Commercially Sexually Exploited Adolescent Girls: The Association Between Externalizing Disorders and Parental Incarceration with Suicide Attempts.

Commercial sexual exploitation (CSE) is a significant public health concern disproportionately affecting ethnoracially minoritized girls. Despite strong associations of CSE with suicide attempts, little is known about correlates of suicide among girls with CSE histories. Elevated rates of externalizing disorders (i.e., attention-deficit/hyperactivity disorder [ADHD], disruptive behavior disorders [DBD], conduct disorder [CD]) were observed among CSE youth, particularly in ethnoracially minoritized samples. Youth with CSE histories are frequently affected by parental incarceration, which is correlated with risk for suicide attempts. We tested cross-sectional simultaneous associations of externalizing disorders and parental incarceration with number of suicide attempts among 360 ethnoracially diverse girls affected by CSE (Mean age = 18.86). ADHD, DBD, and maternal incarceration were positively associated with number of suicide attempts. Findings implicate clinical/familial correlates of suicide attempts in this marginalized group, suggesting early suicide prevention efforts may improve traction on this problem by focusing on individual and family level factors.

Sexting and Behavioral Health in First-time Justice-Involved Adolescents.

Objectives: We examined the prevalence of sexting, related motivations, demographics, and association with behavioral health problems among justice-involved adolescents. Hypotheses: We hypothesized positive associations between sexting and sexual risk, substance use, delinquency, and mental health problems. Methods: Participants were 307 community-supervised justice-involved adolescents with a first-time offense (Mage =14.50 years, 44.6% female) and their caregivers. Adolescents answered questions on technology use and sexting by sending, receiving, or forwarding sexually suggestive text messages and images (pictures or videos). They also completed measures of recent (past 4-month) sexual activity, unprotected sex, cigarette, alcohol, marijuana, and other drug use, and delinquency; current trauma symptoms, internalizing problems, and adaptive functioning. Results: Prevalence of sexting were 37.7% (lifetime overall; 17.0% sent texts; 17.4% sent images) and 29.5% (past-year overall; 12.8% sent texts; 13.6% sent images). Sexts were commonly sent as presents to partners, in response to sexts received, or to have fun. "Sexters" were older than "non-sexters" and more likely to identify as lesbian, gay, bisexual, or questioning. Past-year sexting was significantly associated with recent sexual activity; unprotected sex; alcohol use and days of use; marijuana and other drug use; delinquency and variety of delinquent acts; and elevated trauma symptoms and internalizing problems. Conclusions: Sexting is prevalent among adolescents with a first-time offense and co-occurs with multiple behavioral health needs. Intervention for this population may be informed by routinely assessing sexting in community settings. Familiarity with local reporting laws could help clinicians navigate the legal implications of sexting among adolescents with existing justice-system involvement.

Impact of Racial Discrimination on the Mental Health of Minoritized Youth.

PURPOSE OF REVIEW: The impacts of racism and discrimination on developing minoritized youth are increasingly shown as having the potential to create long-lasting adverse outcomes on children's developmental trajectories. RECENT FINDINGS: From the quality of the schools they attend, to the level and amount of toxicants in the air they breathe, to equitable access to health care, and within interpersonal relationships and experiences with their peers, multiple forms of racism, systemic/structural, interpersonal/personally mediated, and internalized shape the health status of Black, Indigenous, and people of color (BIPoC) youth. Accordingly, it is exceedingly important to use a developmental lens to distinguish the various outcomes these multiple forms of racism have on the health of minoritized youth. Critically, the time is now for rapid identification of these harms in all of the mediums and spaces in which they present followed by prevention and intervention strategies that are effective in equitably ensuring the healthy development for all of America's children.

Reimagining Merit and Representation: Promoting Equity and Reducing Bias in GME Through Holistic Review.

OBJECTIVE: This study aims to evaluate the capacity of a holistic review process in comparison with non-holistic approaches to facilitate mission-driven recruitment in residency interview screening and selection, with particular attention to the promotion of race equity for applicants underrepresented in medicine (URM). METHODS: Five hundred forty-seven applicants to a psychiatry residency program from US allopathic medical schools were evaluated for interview selection via three distinct screening rubrics-one holistic approach (Holistic Review; HR) and two non-holistic processes: Traditional (TR) and Traditional Modified (TM). Each applicant was assigned a composite score corresponding to each rubric, and the top 100 applicants in each rubric were identified as selected for interview. Odds ratios (OR) of selection for interview according to URM status and secondary outcomes, including clinical performance and lived experience, were measured by analysis of group composition via univariate logistic regression. RESULTS: Relative to Traditional, Holistic Review significantly increased the odds of URM applicant selection for interview (TR-OR: 0.35 vs HR-OR: 0.84, p < 0.01). Assigning value to lived experience and de-emphasizing USMLE STEP1 scores contributed to the significant changes in odds ratio of interview selection for URM applicants. CONCLUSIONS: Traditional interview selection methods systematically exclude URM applicants from consideration without due attention to applicant strengths or potential contribution to clinical care. Conversely, holistic screening represents a structural intervention capable of critically examining measures of merit, reducing bias, and increasing URM representation in residency recruitment, screening, and selection.

Reconnecting Homeless Adolescents and Their Families: Correlates of Participation in a Family Intervention.

Behavioral family interventions are an effective way to intervene to prevent negative developmental outcomes for adolescents. Participation in family interventions encompasses behavioral and cognitive/attitudinal dimensions, among others, indicated by retention and engagement, respectively. Two dimensions of participation, retention and engagement, in a family intervention were examined in a sample of newly homeless adolescents and their parents or guardians. Correlates of participation included parents with more income and less perceived family conflict and adolescents with higher endorsement of depression, anxiety, somatization, obsessive-compulsive, phobic, and psychotic symptoms on the Brief Symptom Inventory (BSI). Stronger therapeutic alliance was correlated with being more distressed (i.e., lower income, more hostility), being a female adolescent participant, and having greater comfort discussing sex with parents. Furthermore, parents and adolescents with greater distress and thus greater need were more apt to finish the intervention. The finding that families who were experiencing more distress had higher alliance scores suggests that there is an additional need for development of interventions for families in crisis. Both participant and provider perceptions are also important in development of a strong therapeutic alliance. This study's findings have implications for further exploration of the development of cultural humility and improving mental health literacy among facilitators of behavioral interventions.

Fierce Autonomy: How Girls and Young Women Impacted by Commercial Sexual Exploitation Perceive Health and Exercise Agency in Health Care Decision-Making.

Prior research has examined the high health care needs and vulnerabilities faced by survivors of commercial sexual exploitation (CSE), yet their perspectives are frequently absent. We sought to understand the narratives and views of individuals affected by CSE on their bodies, health, and motivations to seek health care treatment. Twenty-one girls and young women ages 15 to 19 years with self-identified histories of CSE participated in the study. All participants had current or prior involvement in the juvenile justice and/or child welfare systems. Data collection included brief questionnaires, followed by semi-structured individual interviews. The interviews took place between March and July 2017 and were analyzed using iterative and inductive techniques, using the shared decision-making model as a guide. "Fierce Autonomy" emerged as a core theme, depicting how past traumas and absence of control led the girls and young women to exercise agency and reclaim autonomy over decisions affecting their health.

Families and the Juvenile Justice System: Considerations for Family-Based Interventions.

We conducted focus groups with defense lawyers, clinicians, and education advocates to gather their perspectives on families' experiences with the juvenile justice system. Our quantitative descriptive analysis identified a range of themes such as discussions about the poor treatment of families as well as recommendations for a shifting of power to families. These perspectives may provide insights about the context in which families are expected to participate in interventions, meet probationary demands, and provide for their youth's well-being. The results support evidence gathered from families about the impact of youth incarceration on their lives and has implications for practitioners and researchers working with families whose youth have been incarcerated.

Exploring Mental Health and Substance use Treatment Needs of Commercially Sexually Exploited Youth Participating in a Specialty Juvenile Court.

The study sought to: (1) describe the mental health and substance use profiles among participants of a specialty trafficking court program (the Succeed Though Achievement and Resilience Court); (2) describe youths' mental health and substance use treatment prior to participating in the program; and (3) examine whether abuse influences report of mental health problems and/or substance use. Retrospective case review of court files was performed on commercially sexually exploited youth who volunteered to participate in the court from 2012 to 2014 (N = 184). All participants were female. Mental health problems and report of substance use was high among this population. Substance use differed at statistically significant levels between youth with a documented abuse history compared to those with no abuse history. Substance use also differed by report of mental health problems. Unexpected findings included the high rate of hospitalization for mental health problems and relatively low substance use treatment prior to STAR Court participation. Opportunities for improvement in critical points of contact to identify commercially sexually exploited youth and address their health needs are discussed.

Overturning Roe v Wade and Planned Parenthood v Casey: An Assault to Reproductive and Racial Justice and the Mental Health of Youth.

On June 24, 2022, the Supreme Court of the United States overturned Roe v Wade and Planned Parenthood v Casey, ending a woman's constitutional right to access abortion. Child and adolescent psychiatrists should be gravely concerned about these decisions. Youth with mental health disorders are an at-risk population. Lack of access to reproductive care, including abortion, will adversely impact the physical and mental health of teens,2 exerting a disproportionate impact on Black and Brown youth, many of whom experience systemic racism and are in systems that leave them structurally vulnerable (ie, in foster care or legal system). These decisions will have a lasting, negative impact on medical, social, and economic outcomes of youth for generations to come. Thus, we make the case that access to reproductive care is a matter of reproductive and racial justice.

Experiences of Leaders in Diversity, Equity, and Inclusion in US Academic Health Centers.

Importance: The murder of George Floyd in 2020 spurred an outpouring of calls for racial justice in the United States, including within academic medicine. In response, academic health centers announced new antiracism initiatives and expanded their administrative positions related to diversity, equity, and/or inclusion (DEI). Objective: To understand the experiences of DEI leaders at US allopathic medical schools and academic health centers, ie, the structure of their role, official and unofficial responsibilities, access to resources, institutional support, and challenges. Design, Setting, and Participants: This qualitative study used key informant interviews with participants who held formal DEI positions in their school of medicine, health system, or department. Interviews were conducted from December 2020 to September 2021. Transcripts were coded using a phenomenographic approach, with iterative concurrent analysis to identify thematic categories across participants. Data were analyzed from January to December 2021. Exposure: Formal DEI role. Main Outcomes and Measures: Questions elicited reflection on the responsibilities of the role and the strengths and challenges of the unit or office. Results: A total of 32 participants (18 of 30 [56%] cisgender women; 16 [50%] Black or African American, 6 [19%] Latinx or Hispanic, and 8 [25%] White) from 27 institutions with a mean (range) of 14 (3-43) years of experience in medical education were interviewed. More than half held a dean position (17 [53%]), and multiple participants held 2 or more titled DEI roles (4 [13%]). Two-thirds self-identified as underrepresented in medicine (20 [63%]) and one-third as first generation to attend college (11 [34%]). Key themes reflected ongoing challenges for DEI leaders, including (1) variability in roles, responsibilities, and access to resources, both across participants and institutions as well as within the same position over time; (2) mismatch between institutional investments and directives, including insufficient authority, support staff, and/or funding, and reduced efficacy due to lack of integration with other units within the school or health system; (3) lack of evidence-based practices, theories of change, or standards to guide their work; and (4) work experiences that drive and exhaust leaders. Multiple participants described burnout due to increasing demands that are not met with equivalent increase in institutional support. Conclusions and Relevance: In this qualitative study, DEI leaders described multiple institutional challenges to their work. To effectively address stated goals of DEI, medical schools and academic centers need to provide leaders with concomitant resources and authority that facilitate change. Institutions need to acknowledge and implement strategies that integrate across units, beyond one leader and office. Policymakers, including professional organizations and accrediting bodies, should provide guidance, accountability mechanisms, and support for research to identify and disseminate evidence for best practices. Creating statements and positions, without mechanisms for change, perpetuates stagnation and injustice.

Advancing Youth Justice: The Child and Adolescent Psychiatrist's Role.

Child and adolescent psychiatrists (CAPs) play a crucial role beyond the provision of clinical care. CAPs are uniquely placed to understand and help patients navigate the fine line among psychiatric care, health and well-being, and the laws and policies supporting or impairing these processes. Focusing on vulnerable populations, such as legal system impacted youth and families, CAPs can contribute to the ongoing development of a more just and equitable world for the children of today and of tomorrow.

Promoting Racial/Ethnic Identity in Child and Adolescent Mental Health Treatments.

Over the last decade, state and city legislative efforts have underscored that racism is a public health crisis. These legislative shifts have been in concert with several professional medical organizations, including the National Academy of Medicine, the United States Department of Health and Human Services, the Centers for Disease Control, and the National Institute of Health, which have collectively called for structural change to address race inequity in health, from research to patient care. The adverse effects of racism (eg, interpersonal, structural, institutional, and internalized) on health have been documented to include negative effects across the lifespan and developmental continuum, particularly for ethnoracially minoritized youth. Indeed, several studies have specifically identified racism's impact on youths' psychosocial functioning and emotional well-being, particularly around anxiety, depression, and academic functioning. The effects of interpersonal racism on mental health in adolescents and, in particular, Black youth is telling. Although the child and adolescent mental health establishment and literature have advocated for strengths-based (eg, cultural assets) and community engaged (eg, community-based participatory research) frameworks to advance evidence-based treatments for diverse communities, the development of culturally responsive and antiracist interventions remain a gap in our treatment armamentarium for ethnoracially minoritized youth. As in other papers, we have highlighted the criticality of health equity, cultural humility, and culturally informed and responsive clinical practices. We have also underscored that, as a field, child mental health practitioners need to move toward being antiracist to truly address well-being, a shift that requires pivoting toward approaches that promote racial/ethnic identity (REI), which includes racial/ethnic connectedness and racial/ethnic pride. Race-conscious interventions, particularly those that focus on racial/ethnic connectedness and racial/ethnic pride, can not only be protective and health promoting in their ability to mitigate the emotional harms of experiencing racism, but can also foster social-emotional functioning and successful academic outcomes among ethnoracially minoritized individuals.

Revisiting Research Safety Protocols: The Urgency for Alternatives to Law Enforcement in Crisis Intervention.

Research safety protocols are ubiquitous in mental health research involving human subjects and have the potential to harm research participants from racial-ethnic minority populations. For mental health emergencies, such protocols commonly rely on law enforcement for crisis intervention. The authors review inequities experienced by individuals with mental illness in law enforcement encounters, especially Black, Latinx, and other minoritized populations. They then describe the development of a research safety protocol that uses community-based crisis intervention programs as alternatives to law enforcement and provide a roadmap for researchers and institutional review boards to revisit and revise their human subjects safety protocols.

Reimagining Narrative Approaches Through Comics for Systems-Involved Youth.

Broadly speaking, the term "narrative" is defined as any account of connected events and experiences. Narrative is used in several therapeutic interventions within behavioral health. Narrative approaches can be an affirming process for the patient and can increase a therapist's understanding of their patients' perspectives.1 Unfortunately, there is a lack of medical education and training on narrative approaches, and these remain underutilized in clinical settings. Comics are an accessible medium of expression that can empower the voices of underrepresented individuals and communities.

A Systematic Review of Specialty Courts in the United States for Adolescents Impacted by Commercial Sexual Exploitation.

Nationwide efforts to enhance services for adolescents experiencing commercial sexual exploitation (CSE) in the judicial system have led to the emergence of specialty courts, including human trafficking and girls' courts. Given that prior research has documented competing stances on the effectiveness of specialty courts for CSE-impacted populations, we conducted a systematic review of the literature to identify key characteristics of programming, profiles of adolescents served, and effectiveness of these courts. To identify relevant research and information, we systematically searched scholarly databases and information sources, conducted reference harvesting, and forwarded citation chaining. Articles presenting primary data with quantitative, qualitative, or mixed methodologies or programmatic descriptions of specialty courts serving adolescents at risk or with confirmed histories of CSE that were published after 2004 were included. We identified 39 articles on 21 specialty courts serving adolescents at risk or with confirmed histories of CSE, including seven specialty courts with evaluation or outcome data. Across specialty courts, adolescents benefited from an increase in linkage to specialized services, improved residential placement stability, and reduction in recidivism-measured by new criminal charges. Specialty court participation was also associated with improved educational outcomes and decreased instances of running away. A lack of empirical data, specifically of evaluation studies, emerged as a weakness in the literature. Still, findings support that specialty courts can be an integral judicial system response to CSE. Multidisciplinary collaboration can help target and respond to the multifaceted needs of adolescents, encourage healthy behaviors, and promote their overall wellness.

Risk profiles of suicide attempts among girls with histories of commercial sexual exploitation: A latent class analysis.

BACKGROUND: Girls impacted by commercial sexual exploitation (CSE) in the juvenile legal system are three times more likely to have suicide attempts than girls without histories of exploitation. Yet, research on risk profiles and correlates that contribute to elevated suicide risk among girls with CSE histories remains scant. OBJECTIVE: We sought to examine suicide attempts profiles among CSE-impacted girls in the juvenile legal system. PARTICIPANTS AND SETTING: We partnered with a specialty court for CSE-impacted youth in Los Angeles County. METHODS: Data were collected from case files of the 360 girls participating in the court from 2012 to 2016. Latent class analysis was used to identify their profiles of risk indicators. RESULTS: Four risk profiles for suicide attempts emerged: (1) Parental Incarceration (PI; 30 %), (2) Child Welfare Contact (CWC; 25 %), (3) Disruptive Behavior and Sleep Problems (DBS; 25 %), and (4) Pervasive Risk (PR; 22 %). Among youth in the PI group, 5 % had a suicide attempt; however, contrary to our hypothesis, no youth in the CWC group had a suicide attempt. Rates of suicide attempt were significantly higher among youth in the DBS group, as 14 % had a suicide attempt. As hypothesized, youth in the PR were associated with higher risk of suicide attempts, with 28 % reporting a prior suicide attempt. CONCLUSIONS: Findings underscore the need for standardized suicide screenings and treatment referrals for girls with CSE histories and suggest an important opportunity for multidisciplinary collaboration with courts to improve suicide prevention strategies. The present study also supports the importance of examining risk across the socioecological context.

The Association Between Expanded ACEs and Behavioral Health Outcomes Among Youth at First Time Legal System Contact.

A growing body of literature has documented high rates of adverse childhood experiences (ACEs) and their effects on behavioral health among adolescents impacted by the juvenile legal system. Most research with justice-impacted youth assesses the ten standard ACEs, encompassing abuse, neglect, and household dysfunction. This body of work has largely ignored the five expanded ACEs which assess social and community level adversity. Justice-impacted youth commonly experience expanded ACEs (racial discrimination, placement in foster care, living in a disadvantaged neighborhood, witnessing violence, bullying), and inclusion of these adversities may enhance predictive utility of the commonly used ACEs score. The current study examined the prospective impact of total ACEs (standard and expanded) on alcohol and cannabis use, substance-related consequences, and psychiatric symptoms during the year following first ever contact with the juvenile court. Results indicate justice-impacted youth experience multiple expanded ACEs prior to first court contact. The expanded ACEs did not predict any of the behavioral health outcomes assessed, over and above the standard ACEs. Inclusion of expanded ACEs in the standard ACEs score may not increase utility in identifying prospective behavioral health outcomes among youth in first time contact with the juvenile legal system.

United States Youth Arrest and Health Across the Life Course: A Nationally Representative Longitudinal Study.

BACKGROUND: Youth are arrested at high rates in the United States; however, long-term health effects of arrest remain unmeasured. We sought to describe the sociodemographic characteristics and health of adults who were arrested at various ages among a nationally representative sample. METHODS: Using the National Longitudinal Study of Adolescent to Adult Health, we describe sociodemographics and health status in adolescence (Wave I, ages 12-21) and adulthood (Wave V, ages 32-42) for people first arrested at age younger than 14 years, 14 to 17 years, and 18 to 24 years, compared to never arrested adults. Health measures included physical health (general health, mobility/functional limitations, death), mental health (depressive symptoms, suicidal thoughts), and clinical biomarkers (hypertension, diabetes). We estimate associations between age of first arrest and health using covariate adjusted regressions. RESULTS: Among the sample of 10,641 adults, 28.5% had experienced arrest before age 25. Individuals first arrested as children (ie, age <14) were disproportionately Black, compared to White. Compared to individuals never arrested, people arrested before age 25 had more depressive symptoms and higher rates of suicidal thoughts during adolescence. Arrest before age 25 was associated with worse self-reported health, higher rates of functional limitations, more depressive symptoms, and greater mortality by adulthood (ages 32-42). CONCLUSIONS: Arrest before age 25 was associated with worse physical and mental health--and even death in adulthood. Child arrest was disproportionately experienced by Black children. Reducing arrests of youth may be associated with improved health across the life course, particularly among Black youth, thereby promoting health equity.

Editors' Note: Third Annual Report Regarding JAACAP's Antiracist Journey.

In 2020, we wrote to you of our dedication and vision for JAACAP "to be antiracist at every level."1 Over the last 3 years, we have pursued initiatives "to reshape the Journal to pursue this vision."2,3 In this article, we provide an update on these goals and initiatives (Figure 1). With the launching of our new open access journal, JAACAP Open,4 in late 2022, we now extend these initiatives to both scientific journals in the JAACAP family and aspire to be a leader among mental health journals in our intentional pursuit of antiracist policies and practices.