As a medical student, Elizabeth S. Barnert, MD, MPH, MS, worked with families traumatized by separation in El Salvador and helped reunify them. During her pediatrics residency, she searched for that same intersection of violence, poverty and health – in the U.S. It led her straight to the juvenile legal system.
At a community-based health clinic for underserved populations, one of the patients she regularly treated was a teenage boy who was under court supervision. Her experiences with him and others cemented her interest not only in clinical care, but research to advocate for better policies for youth who had been through the juvenile justice system.
“The fundamental issue is not the one kid shoplifting from the liquor store. It's really our approach to childhood in the United States. And us not protecting childhood,” said Dr. Barnert, an associate professor of pediatrics at the David Geffen School of Medicine at UCLA.
Despite a 75% decline in the number of youth detained in juvenile justice centers over two decades, the United States still leads the industrialized world in locking up children – 27,600, as of 2022.
“A lot of this comes down to policymaking and how we define our budgets,” said Dr. Barnert. “Are we putting our budgets into preventive services supporting pregnant women, early childhood education, adolescents doing well in school, adolescents getting the mental health care they need? Or are we waiting for them to fall through the cracks and putting our dollars into the juvenile legal system?”
In the community
Dr. Barnert cares for children at in a local juvenile detention center. Yet that is not where she and other pediatricians will mostly likely encounter children who are in the legal system, as Dr. Barnert noted in her recent article, Childhood Behind Bars.
Like the teenage boy she treated at the community clinic, most children in the legal system are not incarcerated, but at home and under court supervision.
“This is a big issue that most of us haven't wrapped our head around,” she said. “The data show that juvenile justice involvement is harmful to health. However, the kids actually get health care when they're there.
“But for the 80% in the community, there's actually no health care touch point. The kids are experiencing the stress of court involvement and the associated health risks of whatever risky behaviors led them to conflict with the law in the first place.”
Dr. Barnert was encouraged by recent reforms in Medicaid, which go into effect in January 2025. Youth who spent time in a juvenile confinement facility will be provided Medicaid services for several weeks after they're released. She believes this is a step toward disrupting the cycle of incarceration.
Dr. Barnert was co-leader of the American Pediatric Society's issue of the year: improving the care of youth in custody. It was an effort to counteract how correctional health has splintered off, the province of a small group of doctors and nurse practitioners who are already familiar with the system.
The reality is that children who are detained largely receive their non-primary health care outside of incarceration facilities.
“Whenever kids who are in confinement need to see a specialist, go to the emergency room or need to be hospitalized, that is happening in the community,” said Dr. Barnert, adding that more pediatricians should be aware that their patients may be involved in the juvenile legal system. “So, we need to stop ignoring these hidden children and embrace them as an important pediatric population.”
In addition, Dr. Barnert has been working on how to incorporate juvenile justice into medical education. Given that most trainees do not get exposure to children in custody, or even learn about the juvenile legal system, she has been in discussions with the American Board of Pediatrics about how best to formulate questions on the subject for board examinations.
Age limits
In 2018, Dr. Barnert’s research and advocacy helped California pass a minimum age law: children under age 12 cannot be prosecuted in the juvenile legal system (with exclusions for homicide and forcible rape). That is still not the case in many parts of the country, despite extensive research on children’s cognitive development and decision making.
Dr. Barnert worked with UCLA professor of social welfare, Laura Abrams, on the need for a minimum age of juvenile delinquency jurisdiction, arguing children below a certain age are just too young.
“It's incompatible with child development, with healthy development, to lock up an 8-year-old,” said Dr. Barnert. “I'm actually spending time saying this because we don't have minimum ages in many states, and in many states, the minimum ages are too low when you think about it from a developmental perspective.”
In addition, there is still a pathway for prosecuting a child as an adult in all 50 states. Recent legislation in California made it harder to do that, requiring a hearing and a formal decision to treat the child as an adult. Related to that, 1 in 10 children nationwide were incarcerated in adult facilities.
The majority of children in the legal system are adolescents – 15, 16, 17 -- and Dr. Barnert continues to advocate for a system that is developmentally aligned, including peer-to-peer interactions, access to their families, and educational and vocational support.
“Adolescent and developmental science has been huge,” said Dr. Barnert. “It's been really encouraging that policymakers have been responsive to brain science and understanding that the frontal lobe of our brains doesn't fully form until age 25.
“A lot of what we do in the field of juvenile justice is to remind people that these are kids, and we need to treat them as such if we want to have a healthier society and to have optimal public safety.”
