Developmental and behavioral implications for children of incarcerated parents

INTRODUCTION — 

Parental incarceration is an adverse childhood experience (ACE) with important implications for current and future health. Children who have experienced parental incarceration have significantly more ACEs than their peers without a history of parental incarceration [1,2]. The behavior and development of children with an incarcerated parent may be influenced by stressors that occur before, during, and after the parent's incarceration. Pediatric clinicians have a unique opportunity to identify and support children and families affected by a parent's incarceration.

This topic will discuss the epidemiology, process, and effects of parental incarceration.

Adverse childhood experiences and trauma-informed care are discussed separately. (See "Pediatric trauma-informed care".)

EPIDEMIOLOGY

Magnitude of issue — An estimated five million (1 in 14) children in the United States have experienced the incarceration of a parent with whom they lived [3]. The number of children with an incarcerated parent has risen steadily since the 1990s [4,5]. Although 2017 data from the United States Bureau of Justice Statistics suggest a modest decline in the adult prison population [6], updated information on the number of children with incarcerated parents is not available.

Longitudinal data regarding the numbers of children affected by parental incarceration are limited. Despite the magnitude of this issue, there is no centralized system for tracking children whose parents become involved with the criminal justice system [7,8]. National estimates are gathered through periodic surveys conducted by the United States Bureau of Justice Statistics. These interview-based surveys use discrete jail or federal/state prison samples and do not generate total population estimates for all levels of system involvement. Survey statistics rely solely on reports from incarcerated people and may underestimate the number of affected children for several reasons, including concern about how the information may be shared or used against parents (ie, by child welfare agencies) [9].

Characteristics of incarcerated parents — Many incarcerated parents in the United States have been charged with nonviolent offenses [4,10,11]. Several populations are disproportionately affected:

●Parents with minor children – Fifty two percent of adults incarcerated in state prisons and 63 percent of adults in federal prisons are parents with minor children [4].

●Fathers – The majority (92 percent) of incarcerated parents are fathers. However, maternal incarceration is growing more rapidly than paternal incarceration (122 percent versus 76 percent increase in maternal and paternal incarceration, respectively, between 1991 and 2007).

●Younger adults – Most people in prison are younger than 44 years and are of child-rearing age.

●Certain racial and ethnic groups – Almost 60 percent of incarcerated parents are from racial and ethnic groups that are underrepresented in the general population, with Black fathers accounting for the largest percentage [10].

●Individuals with adverse childhood experiences – Incarceration is frequently a marker of social vulnerability. This is reflected in the personal histories of incarcerated parents, many of whom experienced well-recognized childhood risk factors for adverse outcomes [12,13]. For example, approximately one-half of incarcerated parents did not complete high school [10,14]. In addition, in a national survey of adults in jail, the following findings were reported [11]:

•Twelve percent had childhood involvement with the foster care system

•One-third had a parent or guardian with a substance use disorder

•One-half had an immediate family member, parent, or sibling who had been incarcerated

•Almost one-third of women and more than 10 percent of men reported having been physically or sexually abused before age 18 years

Characteristics of affected children — Like their incarcerated parents, affected children become a vulnerable population. These children often have multiple risks for poor developmental outcomes. Data from the United States Department of Justice provide the following characteristics of children of incarcerated parents [4,10]:

●Younger age – One-half of affected children are younger than nine years.

●Certain racial and ethnic groups – Their racial/ethnic backgrounds parallel those of the incarcerated population, with Black children 7.5 times more likely and Hispanic children 2.5 times more likely to have an incarcerated parent than White children.

●Rural areas – Youth in rural areas are more likely than their peers in urban areas to experience parental incarceration [2].

●Lower socioeconomic household – Children from lower socioeconomic households are more likely to be affected by parental incarceration compared with children from higher socioeconomic households [15].

●Residence with incarcerated parent – Approximately one-half of parents in state or federal prison lived with their children before incarceration. This proportion is significantly higher for parents in local or county jails or when the mother is incarcerated.

THE INCARCERATION PROCESS — 

To understand the potential effects of a parent's incarceration, the pediatric clinician first must have some understanding of what it means to be incarcerated. The cycle of arrest, incarceration, and re-entry has been conceptualized as a "series of crises" [16], each uniquely stressing affected children and families.

Arrest and sentencing — Parents are arrested and taken into custody by officers. For some children, this may mean witnessing the parent being arrested and taken away. Children who are present at the time of a parent's arrest become more likely to develop post-traumatic stress disorder than their peers given the trauma of witnessing the arrest [17]. The Bureau of Justice Assistance and the International Association of Chiefs of Police created model policy recommendations for law enforcement officials to mitigate the trauma of an arrest, though these recommendations are not applied uniformly across every jurisdiction [18]. One study found that one in five children witnessed the arrest of their mother; most of these children were less than seven years of age [19].

After arrest, the parent is detained in a local correctional facility awaiting trial or released on bail. This is followed by a plea or trial and sentencing. Throughout these events, families often face a great deal of uncertainty and financial stress, both from court-related costs and loss of the incarcerated parent's income. This can lead to instability in the family's housing situation and disrupt the child's school placement.

Confinement — After sentencing (which can often take many months from time of arrest), the parent serves his or her term. Sentences are served in two main types of institutions, depending on the crime and jurisdiction.

●"Jail" is used to refer to a local or county facility, where people typically serve shorter sentences [5]. Jails may also be holding facilities for individuals awaiting transfer to state or federal institutions or awaiting hearings in federal immigration court.

●"Prison" typically refers to a state or federal facility, where people serve longer sentences. Prisons are additionally classified as minimum, medium, and maximum security. Prisons often are located at a significant distance from the communities where incarcerated people and their families live, which may make visits difficult for some families [10].

Most institutions allow some form of visitation between incarcerated parents and their children, though policies and practices vary widely, from brief noncontact visits (eg, visits through plexiglass) to rarer child-friendly programs that aim to support the parent-child relationship through contact visits with coaching and education, as well as family-friendly environments with toys and books [20].

Release and re-entry — Although not always recognized as such, a parent's release and return to their community can be a stressful transition for children and families. Pre-existing mental health and substance use problems, parenting challenges, and complicated family dynamics are infrequently addressed during incarceration and may resurface when the released parent attempts to resume family life. Parents incarcerated for a significant time may have difficulty recognizing their child has grown or changed, or that relationships may have reconstituted in ways that do not actively involve the parent. When released from prison, people are generally under some form of community supervision (eg, parole), which may include additional monitoring and rules, often posing considerable barriers for the person and their family. In addition, people with felony convictions experience considerable "collateral consequences" from their conviction, creating barriers to housing, employment, economic assistance, and other social services. These barriers create challenges for successful re-entry and increase one's risk for reincarceration, which further disrupts parent-child/family relationships.

EFFECTS OF PARENTAL INCARCERATION

Co-existing and independent risk factors — Children with incarcerated parents often have multiple risk factors for behavioral and developmental problems, including poverty, parental substance use and mental illness, exposure to domestic violence, and inconsistent or unavailable caregivers [1,21,22]. Sorting out the relative effect of each risk factor is a challenge that is only beginning to be addressed [15,23,24]. Research on the effects of parental incarceration has been hampered by several constraints. In addition to difficulties with sample ascertainment and follow-up, most studies do not differentiate between problems existing before the parent's incarceration and those developing as a result of incarceration.

Beyond co-occurring and cumulative risks, there are several ways in which parental incarceration can independently affect developmental outcomes. These mechanisms include trauma, disruption or loss in attachment relationships, stigma, strain, and modeling [25,26]. Children affected by parental incarceration experience loss, trauma, and stigma on multiple levels:

●Loss and trauma due to separation from parent – The most obvious is the immediate separation, which is often unexpected and can be for a prolonged period of time. This is particularly important for young children with incarcerated mothers, as they are at increased risk for developing a pattern of insecure caregiver attachment [27]. In addition, witnessing their parent's arrest may be particularly difficult for infants, toddlers, and preschoolers who have age-related attachment needs [28]. Older children may come home to find their parent, sometimes their sole or primary caregiver, is gone with no explanation as to where the parent went or when they will have contact with the parent again.

●Stigma and loss of trust in parent/caregiver – When a parent is incarcerated, caregivers must decide what to tell the child to explain the parent's absence. This may result in what has been called a "conspiracy of silence" [29] surrounding the parent's circumstance and reasons for absence. Because of worry about stigma and the idea that children should be protected from knowing their parent is incarcerated, children often are not given honest or developmentally appropriate explanations for their parent's absence [30].

Inaccurate explanations for an incarcerated parent's absence include being told that the parent is at school, work, or traveling. Such explanations may make children feel that the parent has chosen to be away. These explanations also may be confusing if the child has deduced or overheard the truth, in which case the child may lose trust in his or her caregivers [30]. This makes maintaining contact and continuing an ongoing relationship with an incarcerated parent difficult.

Short-term consequences of parental incarceration

Socioeconomic changes — The most obvious impact of parental incarceration on a child and family is socioeconomic [31]. Children with incarcerated parents may experience poverty, potentially due to the loss of income when the parent becomes incarcerated. Over one-half of parents in prison report having provided primary financial support for their children before incarceration [4]. When the parent becomes incarcerated, the household loses this income, and relatives caring for the children may incur additional expenses in trying to maintain the parent-child relationship through visits, collect phone calls, and emails (which are often associated with fees). Following release, the parent may have limited access to stable employment. This is due, at least in part, to job applications that commonly require a person to disclose a history of involvement with the criminal justice system. In addition to being stigmatizing, this disclosure can create substantial barriers to obtaining employment and economic stability.

Custodial status — The child's custodial status during the parent's incarceration varies depending upon which parent is incarcerated. Most children with an incarcerated father are cared for by their biological mother, whereas children whose mother is incarcerated often are cared for by a grandparent or other relative [10,14]. When children experience changes in primary caregivers, they also often experience a change in where they are living and attending school. These disruptions can cause further challenges for children. In addition, when a child's mother is incarcerated, the child is more likely to be involved with the child welfare system [32,33]. (See "Epidemiology of foster care placement and overview of the foster care system in the United States", section on 'Risk factors'.)

Behavioral changes — Studies relying on parent or caregiver reports have identified multiple behavioral reactions to parental incarceration, including sadness, social withdrawal, acting out, and aggression [34-39]. These depend, in part, on the timing and duration of the parent's absence and additional factors, such as ongoing parental contact. In general, boys are more likely to display externalizing behaviors (eg, acting out and aggression), whereas girls are more likely to exhibit internalizing behaviors (eg, sadness, withdrawal). Some studies have found that children with incarcerated parents and who experience lower levels of social support have higher levels of both internalizing and externalizing behavior problems [40,41]. Children who are less hopeful (eg, have a less positive outlook and lack confidence in their ability to overcome challenges) also appear to have more behavior problems independent of the effects of stress and lack of social support [41].

Long-term consequences of parental incarceration

Cognitive development and educational outcomes — Limited data are available on the cognitive development of children of incarcerated parents. In a study of 59 children (aged 2.5 to 7.5 years) with an incarcerated mother, 42 percent scored at or below 84 on the Stanford-Binet Intelligence Scale [42]. Parental incarceration also influences cognitive skill acquisition. Another study reported that children with a history of paternal incarceration had lower verbal, reading, math, and memory skills [43]. Given the racial disparities in parental incarceration, these cognitive outcomes may contribute to the achievement gap between Black and White students and perpetuate intergenerational educational inequities. In addition, cognitive outcomes appear to be impacted by other factors. For example, in both studies, children with incarcerated parents were more likely to have parents/caregivers who engaged in higher risk behaviors, including the use of drugs and alcohol, which is associated with worse cognitive outcomes and mediated by the quality of the family environment [42,43].

Delinquency and juvenile justice system involvement — It is often suggested that children with incarcerated parents are significantly more likely to become involved with the justice system themselves. In a nationally representative cross-sectional study, 1.2 percent of adolescents in the United States had experienced both parental incarceration and involvement with the juvenile justice system [44].

Studies regarding an association between having an incarcerated parent and delinquency have mixed findings and are inconclusive. In retrospective reports, compared with juvenile offenders without a history of parental incarceration, juvenile offenders with a history of parental incarceration were more frequently involved with the juvenile justice system by age 12 years and were more likely to have committed previous serious offenses [8].

In several longitudinal studies, parental incarceration was strongly predictive of later delinquency [45,46] and criminality [47]. However, this was attenuated by family factors [47]. In one study, after controlling for parental criminality and independently predictive risks (eg, poverty), children experiencing parent-child separation due to incarceration were more likely to exhibit antisocial behavior and delinquency into early adulthood than children in whom separation was due to other causes (eg, parent death) [45].

However, in a study of adolescents, recent or past parental incarceration did not independently predict child delinquency after family victimization/conflict, which was associated with incarceration, and sibling delinquency were added to the prediction equation [48]. In addition, in a study from Sweden, parental incarceration was not associated with delinquency in offspring independent of parental criminality [49]. Possible explanations for this discrepancy include shorter sentences, more family-friendly prison programs, and different social policies in Sweden than in some other countries.

Mental and physical health outcomes — In longitudinal studies, parental incarceration is associated with adverse mental health and functional outcomes in adolescence or young adulthood. Studies that incorporate parental incarceration or separation into measures of cumulative risk have shown an association between an increased number of adverse childhood experiences and later affective disorders [38,50], as well as lifetime risk of attempted suicide [51] and drug use [52]. Children who experience parental incarceration and/or who are involved in the juvenile justice system are more likely to have depression, anxiety, and post-traumatic stress disorder (PTSD) compared with exposure to neither [44].

Analysis of data from the National Longitudinal Study of Adolescent Health identified possible associations between parental incarceration in childhood and increased risk of adolescent depression, PTSD, anxiety, high cholesterol, asthma, migraines, human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), fair or poor health, foregone health care, substance use, and risky sexual behaviors [15,24,53]. These associations may depend on which parent was incarcerated during childhood [15,24]. In another longitudinal study, parental incarceration was associated with increased risk of teen parenthood, failure to complete high school, anxiety disorder, being charged with a felony or spending time in jail, and being socially isolated in young adulthood [54].

Observational studies suggest that both biologic and social mechanisms, including unmet heath care needs, may contribute to increased risk of adverse health outcomes [55,56]. To inform health-related policy and intervention, additional research is needed to determine the influence of specific characteristics (eg, frequency and cumulative duration of parental incarceration) and other mediators (eg, lack of stable, nurturing relationships and exposure to violence) [24]. For example, the effects of paternal incarceration may differ from those of maternal incarceration [15,24,57]. In a systematic review, paternal incarceration was associated with a negative effect on child health, whereas the association with maternal incarceration was variable [58]. However, in another analysis of self-reported information, parental incarceration was associated with youth physical health risk behaviors, even if the parent was not currently incarcerated [59].

ROLE OF THE PRIMARY CARE CLINICIAN — 

Clinicians who care for children with incarcerated parents and their families have several important roles:

●Screen routinely – The clinician should screen for parental incarceration as a marker for co-occurring risks and as a potential independent risk for poorer developmental outcomes [14,60]. Screening can be integrated into standard care by asking about household composition and inquiring about changes at each health maintenance visit. Established, trusting relationships and use of nonjudgmental language will facilitate disclosure. Although many families do not tell their pediatric clinician about the parent's incarceration, most report not sharing this information because they were not asked.

●Ensure regular follow-up – The clinician should encourage regular appointments to ensure that children with incarcerated parents are growing and developing as expected. If possible, the clinician should address and provide resources to assist with loss of insurance coverage, transportation, or other aspects of child well-being at health maintenance visits.

●Provide counseling – The clinician should provide age-appropriate counseling and information for the child and caregivers. Young children may benefit from "bibliotherapy," which involves using stories and books about parental absence and incarceration [61,62]. Older children may be interested in support groups or specialized programs like Girl Scouts Beyond Bars, when available. (See 'Resources' below.)

●Identify and manage comorbidities – The clinician plays an important role in identifying and actively managing or providing referrals for emotional and behavioral problems affecting either the child or caregiver. Clinicians can develop a list of local resources for referral to address emotional, behavioral, and substance use concerns. They should also ensure follow-up and intervention for developmental delays. (See "Developmental-behavioral surveillance and screening in primary care".)

●Support the parent-child relationship – The clinician should encourage maintenance of the parent-child relationship through the exchange of letters, telephone contact, email, and visitation when appropriate and feasible.

●Cultivate "protective" factors – Family/caregiver stress may be decreased by referring eligible families for financial support; housing, food, and childcare assistance; family therapy; and legal advocacy. Social support can also be enhanced by involvement in athletics, after-school and mentoring programs, or religious and civic groups [63].

RESOURCES

●The National Resource Center on Children and Families of the Incarcerated provides information on children and families of prisoners, prison visitation, parenting programs, and the impact of the justice system on families. It has an extensive article library, directory of programs, and links to related websites.

●Sesame Street Communities Coping with Incarceration is available online and as a mobile app, and provides video and print resources (in English and Spanish) for caregivers and families of young children dealing with parental incarceration.

●The Child Welfare Information Gateway (a service of the Children's Bureau, Administration for Children and Families, United States Department of Health and Human Services) has a number of resources for families affected by incarceration and the professionals who support them.

●Essie Justice Group is an organization whose mission is to support women with incarcerated loved ones.

●Families Against Mandatory Minimums (FAMM - Families for Justice Reform) is an organization that provides public education and targeted advocacy at the state and federal levels.

●Prison Fellowship is a faith-based organization that provides support to currently incarcerated people and their families through programming and advocacy.

SUMMARY AND RECOMMENDATIONS

●Epidemiology and characteristics – An estimated five million (1 in 14) children in the United States have experienced the incarceration of a coresident parent. Several populations are disproportionately affected, including incarcerated parents and affected children who are younger, from racial and ethnic minority groups, from rural areas, or who have experienced well-recognized childhood risk factors for adverse outcomes (eg, lower socioeconomic or educational status, childhood trauma or involvement with foster care, incarceration of parent or other immediate family member). (See 'Epidemiology' above.)

●Incarceration process – Each step in the process of incarceration of a parent (arrest, sentencing, confinement, release, and community supervision) is a stressor for affected children and families. (See 'The incarceration process' above.)

●Effects of parental incarceration

•Co-existing and independent risk factors – Children with incarcerated parents often have multiple risk factors for behavior and developmental problems, including poverty, parental substance use and mental illness, domestic violence, and changes in their home and school environments. In addition to co-existing risk factors, parental incarceration can independently affect developmental outcomes due to the effects of loss, trauma, and stigma. (See 'Co-existing and independent risk factors' above.)

•Short-term consequences – Children with incarcerated parents may experience poverty due to the parental loss of income and changes in primary caregivers, including where they are living and attending school or involvement with the child welfare system. Behavioral reactions to parental incarceration may include sadness, social withdrawal, acting out, and/or aggression. These reactions can be mediated by high levels of social support. (See 'Short-term consequences of parental incarceration' above.)

•Long-term consequences – Parental incarceration can be associated with juvenile delinquency, antisocial behavior, and mental and physical health problems in adolescence and adulthood. (See 'Long-term consequences of parental incarceration' above.)

●Role of the primary care clinician – Clinicians who care for children with incarcerated parents and their families should screen for parental incarceration as a risk for developmental, behavior, and health problems, ensure regular follow-up, and provide age-appropriate counseling and information or referral for the child and family as indicated. Family/caregiver stress may be decreased by referring eligible families for financial support, housing and childcare assistance, and legal advocacy. (See 'Role of the primary care clinician' above and 'Resources' above.)

ACKNOWLEDGMENT — 

The UpToDate editorial staff acknowledges Stephanie Blenner, MD, who contributed to an earlier version of this topic review.