AAP Endorses Position Statement on Restrictive Housing for Youths

Adverse effects of solitary confinement and other restrictive housing practices include higher risks of suicide among youth.

The National Commission on Correctional Health Care (NCCHC) announced that the American Academy of Pediatrics (AAP) has endorsed its position statement on the use of restrictive housing in juvenile correctional settings this fall.

The NCCHC position statement, originally released in February 2021, calls for juvenile correctional settings to stop using or limit the use of restricted housing, which refers to several forms of housing conditions including solitary confinement, protective custody, and disciplinary segregation.1 The position statement also offers several alternatives to restricted housing and asks these facilities to establish clear and specific guidelines for cases in which restricted housing may be unavoidable.2 The NCCHC and AAP’s position on restricted housing stems from research into a wide variety of negative health outcomes associated with these practices.1,2

“Restrictive housing, unless necessary for medical isolation, is not developmentally appropriate or a safe, effective way to care for youth in correctional settings,” said AAP Committee on Adolescence Chair Elizabeth M. Alderman, MD, FSAHM, FAAP, in a press release. Paula Braverman, MD, FSAHM, FAAP—the AAP liaison to the NCCHC board of representatives and former chair of the AAP Committee on Adolescence—agreed, stating that restrictive housing should be “the last alternative” after all other behavioral management strategies have been exhausted.2

According to the NCCHC, research from the World Health Organization, along with other groups, reports that even adults subjected to solitary confinement and other forms of restricted housing often experience depression, anxiety, anger, psychosis, paranoia, and cognitive disturbances, along with higher risks of self-harm and suicide. Incarcerated children and adolescents are at higher risk of adverse reactions to restricted housing due to their developmental vulnerability, which is especially true in regard to risk of suicide.1 The NCCHC cites a US Department of Justice—Office of Juvenile Justice and Delinquency Prevention—survey on juvenile suicide, which found that 62% of youth suicide victims had been subjected to room confinement, and 50% of victims were actually experiencing room confinement at their time of death.3

In order to reduce occurrences of suicide and other adverse effects in incarcerated youth, the NCCHC recommends several alternatives to restricted housing, including trauma-informed de-escalation techniques; evidence-based interventions such as motivational interviewing and cognitive-behavioral therapy; and one-on-one activities (ie, outside recreation, journaling) with a staff member. The position statement also notes that all consequences (ie, loss of privileges, verbal reprimands) should be clear and carefully described; youth should have the option to voluntarily isolate themselves in their cells—with appropriate monitoring—to avoid conflict; and youth should have access to mental health professionals who are trained in conflict resolution.1

In cases in which all of these and other alternatives have been exhausted and restricted housing is deemed unavoidable, the NCCHC outlines a series of steps that facilities need to take to ensure the health and well-being of youth, including clear communication to youth as to when and why restricted housing is used, what specifically it entails, and how its endpoint will be determined; and clear policies specifying how the use of restricted housing is in accordance with all relevant regulations, laws, and standards of ethics. The position statement also holds that isolation should be ended as soon as the youth is no longer a risk to self or others, rather than being imposed for set periods of time, and facilities should obtain medical clearance for youths prior to their placement whenever possible, with specific considerations for the youth’s trauma, any underlying mental or medical health conditions, and risk of suicide.1

Alderman noted that the NCCHC position statement aligns with the AAP’s 2020 policy statement, “Advocacy and Collaborative Health Care for Justice-Involved Youth,”4 which also opposes the use of solitary confinement and offers guidelines for professionals working in juvenile correction settings.2

References

1. National Commission on Correctional Health Care. Restricted housing in juvenile correctional settings. National Commission on Correctional Health Care. February 3, 2021. Accessed December 2, 2021.

2. National Commission on Correctional Health Care. American Academy of Pediatrics endorses NCCHC position statement on restricted housing for youths. News Release. National Commission on Correctional Health Care. October 26, 2021. Accessed December 2, 2021.

3. Hayes LM. Juvenile suicide in confinement: a national survey. US Department of Justice, Office of Juvenile Justice and Delinquency Prevention. February 2009.

4. Owen MC, Wallace SB; American Academy of Pediatrics Committee on Adolescence. Advocacy and collaborative health for justice-involved youth. Pediatrics. July 2020;146(1):e20201755.