Juvenile Detention: Another Boundary Issue for Physicians

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SPECIAL

ARTICLE

Juvenile

Detention:

Another

Boundary

Issue

for Physicians

Karen Hem, MD, Michael I. Cohen, MD, Iris F. Lift, MD,

S.

Kenneth Schonberg, MD, Monica R. Meyer, MD,

Andrea Marks, MD, and Audrey-Jean Sheehy, MD

From the Division of Adolescent Medicine, Department of Pediatrics, Montefiore Hospital and Medical Center, Albert Einstein College of Medicine, Bronx, New York

ABSTRACT. It is estimated that there are 500,000 young-sters in detention in the United States per year. Detention facifities offer a unique environment in which adolescents at high risk for medical problems can be identified and

treated. A health care program within the secure juvenile detention facility for New York is described in order to demonstrate how an academic medical center can effect improvement in the health status of underserved,

mcar-cerated youth while meeting professional educational

oh-jectives for health trainees. Results of medical services are given for the past 11 years. Medical problems were diagnosed in 46% ofthe 47,288 adolescents examined. The

conditions were grouped into those related to the legal

status of the youngsters, socioeconomic background, and! or the institutional setting. The interrelationship of med-ical conditions with legal, ethical, and youth advocacy issues were demonstrated. The setting affords an

oppor-tunity to train primary care physicians with special

em-phasis on issues such as the nature of the doctor-patient

relationship, confidentiality, and patient advocacy, while

providing a necessary service to medically disadvantaged adolescents. Pediatrics 66:239-245, 1980; adolescents,

de-tention, law, education, ethics.

Received for publication Sept 17, 1979; accepted Nov 1, 1979. Dr Hem’s current address is: Columbia-Presbyterian Medical Center, New York, NY 10032.

Dr Litt’s current address is: Stanford University School of Med-icme, Stanford University Medical Center, Stanford, CA 94305. Dr Marks’ current address is: North Shore Community Hospital, 300 Community Drive, Manhasset, NY 11030.

Dr Sheehy’s current address is: Barnard College Health Service, Barnard College, 3009 Broadway, New York, NY 10027. Reprint requests to (K.H.)Division of Adolescent Medicine, Dept of Pediatrics, Babies Hospital, 630 West 168 St, New York, NY 10032.

Over the past decade the special medical needs of the adolescent have been well documented.’ However, there remain large segments of the

teen-age population which still do not have access to

health care. The neediest young people are

fre-quently those with the fewest economic and social

alternatives. Those who are living outside the

framework of the normal adolescent support

sys-tems

of family and school frequently receive no

medical care during adolescence. For these reasons,

sateffite programs beyond the traditional structure

ofhealth services have been established to facilitate access for adolescents.

Teenagers in the juvenile justice system typify

the youngsters on the periphery of the health care delivery system, and for them institutionalization provides the only contact with a potentially sup-portive establishment. It is estimated that there are

1 million runaways2 and 500,000 youngsters in

de-tention3 in the United States per year. Detention

facilities offer an opportunity for screening, assess-ing, and managing the health problems of young

people at significant risk of medical disability. This

unique milieu also offers a special environment for

the training of medical personneL Since most youth detention centers are defined as facilities that house adolescents briefly while court disposition is being

arranged, the setting affords an opportunity to in-tervene in the lives of this otherwise transient pop-ulation. As patterns of institutionalization continue

to

change and more youngsters are incarcerated,4

the medical community should be alerted to the

special needs of this group.

(2)

Adolescent Medicine of Montefiore Hospital and Medical Center created a health service within the single youth detention facility that serves the City

of New York. Data are reported for the past 11

years regarding the types of medical conditions

diagnosed and treated as well as the educational

implications for medical students and house officers

in such peripherally located primary care sites. Spe-cific ethical issues raised within this setting allow

the physician to confront and evolve systems of

thinking regarding confidentiality, the nature of the

physician-patient relationship, and the role of the

physician as child advocate. Finally, a series of

clinical syndromes present in this adolescent

pop-ulation can be explored in sufficient depth so as to enable a clearer definition of the pathophysiologic

or behavioral disturbance. Although these

syn-dromes are not exclusively found in the youth

de-tention environment they are present in sufficient

concentration to provide a unique educational

ex-perience.

PROGRAM DESCRIPTION

Through a contract with several agencies of the

municipal government of the City of New York, a

health service was established within the only Se-cure detention facility serving the metropolitan area. In the preceding decade, health care was provided by physicians employed for specific

lim-ited hours and licensed practical nurses. No data were collected regarding the health status of the

detainees, so that comparison with the data

pre-sented are not available. Approximately 6,000 to

8,000 youngsters were admitted per year

through-out an 11-year period (July 1968 to June 1979) with

an average age of 15 years (range 10 to 18 years).

Approximately 80% of the inmates were male, 60%

were black, and 25% were Hispanic surnamed. The

legal justification for incarceration ranged from

sta-tus offenses to designated felonies. The former

cat-egory included truancy, running away or being

“in-corrigible” whereas the latter included serious

of-fenses such as robbery, assault, rape, and murder.

The rate of recidivism was 55% throughout the

decade. Ultimate disposition by the Court resulted

in

parole to home for 45% and placement with a

parental surrogate or removal to a state institution

for 55% of youngsters. The average length of stay

was 14 days although approximately 25% of the

youths remained for several months. The personnel in the health care unit were 2 faculty-attending

physicians, 3 medical student-house officer trainees, 17 nurses, 3 laboratory technicians, 2 pharmacists, 1 dental hygienist, and 3 clerical staff members. The medical unit was housed within the detention facility, but occupied a separate space with physical

accoutrements designed by the medical personnel. Within the medical premises were housed a phar-macy, laboratory, and dental suite. A 16-bed

inpa-tient infirmary unit was established to care for ill

teenagers. The resources of the 36-bed inpatient

adolescent unit at Montefiore Hospital were

avail-able for adolescents requiring more extensive

med-ical and surgical support. Complex medical

prob-lems could be further evaluated on an ambulatory basis by referral to appropriate subspecialty clinics at Montefiore Hospital.

Each youngster received a brief health screening examination by a nurse within one hour of admis-sion to the facility. This included assessment of vital signs and a brief history of recent trauma, medications, drug addiction, or allergies. Inspection for lice, any obvious communicable diseases, and

application of a skin test for tuberculosis were also

included. The purpose of the limited assessment

was to identify any emergent complaints and to record vital statistics.

within

24

hours the inmate was offered a complete medical history, physical examination, and laboratory tests. The youngster could refuse part or all of the health screening procedure. The results of this general health

ex-amination were shared with court authorities, but

responses regarding sexuality and substance abuse,

while recorded in the medical chart, were not

for-warded to any outside agency.

Follow-up evaluation and care of problems

de-tected in this initial assessment were scheduled for

rapid resolution in the remaining few days the patient would spend in the facility. Those

young-sters becoming ifi in the facility were seen at a daily “sick call.”

The goals of the educational component of the

program are given in Table 1. Medical rounds were conducted three times per week with

representa-tives of each component of the health team present.

Special conferences to debate legal and ethical is-sues were held twice per month. A series of

educa-tional conferences for trainees was repeated

monthly; that introduced the physician-trainee to the various components of the urban service

net-work for teenagers. Each trainee visited the Family Court, became familiar with allied agencies that

offered youth support services, and participated in weekly health education sessions designed specifi-cally for the youngsters.

The attending faculty physicians were

adminis-tratively and professionally responsible for the

ser-vice and training components. Both physicians were an integral part of the hospital and medical school

staff. They attended conferences and seminars at

the hospital, precepted students, and provided at-tending coverage for the inpatient adolescent unit

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TABLE 1

.

Educational Objectives for Trainees Who Participated in Health Care Program in Youth Detention Facility During Their Pediatric Rotation

1. To gain familiarity with the concepts in adolescent growth and development -knowledge of the tasks of physical and psychological development -impact of institutionalization

2. To develop an awareness of the special problems of delinquent youth -aspects of the legal system as they pertain to youth

-health needs of youth who often have been living on their own or away from their families

-approaches to patients who may be depressed and hostile and who do not see health needs as a high priority -acquaint trainees with medical conditions prevalent in the detained population

3. To demonstrate the role a pediatrician can play in an institution that serves functions other than providing medical care

-interaction with family court, counseling, and administrative staff -the interrelationships of various child care agencies

TABLE 2. Health Services Offered t mitted to Detention Faciity*

o Adolescents

Ad-Initial nurse screening 40,800

Complete health assessment 47,300

Return visits for further evaluation 78,100 or sick call

Dental treatments 14,400

Hospital transfer admissions 500

Laboratory services 274,lOOt

Pharmacy services 397,0001:

* Services were offered to 88,106 adolescents during an 11-year period and are reported to the nearest 100.

t

Routine screening included hematocrit, urinalysis,

sickle cell prep, VDRL culture for gonorrhea in males

and females; pregnancy test and Papanicolaou smear in females, SGPT in drug abusers.

1:

Based on average number of patients on medication per day estimating a twice daily dispensing pattern.

medical directors served for 5- and 5#{189}-yearterms.

The mean duration of employment of the nursing

staff was 2.5 years. Stated reasons for leaving

em-ployment at the center varied, but most

profession-als

felt that their length of stay was a function of

the perceived need for their presence, their initial satisfaction with the goals and accomplishments of the program, and a sense ofstaffcohesiveness which

effectively delayed the “burn-out syndrome”

asso-ciated with working in a tense, somewhat volatile atmosphere.

The nursing staff was selected because of

ex-pressed interest in adolescents as well as delinquent youth, and formed a separate unit from the hospital.

Since the housestaff rotated on a monthly basis,

the nurses were the professional group that

pro-vided continuity of care for the youngsters. They

were also an excellent resource for helping the

trainees understand the role of the unit within the

complex judicial system.

The pharmacy utilized the unit dose method of

dispensing medication since this system was both

cost effective and efficient. The laboratory was

equipped for the diagnosis of venereal diseases,

pregnancy, anemia, and urinary tract infection. The

dental suite was staffed by a dental hygienist, dental residents and faculty, and an oral surgeon. Dental diagnostic and treatment capabilities were

main-tamed within this unit.

All

the health professionals

involved in the pharmacy, laboratory, and dental

unit participated

in

medical rounds and in the

teaching functions of the program.

An

after-care program was established in 1971

funded by a federal project for training previously

unemployed workers which ensured that medical

liaison was made once a youngster was released to the community.

RESULTS

From July 1968 through June 1979, 88,106

young-sters were admitted to the detention center. Of this total 40,818 received brief screening since they

re-mained in the center for less than 24 hours, while

47,288 adolescents received a comprehensive health

examination. The specific types of health services offered are summarized in Table 2. Medical prob-lems were found in 46% of the teenagers.

The initial health assessment portion of the med-ical program revealed a striking degree of disability. Included among these problems are the following

items, all of which have been reported in detail

elsewhere. A history of drug abuse was elicited in

17,945 teenagers.5 The greatest number of drug

users were admitted between the year 1969 and

1971 when 58% admitted to opiate abuse. Of these

drug-involved teenagers, 37% were found to have

abnormal liver function tests6 suggestive of chronic

persistent hepatitis. A venereal disease, usually

gon-orrhea, was detected in 1,723 individuals. Most of

these were asymptomatic and represented 6% of

those screened.7 Among the female inmates the

average age at first intercourse was 12 years,8 with 671 diagnosed as being pregnant and 98% electing

to continue their pregnancy.9 In 1,048 girls who had

cervical cytology screening, early forms of cervical intraepithelial neoplasia were documented in 3%#{149}5O

(4)

533 28 151 10 162 291 429 48 156 48 33 66 14 51 138 192 72 8 32 81 323 10 4 result in 7% of patients screened with only three

active cases diagnosed.

When questioned about the last contact with

health care providers, youngsters reported only

ep-isodic care since early childhood, usually following

an

injury or during an acute illness. The only

comprehensive medical history and physical

exam-inations recalled were those experienced by the

recidivists who had prior admission health

assess-ment by the staff of the program described herein.

Sick call was utilized by patients who wished to be evaluated by a health professional as well as by the medical staff for the purpose of follow-up

eval-uation for previously detected ifinesses. Often the

stated reason for the visit by the detainee was not

the underlying concern. The detainees were

en-couraged to use sick call as a means of diffusing

anxiety by talking to a health professional. The

most commonly diagnosed conditions were upper respiratory infections (17%), minor dermatologic

dysfunction: acne, impetigo, tinea (14%), minor trauma: abrasions, lacerations, soft tissue injuries

(21%), and psychosomatic states: insomnia,

abdom-inal complaints, headaches, anorexia, lethargy

(18%). Lactase deficiency was documented by an

abnormal lactose tolerance test in ten of 15

teen-agers tested.

There were 3,353 teenagers admitted to the de-tention center infirmary. The diagnoses are sum-marized in Table 3. Of these teenagers, 20% were referred to the after-care program for medical

prob-lems that were not resolved while in detention.”

The medical service was able to act as the agent

responsible for the health of the institutional

com-munity and its inhabitants. The child care agency

staff found that having health professionals present

24 hours a day provided a sense of support for

emergencies that might arise for the adult staff as well as the youth. Since the institution is a locked facility the sense of isolation from outside services existed in the adult staff as well as the youngsters. Periodic screening for tuberculosis among adult

em-ployees was offered to comply with state employ-ment regulations. Surveying equipment for detec-tion of microbiologic pathogens was readily avail-able. In 1976 the predominant strain causing the

winter influenza epidemic was identified within the detained population several weeks before the

organism was identified in the New York

metropol-it,an area. Scabies and/or pediculosis infestations

were identified in 5% of the detainees during the

screening process.

Health maintenance functions were also under

the purview of the medical unit. Information

re-garding previous immunization status was usually unavailable but assessment of need according to a

youngster’s recollection was carried forth. Visual

and auditory screening were carried out during the

brief stay at the Center, often for the first time.

Patients requesting elective surgery or treatment

of nonemergent conditions requiring hospitalization

were transferred to the adolescent inpatient unit of Montefiore Hospital where the detainees were treated without distinction from the other hospital-ized teenagers.

A

successful suicide attempt during the year

pre-ceding the establishment of the Montefiore pro-gram prompted family court authorities to seek the assistance of the Division of Adolescent Medicine

in creating a health service that might avoid such tragedies. There was one death during the 11 years.

This was a youngster with extensive drug involve-ment who succumbed to massive hepatic necrosis.

In

contradistinction to metropolitan adult facilities and other juvenile detention centers around the country, there have been no successful suicides nor

deaths resulting from trauma. It has not been dem-onstrated that the introduction of medical services can deter or prevent suicide, but the medical unit

TABLE 3. Diagnostic categories of health problem?

Infectious Respiratory Cardiovascular Dermatologic

Central nervous system Gastrointestinal Hepatic Genitourinary Dental Other Metabolic Glycosuria Hematuria Proteinuria Hypertension Other Traumatic Skull Extremities Other Neoplastic Malignant Benign Toxic Overdose syndromes Abstinence syndromes Congenital Cardiac Genitourinary Allergic Asthma Other Psychiatric Miscellaneous 51 3 116 303

CProblems were identified in 3,353 teenagers admitted to

(5)

screened youngsters for depressive affect as well as psychotic or highly self-destructive behavior. Ad-ditionally, the medical staff was available for gen-eral supportive care of youngsters who welcomed a nonjudgmental reception at a time of isolation from community, family, and peers.

While the health service component of the

pro-gram was in operation, a training experience for

health professionals was simultaneously provided. During the 11-year period 260 house officers, 18 postdoctoral fellows in adolescent medicine, and

120 senior medical students spent at least a

one-month clinical rotation at the Center. The educa-tional goals of the rotation are summarized in Table 1. Each physician-trainee participated in all the health assessment, infirmary, and institutional

functions during their rotation. The medical

stu-dents and housestaff provided night and weekend coverage in addition to the full daytime program of

comprehensive screening and follow-up care.

Pa-tients were encouraged to return to see the admit-ting doctor throughout their stay at the Center. Physicians were encouraged to have patients return to the medical unit to offer general support to aid the inmate during this stressful period.

DISCUSSION

Previous studies in the area of juvenile

delin-quency have documented the inadequate health

care provided in court-related facilities.’2 Although health standards for adult correctional institu-tions’3’14 and juvenile court residential facilities were developed,’5 and preliminary results of

medi-cal screening have been reported,’6 there has not

been a long-term comprehensive review of the

ex-perience from the viewpoint ofthe services provided

and health manpower training opportunities

of-fered. In carrying out such a review, four general

areas of importance emerged and prompted this

report.

Medical Issues

Among the medical conditions diagnosed and

treated on an ambulatory or infirmary basis, four distinct subgroupings could be identified. The first subgroup of ifinesses was those in which a clear association was apparent between the legal problem

and the medical diagnosis. For instance, girls who were arrested for status offenses, such as

“persons-in-need-of-supervision” or runaways, were

fre-quently diagnosed as being pregnant (4%),9 having

asymptomatic diseases (6%), and/or an abnormal cervical cytology (3%)10 Similarly, boys who were

arrested for narcotic possession were frequently

opiate users themselves and suffered the somatic conseauences of drug abuse such as hepatitis.6

The second subgroup of medical conditions was

those that would be commonly detected in any group of inner-city impoverished adolescents.’7 The

7%

prevalence of positive skin test for tuberculosis is comparable to surveys of disadvantaged, nonde-linquent youths.’8 Similarly, the majority of young-sters were noted to have prior inadequate dental care as evidenced by caries, missing, fractured, or

infected teeth in approximately 90% of those

screened.

The third subgroup of medical problems may be

viewed as consequences of parental neglect and

family dissolution. Conditions that are usually di-agnosed and evaluated in an annual health main-tenance examination were previously undiagnosed

in this group of youngsters who frequently had not

seen a physician since early childhood. Therefore, congenital defects such as hernias or abnormal

physical findings such as cardiac murmur, which would have been detected and evaluated previously,

were now identified for the first time. Physical signs of neglect and abuse such as cigarette burns, lash

marks, and scald burns were frequently noted on

examination, supporting a youngster’s history of

parental abuse.

Last, there was a group of medical conditions

created by the institutional environment. The un-usually high incidence of gastrointestinal com-plaints led to an investigation of the nutritional

policies of the facility. Due to financial

reimburse-ment formulas, the institution was obliged to offer

milk

as

the staple beverage at all meals and snacks. Since the detainees were predominantly black male

adolescents in whom lactose intolerance would be

expected in a high percentage of the population, the increased lactose load in the diet produced symp-toms in youngsters whose normal eating practices included far less lactose.

A medical problem was found in 46% ofthe young

people’6 although all were considered medically

healthy by court authorities. The abnormalities ranged in seriousness from minor injuries to life-threatening stages of acute and chronic illnesses.

Even prior awareness of a medical problem was

frequently unassociated with previous care because

of the inaccessabifity of health services.

Educational Issues

Rotation through the Detention Center was

man-datory for pediatric house officers and fellows in

adolescent medicine, and elective for medical

stu-dents during their third and fourth year of training in the Department of Pediatrics at the Albert

Ein-stein College of Medicine. The skills needed in

interviewing, examining, and treating incarcerated

(6)

regardless of the ultimate practice setting.

First-hand experience during the formative educational

years with the “hateful” patient’9 in a setting that allows discussion with a preceptor can prepare the physician-trainee for future encounters with diffi-cult patients. Of the 400 physicians who

partici-pated in the program only two trainees were

in-volved in physical confrontations with the

detainees. Neither was injured and no additional

legal charges were initiated against the detainees.

The trainees were exposed to youngsters with

ifiness patterns that were not unique to delinquent youth, but were sufficiently prevalent in this pop-ulation to foster proficiency in their diagnosis and treatment.2#{176} The satellite setting afforded an op-portunity for the physician-trainee to observe

inter-digitation of legal and social needs of patients.

Al-though the experience was perceived as a difficult one by the trainees at the time, 50% viewed it as the most worthwhile experience in adolescent med-icine when they were asked to evaluate the rotation from one to eight years after residency.2’ Exposure during training to this form of institutional medi-cine led some physicians to choose careers in insti-tutional health. Of the 18 physicians who worked in

the Detention Center during their fellowship in

adolescent medicine, seven have subsequently be-come involved in health programs in court-related facilities.

Ethical and Legal Issues

The code of professional conduct as written by the AMA states that: “a physician may not reveal the confidences entrusted to him in the course of medical attendance, or the deficiencies he may ob-serve in the character of patients, unless it becomes necessary in order to protect the welfare of the

individual or the community.” The nature of the

confidential relationship between doctor and pa-tient is frequently challenged in a court-related facility. The problems of content, format, access to,

and long-term storage of medical records of

incar-cerated minors are topics of immediate relevance.

Obtaining consent for medical procedures raises

the issue of the definition of competency for this group of teenagers. Often the young people have been living on their own and supporting themselves,

albeit by illegal means, for substantial amounts of

time. When a parent of a detained youth cannot be located, should the legal guardian, the representa-tive of the child care agency, or the judge become

parens patriae? Should the youth be allowed to

refuse health care? Since much of the previous

behavior of the delinquent population may be

viewed as self-destructive, should the youngster’s autonomy yield to the physician’s sense of

pater-nalism in dictating what course of treatment should be given? Is there a way to enable the youngster to express his or her independence and at the same time allow the physician to balance complicated roles as healer and protector of society? A lawyer and an ethicist were incorporated into the frame-work of the health team and established regular biweekly clinical seminars at the facility to aid in the formulation of approaches to these and other ethical-legal questions.

Youth Advocacy

By broadly defining health to include the creation of a safe, health-promoting environment, the

phy-sician must then extend his or her involvement

beyond the immediate medical needs of the incar-cerated youth. The physician can contribute infor-mation to the members of the team that decides the ultimate disposition ofthe legal case ofthe detainee.

Nonmedical personnel frequently wish to ascribe deviant behavior to an underlying treatable medical disorder.m However, the behavior is rarely attrib-utable solely to the medical condition. The physi-cian can prevent costly unnecessary medical

eval-uation by informing the legal authorities that a

given medical condition is an associated rather than

an

etiologic factor in the behavior.24

The physician can identify and treat the majority

of medical conditions within the brief period of

detention. Follow-up care can be coordinated with

an outside agency.” \Vhile the youngsters are de-tamed, the physician can help to decrease the feel-ing of isolation and depression that affects many incarcerated youths by allowing free access to the health professional through a sick call mechanism and the use of an infirmary unit for general sup-portive care.

Last, the health service team can document the

patterns of illnesses seen in the detainees so that

appropriate preventive measures and treatment

re-sources can be developed. Epidemiologic surveys have resulted in greater awareness of disease prey-alence6’7 and have emphasized the need for early identification of disease states in early adoles-cence.’#{176}By characterizing the medical and social

patterns of behavior regarding sexuality8’m and drug

abuse,#{176}appropriate educational and service mo-dalities can be established. By treating the detainee

as a patient rather than a prisoner, the physician can introduce an atmosphere of respect for individ-ual needs and rights. By applying a medical model to a penal institution, the needs of the incarcerated youth are served while providing an educational experience for the physician-trainee.

(7)

has occurred. As more restrictive laws are enacted and the age of criminal responsibility lowered, it is

likely that more teenagers will be incarcerated. It is

timely, therefore, that the potential role of the

health professional be emphasized in the care of

this high risk segment of the population which has previously been underserved by the medical com-munity.

Although not currently in the mainstream of the health care delivery system, care of juveniles in

detention, as described herein, may demonstrate

the possibilities that such a setting can offer. Many

of the issues that physicians are asked to resolve do

not have their roots in a medical model of disease.

However, the identffication of a medically needy

population is worthwhile when it can be readily

served by an academic medical center. By

integrat-ing such satellite settings into the fabric of the

medical center, these boundary issues that have

been peripheral to medical care and education

be-come, with time, more central themes in medical

education, while providing a high level of medical

service to an otherwise underserved community.

REFERENCES

1. Millar H: Approaches to Adolescent Health Care in the 1970’s. DHEW publication No. 75-5014, US Dept of Health,

Education and Welfare. Washington, DC, US Government

Printing Office, 1975

2. Walker D: Runaway youth: An Annotated Bibliography and Literature Review. DHEW Technical Analysis Paper No. 1, US Dept of Health, Education and Welfare. Washing-ton, DC, US Government Printing Office, 1975

3. Sarni R: Under Lock and Key: Juveniles in Jails and Detention. National Assessment of Juvenile Corrections. Ann Arbor, MI, University of Michigan Press, 1974 4. Kramer M: Psychiatric services and the changing

institu-tional scene, 1950-1985. DHEW Publication No. (ADM)

77-433, US Dept of Health, Education and Welfare. Washing-ton, DC, US Government Printing Office, 1977

5. Hem K, Cohen MI, Litt IF: Illicit drug use among urban

adolescents: A decade in retrospect. Am J Dis Child 133:38,

1979

6. Litt IF, Cohen MI, Schonberg SK: Liver disease in the drug-using adolescent. J Pediatr 81:238, 1972

7. Hein K, Marks A, Cohen MI: Asymptomatic gonorrhea: Prevalence in a population of urban adolescents. J Pediatr 90:634, 1977

8. Hein K, Cohen MI, Marks A, et al: Age at first intercourse among homeless adolescent females. J Pediatr 93:147, 1978 9. Rosner BL, Sheehy AJ, Litt IF: Abortion: Patient acceptance

among adolescents. Read before the Ambulatory Pediatric Society Atlantic City, NJ, April 1971

10. Hein K, Schreiber K, Cohen MI, et a!: Cervical cytology: The need for routine screening in the sexually active adoles-cent. J Pediatr 91:123, 1977

11. Schonberg 5K, Litt IF, Cohen MI: Health care for juveniles on probation. Read before the Annual Meeting, Society for Adolescent Medicine San Francisco, Oct 1974

12. Eisner V, Sholtz R: National survey of health care in insti-tutions for delinquents, in Meyer R (ed): Who Cares for the Adolescent, Report to the Society for Ado! Med, 1973 13. Robinson D: Prison health services. N Engl JMed 290:856,

1974

14. Brecher E, Della Penna R: Health Care in Correctional Institutions. Publication No. 027-000-000349-4, US Dept of Justice. Washington, DC, US Government Printing Office,

1975

15. Committee on Youth, American Academy of Pediatrics: Health standards for juvenile court residential facilities. Pediatrics 52:452, 1973

16. Litt IF, Cohen MI: Prisons, adolescents, and the right to quality medical care: The time is now. Am J Public Health 64:894, 1974

17. Brunswick A, Josephson E: Adolescent health in Harlem. Am J Public Health Supplement, October 1972

18. Kendig EL: Tuberculosis among children in the United States: 1978. Pediatrics 62:269, 1978

19. Groves J: Taking care of the hateful patient. N Engl JMed 298:883, 1978

20. Lift IF, Cohen MI: The drug-using adolescent as a pediatric patient. J Pediatr 77:195, 1970

21. Litt IF, Cohen MI: Training in adolescent health as viewed by pediatric house officers. JMed Educ 53:608, 1978

22. Isele W: Health care in jails: Inmates’ medical records and jail inmates’ right to refuse medical treatment. AMA Publi-cation No. 597, Chicago, IL, American Medical Association, 1977

23. Van Allen M: Epilepsy among persons convicted of crime. JAMA 239:2964, 1978

24. Litt IF: Testimony Before the Subcommittee to Investigate Juvenile Delinquency. Publication No. 5270-02 492, US Sen. ate, Committee on the Judiciary, Washington, DC, US Gov-ernment Printing Office, 1973

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1980;66;239

Pediatrics

Andrea Marks and Audrey-Jean Sheehy

Karen Hein, Michael I. Cohen, Iris F. Litt, S. Kenneth Schonberg, Monica R. Meyer,