely in such a risk-laden society is said to not only require strength and resiliency, but a supportive and an informative environment (Johnson, Roberts & Worell, 1999). In the absence of positive and encouraging adult influences, middle-childhood females are more likely to venture off course between the ages of 8 to 11 years and engage in a variety of “delinquent” behaviors that may inevitably lead to contact with the juvenile justice system (Acoca, 1999).
From the University of Michigan, School of Nursing/Women’s Studies, Ann Arbor, MI, and PACE Center for Girls, Inc., Florida. Supported by the National Institute on Drug Abuse (grant K20-DA000233-01A1). Address correspondence and reprint requests to Barbara J. Guthrie, PhD, RN, Associate Professor, University of Michigan, School of Nursing/Women’s Studies, 400 N. Ingalls, Ann Arbor, MI 48109-0482. E-mail: [email protected]. Copyright 2002, Elsevier Science (USA). All rights reserved. 0882-5963/02/1706-0006$35.00/0 doi:10.1053/jpdn.2002.129793
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Girls between the ages of 8 to 11 years are at a crucial developmental stage. This is especially true for girls who come in contact with the juvenile justice system. For example, nationwide, about half of high school students reported engaging in sexual intercourse, with this number rising to 61% by grade 12 (Centers for Disease Control and Prevention, 2000). Only about 7% of these students had had intercourse before age 13 years. Conversely, a survey of detained adolescents in 39 juvenile correctional facilities found that 60% were sexually active by age 12 years and 90% by age 14 years (Morris, Harrison, Knox, Tromanhauser, Marquis & Watts, 1995). In the Centers for Disease Control and Prevention (2000) national sample, 16% report 4 or more lifetime sex partners, in contrast to more than half of incarcerated teens reporting 7 or more sex partners. Because of the growing downward age trend of higher rates of sexual-related risk behaviors, health care providers, especially pediatric nurses, need to focus on providing high-quality, gender- and age-responsive health care and health promotion services to detained middle-childhood females. Hence, this article is a first step toward providing a profile of the general and specific physical (i.e., illness, weight concerns, sexual history) and mental health (i.e., alcohol, tobacco, other drugs)
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needs of middle-childhood female offenders. The article aims to provide a descriptive profile that has the potential to guide the development of genderand age-responsive health care and health promotion services within the juvenile justice system. In addition, future health-related services for middlechildhood females within the system are provided. By revealing relevant and useful knowledge in the form of descriptive summary, the goal is to provide gender- and age-responsive health care and health promotion recommendations for advanced practice nurses (APNs) providing care within the juvenile justice system (Guthrie, 1996). REVIEW OF LITERATURE In the past, juvenile crime was predominantly a male phenomenon (Poe-Yamagata & Butts, 1996; O’Hara Pepi, 1998). For this reason, programs in the juvenile justice system appear to reflect more the needs of boys than of girls, as does most of the literature on delinquency (Office of Juvenile Justice and Delinquency Prevention (OJJDP), 1998; O’Hara Pepi, 1998). This lack of information likely has been justified simply by the fact that girls always have been a minority in the justice system. Although juvenile crime is still mostly a male phenomenon, girls today are beginning to make up a significant number of the youth who come in contact with the juvenile justice system (OJJDP, 1998). In fact, they currently represent a rapidly growing segment of the juvenile justice system. Females are entering the juvenile justice system more frequently and at younger ages (PoeYamagata & Butts, 1996; Acoca, 1998). For example, between the years 1989 and 1993, the number of girls charged with delinquency offenses increased by 31% and the growth of juvenile female arrests during this time more than doubled, as compared with the increase for males (Poe-Yamagata & Butts, 1996). In fact, in 1993, nearly one third of persons arrested who were under 18 years of age were females (Poe-Yamagata & Butts, 1996). Even more startling is the fact that in 1996, 723,000 adolescent girls were arrested for crimes and status offenses, with more than one third being younger than 15 years of age (OJJDP, 1998). Thus, like other risk behaviors, juvenile delinquency also is experiencing a downward trend to early and middle adolescence. Accordingly, the needs as well as the reasons for females’ contact with the juvenile justice system are considerably different, as compared with their male counterparts. For example, girls more often
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will suffer from more complex vulnerabilities than will boys who are the same age, such as depression and other mental health problems, resulting in girls entering the system with more co-occurring physical and mental health concerns such as substance abuse and eating disorders (Prescott, 1998). For those reasons alone, sensitivity to such gender distinction is warranted when addressing the particular physical and mental health needs of adolescent female offenders. Subsequently, the physical and mental health needs and strengths of girls often have been disregarded or unnoticed in the juvenile justice programs (OJJDP, 1998; O’Hara Pepi, 1998). As a result, much still remains unknown about the developmental trajectory of girls as it relates to their reasons for coming in contact with or being detained within the juvenile justice system. In order to facilitate the healthy development of middle-childhood females in contact with the juvenile justice system, pediatric nurses should consider providing gender- and age-responsive health care and health promotion services for those girls. Intervening knowingly and appropriately requires gender-specific knowledge, such as the ability to differentiate between boys’ and girls’ developmental process, as well as the unique and similar precursors associated with health-compromising behaviors (i.e., drinking, smoking, and early sexual activity). In order to accomplish the aforementioned, pediatric nurses need accurate information and knowledge. A first step is to examine a profile of selected health-related characteristics of young females who have come in contact with the justice system. The growing disproportionate number of African and Latino Americans detained within the juvenile justice system raises another health concern. The health care conditions that are over-represented in detained middle-childhood females generally, and African and Latino American girls in particular, mirror the health conditions in urban communities (Andrulis, 2000; Ousey, 2000). Specifically, early use and abuse of substances, sexually transmitted diseases (STDs), HIV/AIDS, victimization by violence, mental illness, and reproductive health issues are the most noted health-related problems. Despite those findings, health screening, health care, and health promotion services generally, and in particular for middlechildhood females, often are lacking or of poor quality (Andrulis, 2000; Ousey, 2000). The few documented health-related findings about this pop-
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ulation provide substantiation that overall youth who come in contact with the juvenile justice system have a substantial number of pre-existing physical and mental problems, as well as inadequate primary and mental health access and care. In response to the aforementioned concerns, a nonrandomized, self-selected, cross-sectional sample of ethnically diverse middle-childhood females involved with the justice system was studied. A gender-specific framework guided the development and design of the study (Guthrie & Kane Low, 2000). The key concepts inherent in this framework and operationalized in this study are as follows: environmental contexts such as neighborhoods and health care resources, personal attributes such as perceptions of health and related health behaviors, perception of weight, sexual health, mental health, and substance use and abuse (Guthrie, 1996; Guthrie & Kane Low, 2000). The purpose of the study was to generate baseline data about health status and health behaviors of girls who have come in contact with the juvenile justice system. More specifically, the girls were asked to answer questions related to physical health (i.e., illness, weight concerns, sexual history) and mental health (i.e., alcohol, tobacco, other drugs). METHODS
Sample This study is a part of a larger cross-sectional research project titled “Female Adolescent Substance Experience Study” (FASES) that was conducted from 1996 to 2000. The project was funded by the National Institute on Drug Abuse (Guthrie,
Figure 1.
1996). A self-selected and nonrandom network sampling technique was used to collect data on 130 middle-childhood females between the ages of 12 and 18 years. Fliers and posters were placed in 7 of the 17 diversional programs under the auspices of a specific southeastern regional diversional program; the fliers were used to recruit this subsample of middle-childhood females. Therefore the findings cannot be generalized to all adolescent female offenders in diversional programs. All potential participants were given a consent form in order to obtain parental and legal guardian consent for participation. Once initial written assent and consent were obtained, face-to-face interviews were conducted that lasted approximately an hour and a half. Full board human subject approval was obtained through the University’s Internal Review Board before any data collection. A sample of 130 girls was recruited that reflected approximately 17% of the total population receiving direct care from this adolescent female juvenile justice diversional program. The girls interviewed ranged in age from 12 to 18 years, with a mean age of 15.42 years (SD, 1.24) (Figure 1) and a mean grade level of 9.12. The self-defined demographic characteristics of the sample by ethnic group were as follows: 47.7% European American, 28.5% African American, 13.8% Latino American, and 10% other. More than half (62.3%) resided only with their mothers, whereas 37.7% resided with both parents. Fifty-four percent of the respondents indicated that they had not moved within the past year; the remaining 46% moved between 2 and 5 times during the same time period.
Ages of participants.
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Data Analysis Univariate analyses were conducted on all scales and individual items in order to provide descriptive information regarding the girls’ perceptions of relationship with parents, health, disordered eating, weight fluctuation, early sexual activity, and substance use. When appropriate, t tests were used.
Instruments FASES data were collected with a paper-andpencil self-report Likert-type questionnaire. This survey comprises several measures; however, for the purpose of this study, demographic, physical, and psychological health; substance use; sexualrelated activities; self-perceptions; familial and peer relationships; and perceptions of neighborhoods were used. (See Appendix Figure 1 for examples of questions.) Several open-ended questions also were included in the FASES questionnaire. A list of the instruments used in this analysis follows. Substance Use: Monitoring the Future Survey Patterns of substance use were measured by single-item questions adapted from the Monitoring the Future Survey. These are standard self-reported measures of substance use, and prior research supports their validity (Johnston & O’Malley, 1985; Wallace & Bachman, 1991). Perception of Neighborhood Scale The Perception of Neighborhood Scale (Dembo, Schmeidler, Burgos & Taylor, 1996) is a 20-item scale that measures adolescents’ perception of their neighborhood and various images of adolescents
Figure 2.
such as teen moms within their neighborhood. The reported Cronbach alpha is .90. For this sample, the Cronbach alpha was .81 for perception of toughness of neighborhood and .78 for tough images in the neighborhood. In addition to the aforementioned instruments, the participants were asked 1 or 2 single-item questions related to perceptions of health, fluctuation of weight, importance of weight, selected disordered eating patterns, sexual-related practices (eg, ever had sex, ever been pregnant), and patterns of contraceptive use or nonuse. The aforementioned items were chosen in order to provide baseline data about girls’ health status and their health-related behaviors.
Data Collection The data collection was done during the first week of March 1999. The FASES team, consisting of one doctoral candidate, a research associate, and the senior author, traveled to the southeastern region of the United States and administered the survey tool to middle-childhood females in 7 of the 17 existing juvenile justice diversional programs (Guthrie, 1999). RESULTS
Perception of Health and Health-Related Behaviors Respondents’ perceptions of their health ranged from excellent to poor, with 109 respondents (84.5%) indicating good to excellent health (Figure 2). It should be noted, however, that when asked about their perception of health in relation to their peers in general, 64 of the respondents indicated
Self-rating of present health.
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that their health was average, whereas the remaining 55 reported that their health was “a little better” to “much better” than average. Over 67% percent (n ⫽ 85) reported taking prescribed medications such as birth control pills (50%), attention deficit medicines (3%), and depression-related medicines (12%). One hundred eight respondents received health care from a physician, and the remaining twenty-two respondents received care from either a midwife or a nurse practitioner. The top 4 reasons given for seeking health care were as follows: infection (50%), immunization (25%), birth control (15%), and STDs (10%). Only half of the respondents stated that they were comfortable talking to their health care provider about sex, birth control, STDs, and substance abuse. When asked whether they had been exposed to HIV/AIDS, 74 of those who responded reported “not at all likely,” whereas the remaining 42 reported “somewhat likely” (24), “pretty likely” (9), or “extremely likely” (9).
Perception of Weight The respondents were asked a series of questions related to their weight. For example, when asked about whether their weight fluctuates (meaning weight goes up and down a lot), 53 (42.4%) said yes. Ninety-three respondents indicated that they were proud of their body; however, 103 (47.3%) indicated that their weight was very important to the way they felt about themselves. In addition, 83 stated that they feared becoming fat and that their stomachs or thighs were too fat. When asked whether they had ever binged, 56 reported that they had and 34 indicated that their binge eating was out of control (Figure 3).
Figure 3.
Sexual Health Approximately 79% of the respondents had had vaginal sexual intercourse. The mean age of sexual debut was 13.9 years (SD, 1.49) and their partners’ mean age was 16.9 years (SD, 2.77). A closer examination of ethnic differences with regard to age revealed a significant difference between ethnic groups at the p ⫽ .05 level. Specifically, European American girls reported an age of initiation of 13.7 years (SD, 1.3), Latino American girls reported an age of 12.3 years (SD, 2.1), and African American girls reported an age of 14.3 years (SD, 1.3). Thus all girls reported initiation during the early to middle adolescence. The reported age of partners also was significantly different between ethnic groups. European Americans reported that their partners were at least 2.3 years older (SD, 1.67), whereas Latino and African American girls reported that their partners were 4.1 years older (SD, 2.9) and 2.7 years older (SD, 2.7), respectively. When asked whether they had used any form of birth control during first intercourse, 67 said “yes” and 42 said “no.” Of those who used birth control, the types most often used were condoms, birth control pills, and Norplant. Thirteen percent of the respondents used withdrawal. Twenty-one respondents indicated that they had previous pregnancies that ended in either an abortion (8) or miscarriage (13). The mean number of lifetime sex partners was 4.6 (SD, 5.51). European American girls reported more lifetime partners (mean, 5.7; SD, 6.8) than Latino Americans (mean, 3.8; SD, 3.6) and African Americans (mean, 2.6; SD, 2.0). Nineteen respondents indicated that they had anal sex from 1
Importance of weight.
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to 28 times. About one quarter of the respondents reported being pressured to have sex by their boyfriends, friends, or other males. Several respondents (n ⫽ 49) indicated that they had had one or more STDs (syphilis, gonorrhea, genital herpes, genital warts, chlamydia, pelvic inflammatory disease, or Trichomonas).
Mental Health/Patterns of Substance Use Cigarettes One hundred eight respondents (83%) reported ever smoking a cigarette, with the mean age of initiation being 11.7 years (SD, 2.1). Of the 108 who reported ever using cigarettes, 60 reported regular use. Seventy percent of the respondents smoked more than 1 cigarette per day. There were significant differences between European Americans (mean, 11.1 years; SD, 2.1) and African Americans (mean, 12.9 years; SD, 1.8), but not between Latino Americans (mean, 12.2 years; SD, 1.5) and African Americans or European Americans. Alcohol One hundred nine respondents reported ever drinking alcohol, and eighty-nine reported regular to occasional use of alcohol. The mean age of first use was 12.61 years (SD, 2.16). There were no significant differences between the three ethnic groups, in that they all reported age at first use of around 12 years. During the past month, 74 respondents reported drinking a range of “once” to “every day.” The majority of girls drank beer (49%) or hard liquor (43%) and only 8% drank wine. Marijuana
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The mean age at first use of crack was 14 years (SD, 1.53). Heroin Fourteen respondents reported lifetime use of heroin, with a mean age at first use of 14.47 years (SD 1.06). Of the 14 respondents, half used anywhere from once a day to every day during the past month. In addition, 9 girls reported using needles and 2 admitted to sharing needles with proper flushing. Other Substances Other substances used by respondents were barbiturates, inhalants, and tranquilizers. A majority of the respondents reported using substances first with their boyfriends, followed by use with an older sibling or same-gender friends. On the perception of harm substance scale, the mean response was 2.3 (SD, 1.39), with a range of 0 to 4 (in which 4 denotes the most harm). In other words, most of the respondents moderately agreed that drugs could be harmful in nature.
General Substance-Related Patterns Several significant substance abuse patterns were noted. For example, the data revealed a developmental substance use trajectory. Specifically, the timing of first substance used was shortly followed by more harmful and illegal substance use, in that the initiation of first use of cigarettes was 11.7 years of age, alcohol was 12.6 years of age, marijuana was 12.9 years of age, and crack was 14 years of age.
Environmental Contexts
Eighty-nine of the respondents reported lifetime use of marijuana, with a mean age at first use of 12.9 years (SD, 1.53). There were significant differences between European Americans (mean, 12.5 years; SD, 1.3) and African Americans (mean, 13.9 years; SD, 1.4), but not between Latino Americans (mean, 12.7 years; SD, 1.6) and other groups. During the past month, 56 of the 89 respondents reported a range of marijuana use from once a day to every day.
Neighborhood
Crack
Health-Related Services
Although a smaller number of respondents (20) reported lifetime use of crack, over one third of the 20 (7) reported that during the past month they had used crack anywhere from once a day to every day.
When asked about services that they used both presently and in the past, the most commonly cited services used were mental health services, followed by substance abuse treatment services and
On a scale ranging from 1 (peaceful) to 51 (very tough), the respondents’ mean rating of their neighborhoods was 27.7 (SD, 10.43). Therefore it was not surprising that when asked about the availability of substances (alcohol, marijuana, heroin, crack, inhalants, tranquilizers, or barbiturates), over 50% of the respondents indicated that substances not only were available, but also were easy to obtain in their neighborhoods or at school.
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Alateen. In response to services needed but not available, the respondents indicated a need for access to counseling, dental care, drug counseling, job training, and physical and mental health services. DISCUSSION Although the mean age of the patients in the sample was 15.42 years (SD, 1.24), most of the reported compromising behaviors were initiated during early adolescence. For example, most girls reported engaging in early sexual-related behavior before 14 years of age. Specifically, the mean age reported for initiation of early sexual intercourse was 13.9 years, with an SD of 1. This reported mean is lower than the nationwide average, which is approximately 16.7 years of age (Neinstein, Rabinovitz & Schneir, 1996). Second, almost half of the girls (approximately 42%) did not use birth control during first intercourse or report a consistent pattern of using birth control or safer sex practices, thereby increasing their likelihood of becoming pregnant or becoming infected with an STD or HIV/AIDS, which can potentially lead to pelvic inflammatory disease, cervical cancer, and infertility. In addition, inconsistent birth control use, history of unwanted pregnancy as evident by abortions, and utilization of the withdrawal method as birth control strongly suggest that the participants may not have sufficient or age-appropriate information regarding birth control methods, as well as information about resources for accessing contraceptive devices. The elective abortion rate speaks to the fact that some girls used elective abortions as a contraceptive method. Adolescent pregnancy is a major health concern for both the young girl and the fetus, as many risks have been implicated. Risks such as increased maternal mortality, lowbirth-weight babies, and increased infant mortality have been documented (Neinstein, Rabinovitz & Schneir, 1996). Therefore APNs working with or within the juvenile justice system need to address middle-childhood females’ sexual health in an attempt to not only offset the likelihood of the girls becoming teen moms, but also to increase the girls’ perceptions of their ability to engage in safer sex practices. Similarly, for some girls, substance use was initiated as early as 11 years of age. In addition, 70% of the respondents smoked cigarettes on a daily basis and 68% reported occasional or regular alcohol use, both of which have the potential for
killing and disabling youth (Neinstein, Pinsky & Heischober, 1996). This substance use data also point toward a sequential developmental timing of first substance use such as cigarette use (11.7 years of age), alcohol use (12.6 years of age), and marijuana (12.9 years of age). The mental health needs of middle-childhood females in contact with the juvenile justice system should be addressed. In particular, their concerns about fluctuating weight, identifying body parts as fat, and binge eating out of control and use of amphetamines and smoking to control weight are suggestive of disordered eating. Disordered eating potentially leads to eating disorders such as anorexia and bulimia, which are a major health concern for middle-childhood females (StriegelMoore & Cachelin, 1999; Thompson & Smolack, 2001). Enhancing emotional well-being, with specific focus given to the development of a positive body image and self-esteem, would be most beneficial, for one of the key developmental challenges for a middle-childhood female girl in the United States is to become comfortable with and take pride in her body. Puberty is associated with weight gain, and for American middle-childhood females, this change occurs within the cultural context that upholds the female beauty ideal of thinness. Therefore the physical changes of puberty often are at odds with the American culture of female beauty. If an adolescent girl feels that she is at odds with this norm, then she may have low self-esteem that in turn might lead to the development of an eating disorder (Johnson, Roberts & Worell, 1999). The aforementioned results coupled with the girls’ reported use of substances provide substantiation for the need to address these potentially related mental health issues. The co-occurrence of mental health problems such as substance use and eating disorders is one of the national public health priorities for prevention and treatment efforts identified in Healthy People 2010 (US Department of Health and Human Services, 2000). Specifically, the health consequences of eating disorders/symptoms and substance abuse are long-lasting and have the potential to negatively affect life expectancy, as well as the quality of life. Eating disorders and substance use, therefore, are viewed as a continuum, in that many middle-childhood females have similar attitudes and engage in similar behaviors associated with eating disorders/symptoms and substance abuse not considered to be severe enough for clinical diagnosis of addiction or addictive behaviors.
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The noted results indicate the need for genderand age-responsive health care and health promotion services that incorporate not only health-related information about STDs, HIV/AIDS, birth control practices, smoking, alcohol and drug use/ abuse, and eating disorders, but also comprehensive physical assessment and care and treatment related to those specific health problems. IMPLICATIONS FOR NURSING PRACTICE APNs and other health care professionals working within the juvenile justice system can apply this knowledge when working with middle-childhood females. APNs’ assessments should include the use of face-to-face interviews, observations, and health assessment questionnaires. These assessments should include sections on sexual health as well as weight concerns, disordered eating patterns, and substance use and abuse. Middle to older adolescent females who are found to have a history of using or abusing substances and/or disordered eating patterns should be referred to age- and gender-responsive treatment services. The APN should take the lead to ensure that the juvenile
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justice system has both an age-responsive and a gender-responsive substance abuse screening tool and treatment services. The APN, working within the juvenile justice system, should consider the occasion as an opportunity to facilitate the physical and mental wellbeing of middle to older aged adolescent females. With appropriate health care and health promotion services, girls’ contact with the justice system can be viewed as an opportunity in which meaningful connections and interventions can be provided that are focused on facilitating the health of all girls. An encounter with the juvenile justice system can become not only a chance to educate, rehabilitate, and enhance girls’ ability to become active and positive contributors to society, but also to provide quality gender- and age-responsive health care and health promotion services. In summary, the findings from this study point to the growing need to further examine how APNs, working within the juvenile justice system, are addressing or not addressing the influx of younger middle-childhood females with multifaceted physical and mental health needs.
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